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目的 探讨肝脏三维重建技术在腹腔镜肝切除术中的应用价值.方法 采用回顾性队列研究方法.收集2014年1月至2018年12月浙江大学医学院附属邵逸夫医院收治的189例肝癌患者的临床病理资料;男142例,女47例;平均年龄为60岁,年龄范围为27～86岁.189例患者中,50例行腹腔镜复杂肝切除术,其中23例术前行肝脏三维重建设为复杂重建组,27例术前未行肝脏三维重建设为复杂对照组;139例行腹腔镜非复杂肝切除术,其中25例术前行肝脏三维重建设为非复杂重建组,114例术前未行肝脏三维重建设为非复杂对照组.观察指标:(1)肝脏三维重建脉管评估情况.(2)手术及术后情况.(3)典型病例分析.正态分布的计量资料以Mean±SD表示,组间比较采用t检验;偏态分布的计量资料以M(范围)表示,组间比较采用Mann-Whitney U检验.计数资料以绝对数或百分比表示,组间比较采用x2检验或Fisher确切概率法.结果 (1)肝脏三维重建脉管评估情况:189例患者中,48例术前行肝脏三维重建.48例患者脉管评估结果显示:肝动脉Michels Ⅰ型41例,Ⅱ型4例,Ⅲ型、Ⅳ型、Ⅷ型各1例;肝静脉Ⅰ型35例,Ⅱ型12例,肝静脉走行不明确1例;门静脉Ⅰ型5例,Ⅱ型3例,门静脉走行正常38例,门静脉走行不明确2例.(2)手术及术后情况:189例患者中,50例行腹腔镜复杂肝切除术,139例行腹腔镜非复杂肝切除术.复杂重建组和复杂对照组患者手术时间、术中出血量分别为(234±64) min、(289±80) min,200 mL(100～408 mL)、500 mL(400～800 mL),两组比较,差异均有统计学意义(t=-2.474,Z=-2.981,P＜0.05).而两组患者术后并发症、术后住院时间分别为8例、13例,6 d(4～ 12 d)、8 d(6～13 d),两组比较,差异均无统计学意义(x2=0.911,Z=-1.634,P＞0.05).非复杂重建组和非复杂对照组患者手术时间、术中出血量、术后并发症和术后住院时间分别为160.0 min(117.5～221.0 min)、157.5 min(100.0～222.5 min),100 mL(75 ～ 200 mL)、100 mL(50～200 mL),8例、43例,5 d(4～8 d)、6 d(4～7 d),两组比较,差异均无统计学意义(Z=-0.525,-0.797,x2=0.289,Z=-0.011,P＞0.05).(3)典型病例分析:1例48岁男性原发性肝癌患者通过术前肝脏三维重建流域模拟功能制订个性化肝脏切除方案;1例49岁女性肝内胆管细胞癌患者通过三维重建模拟功能间接实现术中导航.结论 肝脏三维重建技术在肝切除术前评估中有利于精准肝切除术手术方案选择及个性化制订手术方案.尤其是在腹腔镜复杂肝切除术中,术前行肝脏三维重建可缩短手术时间、减少术中出血量.

Objective To evaluate the application value of three-dimensional (3D) reconstruction technique in laparoscopic hepatectomy.Methods The retrospective cohort study was conducted.The clinicopathological data of 189 patients with liver cancer who were admitted to the Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine from January 2014 to December 2018 were collected.There were 142 males and 47 females,aged from 27 to 86 years,with an average age of 60 years.According to the difficulty score of surgery,50 of 189 patients underwent laparoscopic complex hepatectomy,including 23 with preoperative 3D reconstruction in the complex reconstruction group and 27 with no preoperative 3D reconstruction in the complex control group;other 139 patients underwent laparoscopic non-complex hepatectomy,including 25 with preoperative 3D reconstruction in the non-complex reconstruction group and 114 with no preoperative 3D reconstruction in the non-complex control group.Observation indicators:(1) vascular assessment of patients who received 3D reconstruction;(2) surgical and postoperative situations;(3) typical case analysis.Measurement data with normal distribution were presented as Mean±SD,and comparison between groups was done using the t test.Measurement data with skewed distribution were presented as M (range),and comparison between groups was done using the Mann-Whitney U test.Count data were represented as absolute number or percentage,and comparison between groups was analyzed using the chi-square test or Fisher exact probability.Results (1) Vascular assessment of patients who received 3D reconstruction:48 of 189 patients were performed preoperative 3D reconstruction.Vascular assessment of 48 patients showed 41 of hepatic arterial Michels Ⅰ type,4 of Michels Ⅱ type,1,1,and 1 of Michels Ⅲ,Ⅳ,Ⅷ type,respectively.There were 35 belonging to hepatic venous Ⅰ type and 12 belonging to hepatic venous Ⅱ type and 1 with unclear distribution of hepatic vein.There were 5 and 3 belonging to portal venous Ⅰ type and Ⅱ type,38 with normal distribution of portal vein,and 2 with unclear distribution of portal vein,respectively.(2) Surgical and postoperative situations:50 of 189 patients underwent laparoscopic complex hepatectomy,and 139 underwent laparoscopic non-complex hepatectomy.The operation time and volume of intraoperative blood loss were (234±64)minutes and 200 mL (range,100-408 mL) in the complex reconstruction group,and (289±80)minutes and 500 mL (range,400-800 mL) in the complex control group,respectively,showing statistically significant differences between the two groups (t=-2.474,Z=-2.981,P＜ 0.05).Cases with postoperative complications and duration of postoperative hospital stay of complex reconstruction group were 8 and 6 days (range,4-12 days),respectively,versus 13 and 8 days (range,6-13 days) of complex control group.There was no significant difference (x2=0.911,Z =-1.634,P＞0.05).The operation time,volume of intraoperative blood loss,cases of postoperative complications and duration of postoperative hospital stay were 160.0 minutes (range,117.5-221.0 minutes),100 mL (range,75-200 mL),8,5 days (range,4-8 days) in the non-complex reconstruction group,157.5 min (range,100.0-222.5 minutes),100 mL (range,50-200 mL),43,6 days (range,4-7 days) in the non-complex control group,showing no significant difference between the two groups (Z=-0.525,-0.797,x2 =0.289,Z=-0.011,P＞0.05).(3) Typical case analysis:one 48-year-old male patient with primary liver cancer developed a personalized hepatectomy plan through simulation function of vascular drainage area in 3D reconstruction.One 49-year-old female patient achieved indirect intraoperative navigation through emulation function of 3D reconstruction.Conclusions The 3D reconstruction of liver in preoperative assessment is beneficial to choice of surgical options and personalized surgical plan in the precise hepatectomy.Especially in the laparoscopic complex hepatectomy,preoperative 3D reconstruction can shorten operation time,and reduce volume of intraoperative blood loss.