Application of computer-assisted surgery system in a child with multiple traumas: a case report

Abstract

Background: Severe traumatic liver rupture in children has a high mortality rate. The computer-assisted surgery (CAS) system is an effective medical image simulation tool, which can display the adjacent relationship between the liver and surrounding tissues (especially compressed blood vessels) in a three-dimensional (3D), dynamic and complete way, and assist in precise liver resection. It provides important guidance for preoperative planning and intraoperative navigation. This chapter reports the individualized computer-assisted surgical planning and progress of a case of complex pediatric abdominal trauma.

Case description: A 3-year-old girl was admitted to the hospital due to a severe abdominal crush injury caused by a car accident. Contrast-enhanced computed tomography (CT) showed grade V liver injuries [2018 American Association for the Surgery of Trauma-Organ Injury Scale (2018 AAST-OIS)], as well as splenic and renal contusion. Emergency CAS was performed to repair liver contusion. Biliary fluid was drained from the chest cavity after the operation, and contrast-enhanced CT showed diaphragmatic rupture and intrahepatic pseudoaneurysm. The ruptured diaphragm was repaired by laparotomy with the assistance of a Hisense CAS system, and the intrahepatic pseudoaneurysm was treated by interventional therapy. The child responded well to the comprehensive treatment, and no complications such as bile leakage and infection were found after the operation. Regular imaging and laboratory tests confirmed that the child recovered stably, and the child displayed satisfactory physical development and growth during the follow-up period.

Conclusions: The CAS system can predict surgical risk, and has important clinical value for in the treatment of children with multiple traumas.

Keywords: Abdominal trauma; case report; computer-assisted; pediatric; precise surgery.

Figure 1

Contrast-enhanced CT images of the abdomen of the child showed grade V liver injuries according to the revised 2018 AAST-OIS. ①②③④ are the positions indicated by red, green, yellow, and blue arrows, respectively. (A) Preoperative arterial phase images with axial enhanced CT of the abdomen showed more than 75% destruction of the right lobe and medial segment of left lobe (①), subcapsular hematoma at the posterior margin of the spleen (②) and a large fluid density shadow in the abdominal cavity (③) were also noted. (B,C) Preoperative venous phase images with axial enhanced CT of the abdomen showed contusion and laceration of parenchyma at the external margin of left kidney (④). (D) Preoperative delayed phase images. (E) Axial contrast-enhanced CT of the abdomen. (F) Coronal contrast-enhanced CT of the abdomen. (G) Sagittal contrast-enhanced CT of the abdomen. AAST-OIS, American Association for the Surgery of Trauma-Organ Injury Scale; CT, computed tomography.

Figure 2

Following the 3D reconstruction using Hisense CAS, the location and extent of liver contusion were precisely visualized through its semi-transparent functionality. (A) Hisense CAS frontal image of liver contusion and surrounding organs. (B) Hisense CAS frontal image of liver contusion and surrounding organs after semi-transparent liver. (C) Hisense CAS back image of liver contusion and surrounding organs. (D) Hisense CAS back image of liver contusion and surrounding organs after semi-transparent liver. (E,F) Computer-assisted liver rupture resection. (G,H) Intraoperative pictures showing hepatic contusion (grey arrow). (I) The appearance of liver after hepatic contusion was repaired during operation. (J) The remaining liver was fixed to the deltoid ligament. 3D, three-dimensional; CAS, computer-assisted surgery.

Video 1

Hisense CAS and axial CT image video showed multiple trauma. CAS, computer-assisted surgery; CT, computed tomography.

Figure 3

Abdominal contrast-enhanced CT images of the child. ①②③④⑤⑥ are the positions of red, yellow, pink, green, blue, and orange arrows, respectively. (A) A pulmonary window image of chest CT showing a pleural effusion on the right (①) with compression atelectasis (②) with a wrapped pneumothorax on the right (③) and inflammation or bleeding on the left (④). (B) A mediastinal window image of chest CT. (C) A liver hemangioma image showing hepatic artery portal vein fistula with pseudoaneurysm formation (⑤). (D) The axial plane image of the right diaphragm rupture (⑥). (E) The coronal plane image of the right diaphragm rupture (⑥). (F) The sagittal plane image of the right diaphragm rupture (⑥). (G) Front view of the upper and lower abdomen. (H) Back view of the upper and lower abdomen. (I) Front view of atelectasis. (J) Back view of atelectasis. (K) Front view of a diaphragm rupture. (L) Back view of a diaphragm rupture. (M) Front view of the liver pseudoaneurysm (white arrow). (N) Blood vessel course of the pseudoaneurysm. CT, computed tomography.

Video 2

Hisense CAS and axial CT image video showed the location of diaphragmatic rupture and intrahepatic pseudoaneurysm. CAS, computer-assisted surgery; CT, computed tomography.

Figure 4

Imaging data of the child undergoing interventional therapy. (A,B) Intrahepatic pseudoaneurysm (blue arrow). (C) The pseudoaneurysm was successfully treated by interventional embolization (blue arrow). (D) Postoperative ultrasound showed that the hepatic artery and portal vein were unobstructed.