摘要目的 研究三维可视化技术指导肝段切除联合胆道硬镜在复杂肝胆管结石诊治中的应用价值.方法 收集2010年7月至2014年6月南方医科大学珠江医院肝胆一科收治的46例复杂肝胆管结石患者的CT数据,利用MI-3 DVS进行三维可视化和个体化分型诊断.男性21例,女性25例,年龄35 ～ 78岁,平均53.2岁;病程2～21年,平均7.8年.肝功能Child-Pugh分级:A级31例,B级15例(其中C级l例,经积极治疗后术前评估为B级).根据门静脉、肝静脉的分布进行个体化肝脏分段和肝脏体积计算.根据结石和肝内胆管狭窄段分布,确定切除肝段,指导术中精准肝段切除.术中选择胆道硬镜对剩余肝叶(段)进行胆管探查、碎石和取石.结果 三维可视化分型诊断:Ⅰ型10例,Ⅱa型11例,Ⅱb型23例,Ⅱc型2例,19例有胆道手术史.肝动脉变异6例(13.0％),门静脉变异8例(17.4％).仿真肝段切除剩余肝体积比均＞50％,其中肝左外叶切除18例,肝左叶切除8例,肝右后叶切除8例,肝右叶切除4例,肝脏4段切除4例,肝右前叶切除2例,肝左外叶切除联合肝右后叶切除2例.实际手术过程与术前手术规划一致.术后未见剩余肝脏缺血、淤血发生,未出现肝功能衰竭.术中结石清除率91.3％(42/46),因化脓性胆管炎不宜一期处理.4例患者残留结石,术后经T管窦道胆道硬镜成功取出结石.结论 三维可视化技术可实现复杂肝胆管结石的术前精确诊断,指导术中肝段切除和胆道硬镜手术操作,有助于提高结石清除率.

abstractsObjective To study the value of hepatic segment resection combined with rigid choledochoscope by the three-dimensional (3D)visualization technology in the diagnosis and treatment of complex hepatolithiasis.Methods Enhance computed tomography (CT) data of 46 patients with complex hepatolithiasis who were admitted to the Zhujiang Hospital of the Southern Medical University from July 2010 to June 2014 were collected.All of the CT data were imported into the medical image three-dimensional visualization system(MI-3DVS) for 3D reconstruction and individual 3D types.The optimal scope of liver resection and the remnant liver volume were determined according to the individualized liver segments which were made via the distribution and variation of hepatic vein and portal vein,the distribution of bile duct stones and stricture of the bile duct,which provided guidance for intraoperative hepatic lobectomy and rigid choledochoscope for the remnant calculus lithotripsy.Results Outcomes of individual 3D types:10 cases of type Ⅰ,11 cases of Ⅱ a,23 cases of Ⅱ b,2 cases of Ⅱ c,19 cases coexisted with history of biliary surgery.The variation of hepatic artery was appeared 6 cases.The variation of portal vein was appeared 8 cases.The remaining liver volume for virtual hepatic lobectomy controlled more than 50％.Eighteen cases underwent left lateral hepatectomy,8 cases underwent left liver resection,8 cases underwent right posterior lobe of liver resection,4 cases underwent the right hepatic resection,4 cases underwent Ⅳ segment liver resection,2 cases underwent right anterior lobe of liver resection,2 cases underwent left lateral hepatectomy combined with right posterior lobe of liver resection,26 cases underwent targeting treatment of rapid choledochoscope and preumatic lithotripsy.The actual surgical procedure was consistent with the preoperative surgical planning.There was no postoperative residual liver ischemia,congestion,liver failure occurred in this study.The intraoperative calculus clearance rate was 91.3％ (42/46) because 4 cases of postoperatively residual calculi were not suitable for one stage management due to suppurative cholangitis but removed calculus successfully with rigid choledochoscope through T tube fistula.Conclusion Hepatic segment resection combined with rigid choledochoscope under the guidance of three-dimensional visualization technology achieves accurate preoperative diagnosis and higher complete stone clearance rate of complicated hepatolithiasis.