Traditional surgical planning of liver surgery is modified by 3D interactive quantitative surgical planning approach： a single-center experience with 305 patients

BACKGROUND： Decision making and surgical planning are to achieve the precise balance of maximal removal of target lesion, maximal sparing of functional liver remnant volume, and minimal surgical invasiveness and therefore, crucial in liver surgery. The aim of this prospective study was to validate the accuracy and predictability of 3D interactive quantitative surgical planning approach （IQSP）, and to evaluate the impact of IQSP on traditional surgical plans based on 2D images. METHODS： A total of 305 consecutive patients undergoing hepatectomy were included in this study. Surgical plans were created by traditional 2D approach using picture archiving and communication system （PACS） and 3D approach using IQSP respectively by two groups of physicians who did not know the surgical plans of the other group. The two surgical plans were submitted to the chief surgeon for selection before operation. The specimens were weighed. The two surgical plans were compared and analyzed retrospectively based on the operation results. RESULTS： The two surgical plans were successfully developed in all 305 patients and all the 3D IQSP surgical plans were selected as the final decision. Total 278 patients successfully underwent surgery, including 147 uncomplex hepatectomy and 131 complex hepatectomy. Twenty-seven patients were withdrawn from hepatectomy. In the uncomplex group, the two surgical plans were the same in all 147 patients and no statistically significant difference was found among 2D calcu- lated resection volume （2D-RV）, 3D IQSP calculated resection volume （IQSP-RV） and the specimen volume. In the complex group, the two surgical plans were different in 49 patients （49/131, 37.4%）. According to the significance of differences, the 49 different patients were classified into three grades. No statistically significant difference was found between IQSP-RV and specimen volume. The coincidence rate of territory analy- sis of IQSP with operation was 92.1% （93/101） for 101 patients of anatomic hepatectomy. CONCLUSIONS： The accuracy and predictability of 3D IQSP were validated. Compared with traditional surgical planning, 3D IQSP can provide more quantitative information of anatomic structure. With the assistance of 3D IQSP, traditional surgical plans were modified to be more radical and safe.

Topological approach of liver segmentation based on 3D visualization technology in surgical planning for split liver transplantation

BACKGROUND Split liver transplantation(SLT)is a complex procedure.The left-lateral and right tri-segment splits are the most common surgical approaches and are based on the Couinaud liver segmentation theory.Notably,the liver surface following right trisegment splits may exhibit different degrees of ischemic changes related to the destruction of the local portal vein blood flow topology.There is currently no consensus on preoperative evaluation and predictive strategy for hepatic segmental necrosis after SLT.AIM To investigate the application of the topological approach in liver segmentation based on 3D visualization technology in the surgical planning of SLT.METHODS Clinical data of 10 recipients and 5 donors who underwent SLT at Shenzhen Third People’s Hospital from January 2020 to January 2021 were retrospectively analyzed.Before surgery,all the donors were subjected to 3D modeling and evaluation.Based on the 3D-reconstructed models,the liver splitting procedure was simulated using the liver segmentation system described by Couinaud and a blood flow topology liver segmentation(BFTLS)method.In addition,the volume of the liver was also quantified.Statistical indexes mainly included the hepatic vasculature and expected volume of split grafts evaluated by 3D models,the actual liver volume,and the ischemia state of the hepatic segments during the actual surgery.RESULTS Among the 5 cases of split liver surgery,the liver was split into a left-lateral segment and right trisegment in 4 cases,while 1 case was split using the left and right half liver splitting.All operations were successfully implemented according to the preoperative plan.According to Couinaud liver segmentation system and BFTLS methods,the volume of the left lateral segment was 359.00±101.57 mL and 367.75±99.73 mL,respectively,while that measured during the actual surgery was 397.50±37.97 mL.The volume of segment IV(the portion of ischemic liver lobes)allocated to the right tri-segment was 136.31±86.10 mL,as determined using the topological approach to liver segmentation.However,during the actual surgical intervention,ischemia of the right tri-segment section was observed in 4 cases,including 1 case of necrosis and bile leakage,with an ischemic liver volume of 238.7 mL.CONCLUSION 3D visualization technology can guide the preoperative planning of SLT and improve accuracy during the intervention.The simulated operation based on 3D visualization of blood flow topology may be useful to predict the degree of ischemia in the liver segment and provide a reference for determining whether the ischemic liver tissue should be removed during the surgery.

Localizing the Language Network with fMRI and Functional Connectivity: Implications for Pre-Surgical Planning

Object: Functional MRI is frequently applied to lateralize language in pre-surgical planning, with potential to localize functionally important cortex too. Here we present BOLD signal activation maps and related functional connectivity, in response to three commonly administered fMRI language tasks. Methods: Datasets from 55 pre-surgical fMRI studies were analyzed. Verbal response naming, covert word generation and passive listening tasks were administered in all studies. Single-subject analyses, group analyses and region-of-interest analyses were conducted, and a multi-subject functional connectivity analysis was performed. Results: Single-subject analyses revealed that clinically important language regions were activated in all but three patients using the panel of tasks. Group analyses revealed significant bilateral BOLD signal increases in anterior and posterior language regions in response to verbal response naming and bilateral signal increase in posterior language regions only in response to passive listening. Covert word generation activated anterior language regions bilaterally and posterior language cortex in the dominant hemisphere. Functional connectivity analyses confirmed that activated regions were significantly correlated in all tasks. Conclusion: The findings of single-subject and group analyses add to the evidence supporting the use of a panel of fMRI tasks to map the language network for pre-surgical planning. Our findings support the additional use of functional connectivity analysis in routine language mapping to add to the localization value to fMRI. In addition, the results of our investigation demonstrate these three commonly applied tasks reliably activate unique aspects of the language network, which advocates closer individual inspection, guided by the surgical intervention planned.

基于深度学习神经网络技术的脊柱椎弓根螺钉自动规划研究

目的:针对骨科手术机器人螺钉手工规划效率低下的问题,实现基于CT的脊柱椎弓根螺钉自动、高效、高质量规划。方法:采用深度学习神经网络对标注分割和螺钉的CT图像进行有监督的机器学习,实现脊柱椎弓根螺钉的自动规划;本实验使用44例腰椎CT共440枚螺钉作为训练集,使用11例CT生成110枚螺钉作为测试集,以手工规划作为对照组,通过盲法专家评价评估螺钉规划效果,并通过记录规划时间评估规划效率。结果:该自动规划方法生成的螺钉规划临床可用率为95.4%,自动规划时间与平均手工规划时间分别为68.8 s和177.6 s。结论:该自动规划方法可初步实现高效、高质量的脊柱椎弓根螺钉自动规划,但仍需临床医生监督复核。

“E骨”-反肩置换术一站式术前规划系统

目的为提高反肩置换术术前规划的精准度和效率,本研究开发了“E骨”—反肩置换术一站式术前规划系统。方法利用nnU-net深度神经网络进行肩胛骨分割,获得精确的肩胛骨分割结果;结合骨密度、上下倾角和入钉长度3个关键因素自动定位基座,并计算出手术规划所需定量参数;结合关节盂形态和基座定位信息生成个性化导板;编写系统界面,将各部分功能模块化组装便于使用,提供交互操作与规划结果显示的功能。结果构建出“E骨”术前规划系统。本系统与Mimics系统相比,减少了规划过程中繁琐的手动调整,平均入钉长度规划结果长于Mimics系统,且规划时间缩短86%。本系统肩胛骨分割精度达到99.93%,较Mimics更高。结论本研究为反肩置换术提供了一套一站式的高效、精准的术前规划方案,具有广泛的临床应用前景。

Preoperative surgical planning for intracranial meningioma resection by virtual reality

Background The Dextroscope system by Volume Interactions （Singapore） had been applied to minimally invasive neurosurgery in many units. This system enables the neurosurgeon to interact intuitively with the three-dimensional graphics in a direct manner resembling the way one communicates with the real objects. In the paper, we explored its values in pre-operation surgical planning for intracranial meningiomas resection. Methods Brain computed tomography （CT）, magnetic resonance imaging （MRI）, and magnetic resonance venography （MRV） were performed on 10 patients with parasagittal and falcine meningiomas located on central groove area; brain CT, MRI and magnetic resonance angiography （MIRA） were performed on 10 patients with anterior skull base meningiomas and 10 patients with sphenoid ridge meningiomas. All these data were transferred to Dextroscope virtual reality system, and reconstructed. Then meningiomas, skull base, brain tissue, drainage vein and cerebral arteries were displayed within the system, and their anatomic relationships were evaluated. Also, the simulation operations were performed. Results For parasagittal and falcine meningiomas, the relationships of tumor with drainage vein and superior sagittal sinus were clearly displayed in the Dextroscope system. For anterior skull base and sphenoid ridge meningiomas, the relationships of tumor with bilateral internal carotid arteries, anterior cerebral arteries, middle cerebral arteries and skull base were vividly displayed within the virtual reality system. Surgical planning and simulation operation of all cases were performed as well. The real operations of all patients were conducted according to the simulation with well outcomes. Conclusions According to the virtual reality planning, neurosurgeons could get more anatomic information about meningioma and its surrounding structures, especially important vessels, and choose the best approach for tumor resection, which would lead to better prognosis for patients.

3D-printed models improve surgical planning for correction of severe postburn ankle contracture with an external fixator

Gradual distraction with an external fixator is a widely used treatment for severe postburn ankle contracture(SPAC).However,application of external fixators is complex,and conventional two-dimensional(2D)imaging-based surgical planning is not particularly helpful due to a lack of spatial geometry.The purpose of this study was to evaluate the surgical planning process for this procedure with patient-specific three-dimension-printed models(3DPMs).In this study,patients coming from two centers were divided into two cohorts(3DPM group vs.control group)depending on whether a 3DPM was used for preoperative surgical planning.Operation duration,improvement in metatarsal-tibial angle(MTA),range of motion(ROM),the American Orthopedic Foot and Ankle Society(AOFAS)scores,complications,and patient-reported satisfaction were compared between two groups.The 3DPM group had significantly shorter operation duration than the control group((2.0±0.3)h vs.(3.2±0.3)h,P<0.01).MTA,ROM,and AOFAS scores between the two groups showed no significant differences pre-operation,after the removal of the external fixator,or at follow-up.Plantigrade feet were achieved and gait was substantially improved in all patients at the final follow-up.Pin-tract infections occurred in two patients(one in each group)during distraction and were treated with wound care and oral antibiotics.Patients in the 3DPM group reported higher satisfaction than those in the control group,owing to better patient-surgeon communication.Surgical planning using patient-specific 3DPMs significantly reduced operation duration and increased patient satisfaction,while providing similar improvements in ankle movement and function compared to traditional surgical planning for the correction of SPAC with external fixators.

Virtual surgical planning is a useful tool in the surgical management of mandibular condylar fractures

Purpose:The aim of this study is to evaluate the application value of virtual surgical planning in the management of mandibular condylar fractures and to provide a reliable reference.Methods:This was a prospective randomized controlled study and recruited 50 patients requiring surgical treatment for their mandibular condylar fractures.The inclusion criteria were patients(1)diagnosed with a condylar fracture by two clinically experienced doctors and required surgical treatment;(2)have given consent for the surgical treatment;and(3)had no contraindications to the surgery.Patients were excluded from this study if:(1)they were diagnosed with a non-dislocated or only slightly dislocated condylar fracture;(2)the comminuted condylar fracture was too severe to be treated with internal reduction and fixation;or(3)patients could not complete follow-up for 3 months.There were 33 male and 17 female patients with 33 unilateral condylar fractures and 17 bilateral condylar fractures included.The 50 patients were randomly(random number)divided into control group(25 patients with 35 sides of condylar fractures)and experimental group(25 patients with 32 sides of condylar fractures).Virtual surgical planning was used in the experimental group,but only clinical experience was used in the control group.The patients were followed up for 1,3,6 and 12 months after operation.Variables including the rate of perfect reduction by radiological analysis,the average distance of deviation between preoperative and postoperative CT measurements using Geomagic software and postoperative clinical examinations(e.g.,mouth opening,occlusion)were investigated for outcome measurement.SPSS 19 was adopted for data analysis.Results:The average operation time was 180.60 min in the experimental group and 223.2 min in the control group.One week postoperatively,CT images showed that the anatomic reduction rate was 90.63%(29/32)in the experimental group and 68.57%(24/35)in the control group,revealing significant difference(X^(2)=4.919,p=0.027).Geomagic comparative analysis revealed that the average distance of deviation was also much smaller in the experimental group than that in the control group(0.639 mm vs.0.995 mm;t=3.824,p<0.001).Conclusion:These findings suggest that virtual surgical planning can assist surgeons in surgical procedures,reduce operative time,and improve the anatomic reduction rate&accuracy,and thus of value in the diagnosis and treatment of condylar fractures.

Lumped parameter model based surgical planning for CABG

The current 3D CABG model is time consuming,a lumped parameter CABG model may solve this problem.A coronary lumped parameter model without stenosis and graft was constructed.The stenosis resistance was calculated and graft model was constructed.After calculation,the graft flow results of CABG lumped parameter model fit well with 3D CABG model results.

Face transplantation for massive mandibular defects: considerations for allograft design and surgical planning

Modern face transplant techniques have advanced to allow for the transfer of vascularized skeletal components in addition to overlying soft tissue.This represents significant opportunity for individuals with mandibular defects that are not amenable to traditional reconstruction.Care must be taken when planning and executing transplants with these complex grafts,as satisfactory functional and aesthetic outcomes rely on achieving proper spatial relationships between the mandible,skull base,and midface.Which donor skeletal elements are included in the allograft and how they are harvested are important considerations in this planning and are associated with controversy.To optimize outcomes in the reconstruction of single-jaw defects,some advocate for transplantation of only the affected jaw while others support bimaxillary transplantation.Clinical evidence in this debate is not conclusive at this time.In current practice,including donor dentoalveolar anatomy by utilizing a bilateral sagittal split osteotomy of the mandible is favored to optimize outcomes such as dental occlusion.It has been suggested that harvesting the mandible at the level of the condyle or even the temporal bone may also be possible and may improve temporomandibular joint-related outcomes.Despite encouraging preclinical evidence,these strategies remain controversial.After allograft design,successful mandibular reconstruction with face transplantation relies on surgical precision in the donor and recipient procedures.Computerized surgical planning,computer-aided design and manufacturing,and intraoperative navigation are technologies currently in use to mitigate operative complexity.Results in both cadaveric and clinical face transplantations suggest these technologies are reliable and beneficial,although some room for improvement remains.

单侧微小型唇裂手术方案与规范化建议

单侧微小型唇裂尽管畸形程度较轻,但仍有可能涉及鼻唇皮肤、肌肉、黏膜及软骨等多组织类型异常。目前,微小型唇裂整复尚无标准化治疗方案,针对同一畸形特征的手术技术选择较多,术者在手术设计时常常存在较大的随意性和自由度。临床个体化治疗绝不等同于随意的手术技术组合,必须发展出规范化的设计思路。达到这一目标的前提是全面理解不同手术操作的技术特点。本文在全面梳理单侧微小型唇裂整复手术入路、肌肉重建、鼻畸形整复等关键操作的技术选择基础上,针对规范化制定个体化治疗方案提出建议。

从“经验外科”到“精准外科”——精准正颌外科体系的建立与临床应用

近年来,通过截骨和移动牙-颌骨复合体的正颌外科手术已成为治疗牙颌面畸形的重要方法。上、下颌骨最终的空间位置将直接影响正颌手术的治疗效果,也是治疗的关键步骤。为了精准实现理想的颌骨空间位置,在数字化外科和3D打印技术迅猛发展的推动下,正颌外科已经从过去的“经验外科”时代进入“精准外科”的新时代。本文详细阐述了多年来我们在“精准正颌外科”治疗模式方面的探索和研究,介绍其技术体系及在“Ortho+X”治疗模式中的应用,旨在为广大同行提供参考和帮助。

小切口胆囊切除术与腹腔镜胆囊切除术在胆结石手术治疗中的意义及有效率分析

目的 探讨胆结石患者选择小切口胆囊切除术以及腹腔镜胆囊切除术两种治疗方案的效果。方法 方便选择2019年4月—2020年6月福建省龙岩市第二医院收治的胆囊结石患者72例为研究对象,采用随机数表法分为对照组与研究组,各36例。对照组患者采用常规小切口胆囊切除术进行治疗,研究组患者则选择腹腔镜胆囊切除术进行治疗。比较两组治疗效果,包括手术相关指标、并发症发生状况。结果 研究组研究组除手术时间长于对照组外,其他各项手术相关指标均优于对照组,差异有统计学意义(P<0.05)。研究组并发症发生率为1.25%,低于对照组的27.77%,差异有统计学意义(χ^(2)=8.692,P<0.05)。结论 对胆结石患者通过腹腔镜胆囊切除术进行治疗,能够缩短手术时间、住院时间、术后排气时间以及术后下床活动时间,且并发症发生率低,安全性较高。

基于MRI的有限元建模和分析在髋臼周围截骨术中的应用

髋臼周围截骨术(PAO)是一种矫正发育性髋关节发育不良(DDH)髋臼方向的手术方法.本文基于DDH患者的髋关节磁共振成像(MRI)数据,构建有限元模型,进行PAO虚拟手术规划研究.通过计算髋臼从原始中心边缘(CE)角以5°增量变化旋转时,骨盆和股骨软骨间的峰值接触压力和接触面积,确定PAO中髋臼的最佳位置.此外,我们进一步利用有限元分析对术前和获得最佳位置的计划模型进行6个方向的模拟运动,并对所有方案的术前模型和计划模型进行了比较.分析结果表明,该患者髋臼最佳手术位置在CE角为20°时,且在髋关节运动过程中,计划模型中的峰值接触压力均低于术前模型,接触面积均大于术前模型,从生物力学的角度验证了虚拟手术规划的有效性.

数字化手术设计流程在颌面部骨折整复治疗中的应用分析

目的探讨颌面部骨折精准治疗中数字化手术设计的应用效果,总结工作流程。方法回顾性分析2019年1月至2022年12月在我院口腔颅颌面科行术前数字化手术设计的40例颌面部骨折患者的临床资料,总结颌面部骨折整复治疗中的手术设计流程。结果40例患者均在手术设计的当天完成所有术前检查,平均检查耗时<3 h。患者手术均在预定时间内顺利完成,术后功能与外形得到良好的恢复,效果满意。结论规范化的数字化手术设计流程能优化颌面部骨折患者的检查流程,提高医护工作效率,提高手术精度,是保证手术达到预期效果的重要环节。

面向肝癌消融术的多约束最优穿刺路径规划算法

针对经典穿刺路径规划算法在量化路径情况时没有考虑路径周围区域的问题,提出新的约束条件来弥补对路径周围信息量化的不足.基于血管位置信息提出一个严格约束条件(周围区域避开血管),并基于骨骼密度、血管密度和直径信息提出3个软约束条件(骨骼密集度、血管密集度、血管风险度),将周围信息添加到路径的量化中,提高穿刺路径的安全性.为了适应患者的特异性,提出软约束优化度评分算法,根据软约束的优化度设置权重,并将最大优化度对应的穿刺路径作为最优穿刺路径.为了验证算法的有效性,在公开数据集3D-IRCADb上进行实验,结果表明,本文提出的算法可以快速计算出符合临床需求的最优穿刺路径.

3D打印技术辅助切开复位内固定与常规手术治疗髋臼骨折疗效的Meta分析

目的通过Meta分析比较3D打印技术辅助切开复位内固定(ORIF)与常规手术治疗髋臼骨折的临床疗效差异。方法通过计算机检索建库至2022年7月1日PubMed、EMBASE、Cochrane Library、知网、万方和维普数据库中3D打印技术辅助ORIF与常规手术治疗髋臼骨折的相关文献,根据纳入与排除标准筛选符合的临床对照试验,利用Cochrane评价手册和渥太华纽卡斯尔量表(NOS)对纳入研究进行质量评价,采用RevMan 5.3软件对两组术式临床疗效结果进行统计分析。结果共纳入6篇随机对照试验,14篇非随机对照试验,研究对象821例(3D打印手术组372例,常规手术组449例)。Meta分析结果显示:在手术时间[MD=-43.41,95%CI(-56.19,-30.62),P<0.00001]、术中出血量[MD=-216.47,95%CI(-298.39,-134.56),P<0.00001]、术中透视次数[MD=-5.43,95%CI(-7.71,-3.15),P<0.00001]、术中器械安装时间[MD=-27.31,95%CI(-31.29,-23.33),P<0.00001]、术后CT上残余位移[MD=-0.67,95%CI(-1.12,-0.22),P=0.004]、并发症发生率[OR=0.51,95%CI(0.34,0.76),P=0.001]及创伤性关节炎发生率[OR=0.43,95%CI(0.20,0.94),P=0.03]方面,3D打印手术组优于常规手术组;而在术后骨折复位质量Matta评分优良率、末次随访时髋关节Merle D’Aubigne&Postel评分及Harris评分优良率方面两组相比差异无统计学意义(P=0.07、P=0.11和P=0.69)。结论3D打印技术辅助ORIF治疗髋臼骨折,可缩短手术时间及术中器械安装时间,减少术中出血量、术中透视次数、术后残余位移及术后并发症发生率,是髋臼骨折的一种有效治疗方式。

一种面向介入类手术的增强现实导航系统

传统的手术导航系统需要术者将视线在显示屏和病灶区之间切换,为了解决这个问题,引入了增强现实手术导航技术。为解决介入类手术中术者无法直接观察到患者病灶与手术器械的相对位置的问题,设计了一种面向介入类手术的增强现实导航系统。术前以Unity软件为开发平台设计虚拟手术路径,并实时显示术中病灶区与手术器械的相对距离。利用头骨和梯台实验对导航系统进行了精度验证,虚拟显示的误差约为3.3 mm。该研究证实了增强现实手术导航在介入类手术术前规划和术中实时引导的可行性。

三维可视化技术在肝癌转化切除中的应用

目的总结三维可视化技术在肝癌转化切除中的应用经验。方法回顾性分析2019年1月—2021年8月本院接受转化治疗的15例肝癌病例资料。转化方案包括:经导管肝动脉化疗栓塞(TACE)、经导管肝动脉灌注化疗(HAIC)、仑伐替尼、免疫检查点阻断剂、门静脉放疗等。取回CT或MRI片源后,使用Myrian医学软件对患者的CT和/或MRI实施三维重建,评估病情,规划手术。结果男性11例,女性4例,中位年龄56(32~69)岁,均为首次诊治的患者,CNLCⅠb期2例,Ⅱa期1例,Ⅲb期6例,Ⅲa期6例。TACE+门静脉放射性粒子置入术1例、TACE+仑伐替尼+信迪利单抗1例、TACE+仑伐替尼+替雷利珠单抗+门静脉放疗2例、TACE+仑伐替尼2例,TACE+仑伐替尼+替雷利珠单抗3例、HAIC+TACE+仑伐替尼2例,HAIC+TACE+仑伐替尼+替雷利珠单抗2例,HAIC+TACE+仑伐替尼+帕博利珠单抗1例,TACE+仑伐替尼+卡瑞利珠单抗1例。转化治疗后肿瘤缩小12例,转化成功7例,切除4例。转化成功的病例通过三维可视化技术分析,1例术式由治疗前的右半肝切除术转化为肝部分切除术(肝Sg5、Sg6),1例由肝Sg6+7+8段切除术,转化为Sg6+7段切除术,2例由扩大右半肝切除术,转化为右前叶切除术。结论在肝癌转化切除中,常需要借助三维可视化技术反复、多次评价转化是否成功。