Application of liver three-dimensional printing in hepatectomy for complex massive hepatocarcinoma with rare variations of portal vein: preliminary experience

Abstract

Background: To discuss the role of Liver 3D printing in the treatment of complex massive hepatocarcinoma with rare variations of portal vein.

Methods: Data of enhanced computed tomography (CT) were imported into the medical image three-dimensional visualization system (MI-3DVS) to create Standard Template Library (STL) files, which were read by 3D printer to construct life-size 3D physical liver model. The preoperative surgical planning was performed on the 3D model according to individualized segmentation, volume calculation, and virtual operation.

Results: The 3D printing liver model was consistent with the model in MI-3DVS. The segment 4 portal vein (S4PV) was absent and variant S4PV originated from right anterior portal vein (RAPV). The preoperative surgical planning was designed according to the relationship between tumor and portal vein variation. Theoretically, the residual liver volume was 40.76%, if the right hemihepatctomy was carried out after the trunk of right portal vein (RPV) ligated. However, the actual residual volume was only 21.37% due to the variant S4PV originates from RAPV, thus, right trisegmentectomy would have to be performed. Interestingly, after optimization, the residual liver volume increased to 57.25% as narrow-margin right hemihepatectomy with the variant S4PV reserved were performed. The final resection was determined to be narrow-margin right hemihepatectomy. The actual surgical procedure was consistent with the preoperative surgical planning.

Conclusion: Liver 3D printing may be a safe and effective technique to improve the success rate of surgery and reduce the operation risk for patients with complex massive hepatocarcinoma with variations of portal vein.

Keywords: Three-dimensional printing; hepatocarcinoma; three-dimensional reconstruction.

Figure 1

Preoperative surgical planning aided by the 3D visualization and 3D printing model. The 3D visualization model of celiac artery (A) a. gastroduodenal artery (GDA); b. replaced right hepatic artery (ReRHA); c. superior mesenteric artery (SMA); d. celiac trunk (CT); e. replaced left hepatic artery (ReLHA); f. left gastric artery (LGA). The 3D visualization model of portal vein (B) a. portal vein (PV); b. right portal vein (RPV); c. left portal vein (LPV); D. right anterior portal vein (RAPV); e. right posterior portal vein (RPPV); f. portal vein in the segment IV (S4PV). Individual hepatic segmentation (C) a. The carcinoma; b. segment V; (C) Segment VIII; d. S4PV; e. Segment IV; f. Segment II; g. Segment III. The 3D printed mode of liver (D). The carcinoma is in brown. The artery is in red. The portal vein is in light blue. The hepatic vein is in deep blue. The shortest distances from the carcinoma to the targeted blood vessels (E) a. PV; b. RPV; c. S4PV; d. portal vein in the segment VIII (S8PV). The virtual right semihepatectomy (F) a. The plane of resected live; b. RPV; c. S4PV; d. The resected liver (in red); e. The liver residuals (in green). The virtual right trihepatectomy (G) a. The plane of virtually resected liver; b. S4PV; c. The resected liver (in red); d. The live residuals (in green). The narrow margin right hemihepatectomy (H) a. The plane of virtually resected liver; b. S4PV; c. The resected liver (in red); d. The live residuals (in green).

Figure 2

The real surgical results and the postoperative results in the 3D printed physical liver model. Ascertaining the ischemic boundary in the liver (A) a. The segment IV; b. The marker for right semihepatectomy; c. The marker for right trisegmentectomy. Resecting the hepatocarcinoma 1.5 cm to its boundaries (B) a. The carcinoma; b. The branches of portal vein in the carcinoma. Ligating and mutilating the posterior right branch of right hepatic artery and the posterior right branch of portal vein and meanwhile blocking the right hepatic artery and the posterior right branch of portal vein under the guidance of the 3D printed physical liver model (C) a. RPV; b. RAPV; c. The residual of RPPV; d. S4PV; e. S8PV; f. ReRHA; g. The residual of ReRHA; The postoperative 3D visualization model of portal vein (D) a. PV; b. RPV; c. LPV d. S4PV; e. S8PV; f. S5PV.