Method Article
The utilization of 3D reconstruction and virtual simulations in preoperative planning for liver resections represents a significant advancement in surgical oncology. Our team's 3D-LAST (three-dimensional location approach with the silk thread) technique enables safe, efficient, precise tumor removal with practical intraoperative navigation, promising broad medical adoption.
When performing hepatectomy to treat liver tumors, accurately determining the resection margin and ensuring the adequacy of residual liver parenchyma are of utmost importance. At present, intraoperative ultrasound and indocyanine green fluorescence navigation are frequently utilized methods. However, certain technical constraints prevent their extensive application. We have developed the 3D-LAST technique for precise liver tumor resection. This technique makes use of computer post-processing to extract features from computed tomography (CT) scans and generate volumetric images, creating three-dimensional (3D) visualizations. This provides a valuable resource for clinical decision-making, as it can vividly display complex internal anatomical structures in an intuitive and stereoscopic manner. In this study, preoperative 3D positioning was carried out on patients with a single liver tumor to identify anatomical landmarks and calculate the resection range. During the surgical procedure, margin lines of lengths calculated by preoperative 3D software were set up, and silk thread was used to mark the edges. This approach offers a time-saving and accurate way to determine the optimal cutting plane. The objective of this article is to demonstrate the viability of applying 3D-LAST in laparoscopic segmentectomy for liver tumors. The results of the research indicate that 3D-LAST is a safe, effective, and practical new method for intraoperative liver navigation, and it has great potential for widescale promotion.
Hepatectomy remains a cornerstone treatment for liver tumors. Over recent decades, surgical approaches have evolved from irregular resections to precise anatomical resections, driven by advancements in assistive technologies such as intraoperative ultrasound (IOUS) and indocyanine green (ICG) fluorescence imaging1,2. Despite these innovations, achieving optimal resection margins while preserving sufficient functional liver volume remains a critical challenge. The overall goal of our proposed 3D-LAST (three-dimensional location approach with silk thread) technique is to provide a precise, cost-effective, and universally accessible intraoperative navigation method for liver tumor resection, minimizing reliance on specialized equipment while improving spatial accuracy.
The rationale for developing 3D-LAST stems from the limitations of current techniques. IOUS, while valuable for real-time tumor localization, requires skilled sonographers for image interpretation and struggles with two-dimensional (2D) spatial visualization, often prolonging operative time3,4. ICG fluorescence navigation, though effective for superficial tumors, is constrained by its limited tissue penetration depth (5-10 mm), rendering it unreliable for deeper lesions5,6. Both methods depend on costly, specialized hardware, limiting their adoption in resource-constrained settings.
The advantages of 3D-LAST over existing techniques are multifaceted. Three-dimensional visualization, derived from preoperative computed tomography (CT) reconstructions, overcomes the spatial ambiguity of 2D imaging by providing stereoscopic anatomical guidance. Unlike ICG, which lacks depth resolution, 3D-LAST enables precise volumetric resection planning, reducing the risk of positive margins or excessive parenchymal loss. Furthermore, the use of silk thread for intraoperative marking eliminates the need for real-time imaging devices, streamlining workflow and reducing costs.
3D-LAST is particularly suited for centers lacking advanced imaging infrastructure or expertise in complex intraoperative navigation. It is ideal for single-tumor resections where anatomical landmarks are identifiable on preoperative CT and where minimizing procedural complexity is prioritized. By addressing the limitations of current methods and leveraging validated 3D technologies, 3D-LAST represents a pragmatic advancement in achieving precision liver surgery with broad clinical adaptability.
Case Presentation:
A 59-year-old man with upper abdominal discomfort was diagnosed with a 2.7 cm x 1.6 cm liver tumor in the right liver. The patient was previously diagnosed with gastric adenocarcinoma and underwent radical gastrectomy for gastric cancer, followed by routine chemotherapy. No extrahepatic metastasis was found on the preoperative contrast-enhanced CT scan. CA19-9, CA15-3, CA72-4, AFP, and CEA were normal.
The study was approved by the review committee of West China Hospital of Sichuan University. Informed consent was obtained from the patient before the surgery.
1. Preoperative preparation
2. Operative procedure
3. Post-hepatectomy management
The total operation time was 150 min, with 50 mL of blood loss that did not require a blood transfusion. Intraoperative urine volume was 500 mL, and intraoperative infusion volume was 800 mL. On the 1st day after surgery, the blood test results showed a mild increase in transaminase levels. CT scan of the abdomen showed complete resection of the liver tumor and no significant ascites 3 days after surgery. The drain was removed on postoperative day 4. The patient had an uneventful postoperative course and was discharged on the 5th day after the operation. Postoperative gross pathological specimen demonstrated that the tumor size was 1.5 cm x 1.5 cm, confirming R0 resection as shown in Table 1.
Figure 1: CT showing the mass and 3D reconstruction of the liver and mass. (A) The CT scan showing the tumor located in the right liver (black arrow indicating mass). (B) 3D reconstruction of liver, vessel, and mass (black arrow indicating mass). Please click here to view a larger version of this figure.
Figure 2: Mark the resection line on the 3D model. (A-D) Reconstruct the intrahepatic duct structure and tumor in 3D, and mark the key points (S1, S2, S3, S4) of the cutting edge with a small stick. Draw liver lines along the key points on the surface of the virtual liver model and measure the length of each line (S1-S2 = 9.8 cm, S1-S3 = 7.2 cm, S2-S3 = 10.4 cm, S4-S2 = 8.2 cm, S4-S3 = 6.5 cm). Please click here to view a larger version of this figure.
Figure 3: Intraoperative layout of the surgeon, patient, and trocar placement. (A) The operating surgeon is on the right, the assistant on the left, and the camera man between the legs. (B) The laparoscopic hepatectomy procedure is performed using a five-port technique. Please click here to view a larger version of this figure.
Figure 4: Silk thread marking the resection line. (A-D) During liver surgery, use silk thread to mark the cutting edge, prepare silk threads of the same length, and place them at the anatomical position on the surface of the liver. The shape enclosed by the silk thread is the cutting line for the liver. Please click here to view a larger version of this figure.
Figure 5: Liver resection and specimen. (A) Sew a rubber band on the liver for traction. (B) Expose the middle hepatic vein in the liver resection plane (black arrow indicating the middle hepatic vein). (C-D) Complete resection of the liver mass (black arrow), the cross-sectional view showing the tumor margin is intact and matching the preoperatively planned margin. Please click here to view a larger version of this figure.
Figure 6: Postoperative CT scan. The CT scan indicated successful tumor removal without perihepatic fluid accumulation on postoperative day 3. Please click here to view a larger version of this figure.
Parameters | Results |
Duration of surgery | 150 min |
Blood loss | 50 mL |
Postoperative liver function | ALT 222 IU/L, AST 217 IU/L |
Postoperative CT re examination | POD 3 |
Rmovement of drainage tube | POD 4 |
Day of discharge | POD 5 |
Tumor size | 1.5 cm x 1.5 cm |
Pathological type | Adenocarcinoma |
Table 1: The patient's surgical outcomes. Abbreviations: ALT = Alanine Aminotransferase; AST = Aspartate Aminotransferase; POD = Postoperative Day.
With the development of technology and the accumulation of experience, laparoscopic liver resection has become more and more common, and its indications are almost as extensive as those of open surgery. Compared with laparotomy, laparoscopic liver resection has many advantages, such as less pain, fewer perioperative complications, and faster recovery7,8,9. However, laparoscopic liver resection also faces some inherent difficulties. The lack of tactile and depth perception, limited operating space, and restricted visual field pose challenges to its widespread use10,11,12. To address these issues, IOUS and ICG fluorescence imaging have been used as real-time navigation tools in recent years. IOUS, when applied directly on the liver surface, can improve the accuracy of lesion detection and localization13,14.
However, since it is usually operated by sonographers, surgeons often need to pause the operation to wait for them, which not only prolongs the operation time but also increases the dependence on ultrasound technology. In addition, in cirrhotic livers, IOUS may misinterpret regenerative nodules as tumors, leading to over-diagnosis15,16,17. ICG, a harmless water-soluble near-infrared fluorescent agent, can help visualize anatomical structures during the operation through special scopes. Its high sensitivity and clear contrast make it a popular tool for surgical navigation in various liver surgeries. However, due to the limited tissue penetration of near-infrared light (up to 10 mm), its application in detecting deep-seated liver lesions is restricted. Moreover, an excessive dose of ICG may cause false-positive results, and the success of tumor staining is related to factors such as blood supply, liver cirrhosis, and necrosis18,19,20. Therefore, developing an innovative, efficient, and accurate method for localizing deep-seated liver tumors is of great clinical significance.
In this study, preoperative 3D positioning was used to identify anatomical landmarks and calculate the resection area for patients with solitary liver tumors. During the operation, margin lines of lengths calculated by preoperative 3D software were arranged, and silk thread was used to mark the edges. This method provides a time-efficient and accurate way to navigate the optimal cutting plane21. The operation time in our study was significantly shorter than that reported in studies using IOUS and ICG-guided hepatectomy. This approach reduces the reliance on IOUS, saving surgical time and lowering technical and conditional requirements. It can be applied to various liver tumor navigation situations, regardless of the size and depth of the tumor.
Despite its advantages, this approach has limitations. First, its accuracy depends on preoperative imaging quality; motion artifacts or low-resolution scans may compromise 3D model fidelity. Second, the technique assumes static liver anatomy, whereas respiratory movements or surgical manipulation can shift tumor positions, necessitating real-time adjustments. Third, the learning curve for 3D software operation and intraoperative spatial translation may limit adoption in surgery without specialized training. In addition, the sample size of this study is relatively small, and future large-scale prospective studies are needed to verify the effectiveness of this method further. Developing a simple and widely applicable 3D reconstruction program is also an important goal for future research.
The authors report no conflict of interest.
This work was supported by the Guizhou Provincial Health Commission Science and Technology Fund Project(gzwkj2025-300), the Project of Guizhou Provincial Department of Science and Technology (Qian Ke He Cheng Guo, LC[2024]109 ).
Name | Company | Catalog Number | Comments |
BiClamp LAP | ERBE Company | No.20195-132 | |
Laparoscopic system | Olympus | VISERA OTV-S400 | |
Ultrasonic knife | Johnson and Johnson MedTech | ETHICON HARMONIC |
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