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Background: Hepatolithiasis is a complex condition that poses challenges and difficulties in surgical treatment. Three-dimensional visualization technology combined with fluorescence imaging (3DVT-FI) enables accurate preoperative assessment and real-time intraoperative navigation. However, the perioperative outcomes of 3DVT-FI in hepatolithiasis have not been reported. We aim to evaluate the efficacy of 3DVT-FI in the treatment of hepatolithiasis., Methods: A retrospective analysis was performed on 128 patients who underwent hepatectomy for hepatolithiasis at the Department of Hepatobiliary Surgery, Zhujiang Hospital, between January 2017 and December 2022. Among them, 50 patients underwent hepatectomy using 3DVT-FI (3DVT-FI group), while 78 patients underwent conventional hepatectomy without 3DVT-FI (CH group). The operative data, postoperative liver function indices, complication rates and stone residue were compared between the two groups., Results: There were no significant differences in preoperative baseline data between the two groups (p > 0.05). Compared with the CH group, the 3DVT-FI group exhibited lower intraoperative blood loss (140.00 ± 112.12 vs. 225.99 ± 186.50 mL, p = 0.001), and a lower intraoperative transfusion rate (8.0% vs. 23.1%, p = 0.027). The overall incidence of postoperative complications did not differ significantly (22.0% vs. 35.9%, p = 0.096). The 3DVT-FI group was associated with a lower immediate residual stone rate (16.0% vs. 34.6%, p = 0.021). There were no perioperative deaths in the 3DVT-FI group, while one perioperative death occurred in the CH group., Conclusions: The 3DVT-FI may offer significant benefits in terms of surgical safety, reduced intraoperative bleeding and decreased stone residue during hepatectomy for hepatolithiasis., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Introduction: Digital intelligent technology represented by three-dimensional (3D) visualization technology and surgical navigation system may provide preoperative and intraoperative anatomical information more accurately than CT and MRI [1]. Besides, the fusion of 3D model with surgical visual field through surgical navigation system may also compensate for the defects of visual fields and tactile sense to some extent in laparoscopic liver surgery [2]., Video: A 49-year-old male patient with a tumor mainly located at the left inner area of liver and oppressing the middle hepatic vein (MHV). We formulated preoperative planning by using the Medical Image 3D Visualization System (MI3DVS, software copyright No: 2008SR18798) [3]. It was acknowledged that the right hepatic vein (RHV) was strong enough to drain the right anterior hepatic sector. Ultimately, 3D laparoscopic extended left hepatectomy with resection of the MHV was selected as the optimal operation scheme for the patient due to the RHV would avoid hepatic venous congestion in segment V and VIII after resection of the MHV, and more liver parenchyma than left trisegmentectomy would be retained. The operation was performed under assistance of the Laparoscopic Hepatectomy Navigation System (LHNS, software copyright No. 2018SR840555) [4]., Results: The total operation time was 180 min, estimated blood loss of 200 ml. The final histopathological diagnosis showed an 8*6*6-cm-sized hepatocellular carcinoma. And the patient was discharged on postoperative day 6 without any complications., Conclusion: Digital intelligent technology may be helpful to formulate preoperative planning and identify intraoperative important anatomical structures in 3D laparoscopic extended left hepatectomy with resection of the MHV., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Understanding the internal anatomy of the liver remains a major challenge in anatomical liver resection. Although virtual hepatectomy and indocyanine green (ICG) fluorescence imaging techniques have been widely used in hepatobiliary surgery, limitations in their application for real-time navigation persist., Objective: The aim of the present study was to evaluate the feasibility and clinical utility of the novel laparoscopic hepatectomy navigation system (LHNS), which fuses preoperative three-dimensional (3D) models with ICG fluorescence imaging to achieve real-time surgical navigation., Methods: We conducted a retrospective review of clinical outcome for 64 patients who underwent laparoscopic hepatectomy from January 2018 to December 2018, including 30 patients who underwent the procedure using the LHNS (LHNS group) and 34 patients who underwent the procedure without LHNS guidance (Non-LHNS group)., Results: There was no significant difference in preoperative characteristics between the two groups. The LHNS group had a significantly less blood loss (285.0 ± 163.0 mL vs. 391.1 ± 242.0 mL; P = 0.047), less intraoperative blood transfusion rate (13.3% vs. 38.2%; P = 0.045), and shorter postoperative hospital stay (7.8 ± 2.1 days vs. 10.6 ± 3.8 days; P < 0.001) than the Non-LHNS group. There was no statistical difference in operative time and the overall complication rate between the two groups. The liver transection line was clearly delineated by the LHNS in 27 patients; however, the projection of boundary was unclear in 2 cases, and in 1 case, the boundary was not clearly displayed by ICG fluorescence imaging., Conclusions: We developed the LHNS to address limitations of current intraoperative imaging systems. The LHNS is hopefully to become a promising real-time navigation system for laparoscopic hepatectomy.

Background: With the improvement in diagnostic imaging, perioperative care and surgical technique, the indications and complexity of liver resections have developed. However, the surgical indications remain controversial especially for some complex or advanced hepatocellular carcinomas. This study was designed to evaluate the concordance between hepatectomy recommendations proposed by Watson for Oncology, a cognitive technology providing decision support, and those determined by surgeons in our center for patients with hepatocellular carcinoma., Methods: We retrospectively reviewed 243 patients with hepatocellular carcinoma who were recommended for surgical treatment and received hepatectomy between 2008 and 2016 at the Zhujiang Hospital of Southern Medical University. Watson for Oncology classified the treatment options into three categories: recommended, for consideration and not recommended. Treatment recommendations were considered concordant if the hepatectomy recommendations were designated "recommended" or "for consideration" by Watson for Oncology. The factors potentially affecting concordance rate were also analyzed in our study., Results: The hepatectomy recommendations of 174 patients were concordant. There were significant differences in the coincidence rate between concordant group and discordant group considering tumor numbers (P = 0.006), extension of hepatectomy (P = 0.009) and BCLC staging system (P < 0.001). Lower degrees of concordance were observed in patients with multiple tumors, major hepatectomy and portal hypertension by using logistic regression analysis (OR = 0.309, P = 0.004; OR = 0.384, P = 0.004; and OR = 0.376, P = 0.022, respectively)., Conclusion: The concordance between Watson for Oncology and surgeons' hepatectomy recommendation for hepatocellular carcinoma was only 72%. Differences in practice patterns for HCC between the USA (where Watson for Oncology was calibrated) and China may be the major cause of discordance. Watson for Oncology still requires further improvement and localization to be widely applied in China.

Objectives: To develop and validate a radiomics-based nomogram for the preoperative prediction of posthepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC)., Methods: One hundred twelve consecutive HCC patients who underwent hepatectomy were included in the study pool (training cohort: n = 80, validation cohort: n = 32), and another 13 patients were included in a pilot prospective analysis. A total of 713 radiomics features were extracted from portal-phase computed tomography (CT) images. A logistic regression was used to construct a radiomics score (Rad-score). Then a nomogram, including Rad-score and other risk factors, was built with a multivariate logistic regression model. The discrimination, calibration and clinical utility of nomogram were evaluated., Results: The Rad-score could predict PHLF with an AUC of 0.822 (95% CI, 0.726-0.917) in the training cohort and of 0.762 (95% CI, 0.576-0.948) in the validation cohort; however, the approach could not completely outmatch the existing methods (CP [Child-Pugh], MELD [Model of End Stage Liver Disease], ALBI [albumin-bilirubin]). The individual predictive nomogram that included the Rad-score, MELD and performance status (PS) showed better discrimination with an AUC of 0.864 (95% CI, 0.786-0.942), which was higher than the AUCs of the conventional methods (nomogram vs CP, MELD, and ALBI at P < 0.001, P < 0.005, and P < 0.005, respectively). In the validation cohort, the nomogram discrimination was also superior to those of the other three methods (AUC: 0.896; 95% CI, 0.774-1.000). The calibration curves showed good agreement in both cohorts, and the decision curve analysis of the entire cohort revealed that the nomogram was clinically useful. A pilot prospective analysis showed that the radiomics nomogram could predict PHLF with an AUC of 0.833 (95% CI, 0.591-1.000)., Conclusions: A nomogram based on the Rad-score, MELD, and PS can predict PHLF., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Hepatectomy is the optimal method for liver cancer; the virtual liver resection based on three-dimensional visualization technology (3-DVT) could provide better preoperative strategy for surgeon. We aim to introduce right posterior lobe allied with part of V and VIII sectionectomy assisted by 3-DVT as a promising treatment for massive or multiple right hepatic malignancies to retain maximum residual liver volume on the basis of R0 resection., Methods: Among 126 consecutive patients who underwent hepatectomy, 9 (7%) underwent right posterior lobe allied with part of V and VIII sectionectomy. 21 (17%) underwent right hemihepatectomy (RH). The virtual RH was performed with 3-DVT, which provided better observation of spatial position relationship between tumor and vessels, and the more accurate estimation of the remnant liver volume. If remnant liver volume was <40%, right posterior lobe allied with part of V and VIII sectionectomy should be undergone. Then, the precut line ought to be planned on the basis of protecting the portal branch of subsegment 5 and 8. The postoperative outcome of patients was compared before and after propensity score matching., Results: Nine patients meeting the eligibility criteria received right posterior lobe allied with part of V and VIII sectionectomy. The variables, including the overall mean operation time, blood transfusion, operation length, liver function, and postoperative complications, were similar between two groups before and after propensity matching. The postoperative first, third, fifth, and seventh days mean value of aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin (ALB), and total bilirubin had no significant difference compared with preoperative value. One patient in each group had recurrence six months after surgery., Conclusion: Right posterior lobe allied with part of V and VIII sectionectomy based on 3-DVT is safe and feasible surgery way, and can be a very promising method in massive or multiple right hepatic malignancy therapy.

Background: Liver cancer is the second most common cause of cancer death worldwide. The hepatectomy is the most effective and the only potentially curative treatment for patients with resectable neoplasm. Precisely preoperative assessment of remnant liver volume is essential in preventing postoperative liver failure. The aim of our study is to report our experience of using a medical image three dimensional (3D) visualization system (MI-3DVS), which was developed by our team, in assisting hepatectomy for patients with liver cancer., Methods: Between January 2010 and June 2016, 69 patients with liver cancer underwent hepatic resection based on the MI-3DVS were enrolled in this study. All patients underwent CT scan 5 days before the surgery and within 5 days after resection. CT images were reconstructed with the MI-3DVS to assist to perform hepatectomy. Simple linear regression, intra-class correlation coefficient (ICC) and Bland-Altman analysis were used to evaluate the relationship and agreement between actual excisional liver volume (AELV) and predicted excisional liver volume (PELV)., Results: Among 69 patients in this study, 62(89.85%) of them were diagnosed with hepatocellular carcinoma by histopathologic examination, and 41(59.42%) underwent major hepatectomy. The average AELV was 330.13 cm 3 and the average PELV was 287.67 cm 3 . The simple regression equation is AELV = 1.016 × PELV+30.39(r = 0.966; p < 0.0003). PELV (ICC = 0.964) achieved an excellent agreement with AELV with statistical significance (p < 0.001). 65 of 69 dots are in the range of 95% confidence interval in Bland-Altman analyses., Conclusions: The MI-3DVS has advantages of simple usage and convenient hold. It is accurate in assessment of postoperative liver volume and improve safety in liver resection., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Purpose: Bilateral hepatolithiasis tends to show recurrent attacks, which may lead to liver damage and bile duct cancer. This study aimed to assess long-term outcome of hepatectomy for bilateral hepatolithiasis based on three-dimensional reconstruction., Method: A total of 258 bilateral hepatolithiasis patients were enrolled in this retrospective study from January 2008 to October 2014. There are 74 individuals in Three-Divisional Visualization System (MI-3DVS) group (group A) and 74 individuals in non-MI-3DVS group (group B) after propensity score matching (PSM), respectively. Then, complication incidence, stone clearance, recurrence, and recurrence-free survival rates were compared between the two groups. Multivariate Cox analysis was used to test impact of MI-3DVS on recurrence-free survival (RFS)., Results: The Median (Range) volumes of intraoperative blood loss were 300 (30-1050) and 400 (50-1800) mL in group A and B, respectively (P = .037). Meanwhile, immediate clearance (77% versus 53%, P = .002) and final clearance (95% versus 80%, P = .007) rates were higher in group A compared with values obtained for group B. Multivariate Cox analysis showed non-MI-3DVS (HR = 2.00, 95% confidence interval [CI] = 1.02-3.95, P = .045) and patients with bilateral cirrhosis (Hazard Ratio [HR] = 10.60, 95% CI = 4.45-25.25, P < .001) were independent predictors of RFS., Conclusion: Compared with conventional radiological technology, MI-3DVS-based hepatectomy resulted in higher stone clearance rate of bilateral hepatolithiasis patients. Non-MI-3DVS and patients with bilateral cirrhosis were independent predictors for recurrence-free survival.

Background: Laparoscopic left hemihepatectomy (LLH) has been shown to be an effective and safe method for treating hepatolithiasis primarily affecting the left hemiliver. However, this procedure still presents challenges. Due to pathological changes in intrahepatic duct stones, safely dissecting the hilar vessels and determining precise resection boundaries remains difficult, even with fluorescent imaging. Our team proposed a new method of augmented reality navigation (ARN) combined with Indocyanine green (ICG) fluorescence imaging for LLH in hepatolithiasis cases. This study aimed to investigate the feasibility of this combined approach in the procedure. Methods: Between May 2021 and September 2023, 16 patients with hepatolithiasis who underwent LLH were included. All patients underwent preoperative 3D evaluation and were then guided using ARN and ICG fluorescence imaging during the procedure. Perioperative and short-term postoperative outcomes were assessed to evaluate the safety and efficacy of the method. Results: All 16 patients successfully underwent LLH. The mean operation time was 380.31 ± 92.17 min, with a mean estimated blood loss of 116.25 ± 64.49 ml. ARN successfully aided in guiding hilar vessel dissection in all patients. ICG fluorescence imaging successfully identified liver resection boundaries in 11 patients (68.8%). In the remaining 5 patients (31.3%) where fluorescence imaging failed, virtual liver segment projection (VLSP) successfully identified their resection boundaries. No major complications occurred in any patients. Immediate stone residual rate, stone recurrence rate, and stone extraction rate through the T-tube sinus tract were 12.5%, 6.3%, and 6.3%, respectively. Conclusion: The combination of ARN and ICG fluorescence imaging enhances the safety and precision of LLH for hepatolithiasis. Moreover, ARN may serve as a safe and effective tool for identifying precise resection boundaries in cases where ICG fluorescence imaging fails. [ABSTRACT FROM AUTHOR]

Background: Precision surgery for liver tumors favors laparoscopic anatomical liver resection (LALR), involving the removal of specific liver segments or subsegments. Indocyanine green (ICG)-negative staining is a commonly used method for defining resection boundaries but may be prone to failure. The challenge arises when ICG staining fails, as it cannot be repeated during surgery. In this study, we employed the virtual liver segment projection (VLSP) technology as a salvage approach for precise boundary determination. Our aim was to assess the feasibility of the VLSP to be used for the determination of the boundaries of the liver resection in this situation. Methods: Between January 2021 and June 2023, 12 consecutive patients undergoing subsegment-oriented LALR were included in this pilot series. The VLSP technology was utilized to define the resection boundaries at the time of ICG-negative staining failure. Routine surgical parameters and short-term outcomes were evaluated to assess the safety of VLSP in this procedure. In addition, its feasibility was assessed by analyzing the accuracy between the predicted resected liver volume (PRLV) and actual resected liver volume (ARLV). Results: Of the 12 enrolled patients, the mean operation time was 444.58 ± 101.70 min (range 290–570 min), with a mean blood loss of 125.00 ± 96.53 ml (range 50–400 mL). One patient (8.3%) was converted to laparotomy for subsequent parenchymal transection, four (33.3%) received blood transfusions and four (33.3%) had postoperative complications. All patients received an R0 resection. The Pearson correlation coefficient (r) between PRLV and ARLV was 0.98 (R2 = 0.96, p < 0.05), and the relative error (RE) was 8.62 ± 6.66% in the 12 patients, indicating agreement. Conclusion: Failure of intraoperative ICG-negative staining during subsegment-oriented LALR is possible, and VLSP may be an alternative to define the resection boundaries in such cases. [ABSTRACT FROM AUTHOR]

Background: Accurate determination of intrahepatic anatomy remains challenging for laparoscopic anatomical hepatectomy (LAH). Laparoscopic augmented reality navigation (LARN) is expected to facilitate LAH of primary liver cancer (PLC) by identifying the exact location of tumors and vessels. The study was to evaluate the safety and effectiveness of our independently developed LARN system in LAH of PLC. Methods: From May 2018 to July 2020, the study included 85 PLC patients who underwent three-dimensional (3D) LAH. According to whether LARN was performed during the operation, the patients were divided into the intraoperative navigation (IN) group and the non-intraoperative navigation (NIN) group. We compared the preoperative data, perioperative results and postoperative complications between the two groups, and introduced our preliminary experience of this novel technology in LAH. Results: There were 44 and 41 PLC patients in the IN group and the NIN group, respectively. No significant differences were found in preoperative characteristics and any of the resection-related complications between the two groups (All P > 0.05). Compared with the NIN group, the IN group had significantly less operative bleeding (P = 0.002), lower delta Hb% (P = 0.039), lower blood transfusion rate (P < 0.001), and reduced postoperative hospital stay (P = 0.003). For the IN group, the successful fusion of simulated surgical planning and operative scene helped to determine the extent of resection. Conclusions: The LARN contributed to the identification of important anatomical structures during LAH of PLC. It reduced vascular injury and accelerated postoperative recovery, showing a potential application prospects in liver surgery. [ABSTRACT FROM AUTHOR]

Purpose: To establish a valid prediction model to prognose the occurrence of microvascular invasion (MVI), and to compare the efficacy of anatomic resection (AR) or non-anatomic resection (NAR) for hepatocellular carcinoma (HCC). Methods: Two hundred twenty-eight patients with HCC who underwent surgical treatment were enrolled. Their hematological indicators, MRI imaging features, and outcome data were acquired. Result: In the multivariable analysis, alpha-fetoprotein >15 ng/mL, neutrophil to lymphocyte ratio >3.8, corona enhancement, and peritumoral hypointensity on hepatobiliary phase were associated with MVI. According on these factors, the AUROC of the predictive model in the primary and validation cohorts was 0.884 (95% CI: 0.829, 0.938) and 0.899 (95% CI: 0.821, 0.967), respectively. Patients with high risk of MVI or those with low risk of MVI but tumor size >5 cm in the AR group were associated with a lower rate of recurrence and death than patients in the NAR group; however, when patients are in the state of low-risk MVI with tumor size >5 cm, there is no difference in the rate of recurrence and death between AR and NAR. Conclusion: Our predictive model for HCC with MVI is convenient and accurate. Patients with high-risk of MVI or low-risk of MVI but tumor size >5 cm executing AR is of great necessity. [ABSTRACT FROM AUTHOR]

BACKGROUND: Laparoscopic hepatectomy for centrally located hepatocellular carcinoma is challenging to perform. Augmented reality navigation (ARN) and fluorescence imaging are currently safe and reproducible techniques for hepatectomy, but the efficacy results for centrally located hepatocellular carcinoma have not been reported. This study aimed to evaluate the efficacy of an ARN system combined with fluorescence imaging (ARN-FI) in laparoscopic hepatectomy for centrally located hepatocellular carcinoma. STUDY DESIGN: This was a post hoc analysis of an original nonrandomized clinical trial that was designed to evaluate the feasibility and efficacy of ARN-FI for laparoscopic liver resection. A total of 76 patients were consecutively enrolled from June 2018 to June 2021, of which 42 underwent laparoscopic hepatectomy using ARN-FI (ARN-FI group), and the other 34 who did not use ARN-FI guidance (non–ARN-FI group). Perioperative outcomes and disease-free survival were compared between the 2 groups. RESULTS: Compared with the non–ARN-FI group, the ARN-FI group had less intraoperative blood loss (median 275 vs 300 mL, p = 0.013), lower intraoperative transfusion rate (14.3% vs 64.7%, p < 0.01), shorter postoperative hospital stay (median 8 vs 9 days, p = 0.005), and lower postoperative complication rate (35.7% vs 61.8%, p = 0.024). There was no death in the perioperative period and follow-up period. There was no significant difference in overall disease-free survival between the 2 groups (p = 0.16). CONCLUSIONs: The ARN system and fluorescence imaging may be of value in improving the success rate of surgery, reducing postoperative complications, accelerating postoperative recovery, and shortening postoperative hospital stay. This study found that augmented reality navigation and fluorescence imaging showed favorable results in the perioperative period. In addition, although no significant differences in disease-free survival (DFS) were found between the 2 groups overall, the cohort with both techniques showed higher DFS in subgroup analysis of type IV centrally located hepatocellular carcinoma. [ABSTRACT FROM AUTHOR]

BACKGROUND: The augmented reality-assisted navigation system (AR-ANS) has been initially applied to the management of hepatolithiasis. The current study examines the safety and efficacy of the AR-ANS for hepatectomy in the treatment of hepatolithiasis. It is the first study to assess the preoperative and long-term outcomes of hepatectomy guided by the AR-ANS for hepatolithiasis. STUDY DESIGN: From January 2018 to December 2021, 77 patients with hepatolithiasis who underwent hepatectomy at Zhujiang Hospital of Southern Medical University were included. The subjects were divided into the AR group (n = 31) and the non-AR group (n = 46) according to whether the surgery was guided by the AR-ANS. Clinical baseline features, operation time, intraoperative blood loss, immediate postoperative residual stone rate, postoperative stone recurrence rate at 6 months, and postoperative complications were analyzed. RESULTS: There was no significant difference between preoperative baseline data from the 2 groups (p > 0.05). The AR group had a longer surgical time than the non-AR group (p < 0.001). The intraoperative blood loss in the AR group was lower than in the non-AR group (p < 0.001). Alanine transaminase, aminotransferase, immediate residual stone rate, and stone recurrence rate in the AR group were lower than in the non-AR group (p < 0.05). There was no significant difference in postoperative complications between the 2 groups. CONCLUSIONS: The application of the AR-ANS in hepatectomy for hepatolithiasis has not only achieved satisfactory therapeutic efficacy, but has also shown significant advantages in reducing intraoperative blood loss, immediate stone residual rate, and stone recurrence rate, which has clinical promotion value. [ABSTRACT FROM AUTHOR]