LC is the most common cause of iatrogenic bile duct injury [10]. Some patients are identified and repaired intraoperatively, but most cases are discovered postoperatively when the damage is more severe [11, 12]. The timing of postoperative repair surgery for LC-related bile duct injury is a subject of ongoing debate [13]. Many experts consider 4–6 weeks post-LC as a critical cut-off point, dividing it into early and late (or deferred) repair [14]. By this time, infection-induced edema typically subsides, reducing the risk of infection and improving the outcomes of the repair surgery. Some studies have indicated [15] that there is no significant difference between the timing of repair surgery and the occurrence of postoperative complications. However, we believe that delaying biliary tract repair time may cause prolonged pain for patients and long-term psychological pressure for the surgeon. Accurate evaluation and early repair surgery should be the ideal strategy for the repair of LC-related biliary tract injury. Our results demonstrated that early repair of biliary tract injury in LC with the assistance of 3D visualization technology highlights certain advantages.
A total of 15 patients were diagnosed with postoperative iatrogenic bile duct injury. Despite the initial clinical physicians understanding of bile duct injury degree, referral, and repair preparation factors leading to variability in the timing of early repair surgery, the 15 cases of patients with LC implement biliary surgery to repair a distance interval in 5–28 (14.2 ± 9.7) days. All patients underwent early repair surgery after LC. We believe that the timing of LC postoperative biliary injury repair should consider the classification of bile duct injury, including clinical characteristics such as jaundice, bile leakage, and combined jaundice-type with bile leakage. This helps specialists determine the appropriate timing for the repair operation. Among the 15 patients with primary gallbladder diseases, acute cholecystitis accounted for 53.33% (8/15), and the proportion of patients with bile leakage was 66.66% (10/15). With the assistance of 3D visualization technology, we accurately evaluated the classification of bile duct injury before operation and combined the results of 3D reconstruction during operation to improve the efficiency of bile duct injury opening exploration. All 15 bile duct injury repairs were successful, demonstrating the practical application value of early surgery with 3D visualization assistance.
The value of plain CT in the diagnosis of bile duct injury is limited. The cholangiogram characteristics of enhanced CT in different periods, providing raw images for 3D visualization technology, could help radiologists to initially determine the approximate location and adjacent vessels of biliary tract injury [16, 17]. However, enhanced CT is a two-dimensional image, and only when combined with sufficient knowledge of liver anatomy and surgical experience in dealing with biliary tract injury, biliary surgeons can image the shape of bile duct tree in the brain to complete the repair of biliary tract injury. MRCP can fully display the bile duct tree and has significant diagnostic value for bile duct defects [4, 18]. The injury caused by hemlock clamping the hepatic duct only shows false lines on MRCP while the bile duct is of good continuity (as shown in Fig. 1), which is easy to cause misdiagnosis.The 3D visualization technology can intuitively, stereoscopically, and comprehensively evaluate the confluence mode and spatial conformation of hepatic hilar vessels. It can quantitatively evaluate the position of bile duct stenosis, the depth of the hepatic hilar, the rotation angle of hepatic hilar, and the volume of liver segments to determine whether there is liver atrophy. Furthermore, the team of surgeons can use 3D visualization technology to better communicate the understanding of hepatobiliary anatomy, without being limited to the abstract impression of two-dimensional images. In the preoperative evaluation of early repair of biliary tract injury during LC in this group of 15 cases, compared with abdominal enhanced CT and MRCP, 3D visualization technology proved more intuitive and comprehensive in the evaluation of iatrogenic biliary tract injury. For middle and low bile duct injury caused by transection or stenosis of the common bile duct, 3D visualization technology indicated the location and length of the bile duct injury and its relationship with the main vessels in the hepatic hilar area.For minor bile duct injury, such as bile leakage caused by minor injury of the aberrant bile duct in the gallbladder bed, because the bile duct above the injury site is in a non-dilated state, 3D visualization technology based on CT cannot directly determine the classification of bile duct injury, while ERCP [19] or PTC [5, 20] has more advantages.
In evaluating high-level bile duct injury, the advantages of 3D visualization technology lie in simulating the exposure of the bile duct opening and evaluating the need for perihilar resection. During the bile duct 3D visualization model set-up process, the distribution of biloma after laparoscopic cholecystectomy and the severity of the biliary injury may have a certain correlation. Biloma is considered to be caused by abdominal cavity fluid accumulation formed in the process of bile leakage [21]. This study showed that the distribution characteristics of biloma in the hilar region were partially correlated with the Strasberg-Bismuth classification of bile duct injury. The higher the biliary injury, the wider the distribution of biloma, which may extend through the lumen of the lesser omentum. We speculate that the reason may be that the higher the position of biliary tract injury at the level of hepatic hilar, the greater the destruction scope of minor omental cavity, which is not conducive to the aggregation of biliary effusion. A multicenter retrospective study also reported [22] a statistically significant correlation between the presence of biloma after laparoscopic cholecystectomy and the severity of bile duct injury (P = 0.02). The correlation of complicated bile duct injuries is eventually a clear diagnosis of Strasberg-Bismuth E3–E4 biliary injury risk increased 41.7 times. The existence of biloma affects the intuitive judgment of bile duct injury by abdominal CT or MRCP. By applying the 3D visualization technology to remove the biloma imaging part, we can finally visually display the 3D biliary tract imaging. However, we argue that the correlation between the distribution of hilar biloma and the degree of bile duct injury needs more refinement and verification of 3D visualization models due to the differences in the effect of abdominal tube drainage during LC.
We reported the experience of diagnosis and treatment of 30 cases of bile duct injury during LC. These cases were retrospectively analyzed with a focus on high-level damage. Among the patients, 15 cases were classified as Strasberg-Bismuth E2 or above of 9 cases of bile duct injury, accounting for 60%. The key to the successful repair of high-level bile duct injury is the exposure of the damaged bile duct opening. This often requires descending or perihilar resection to repair the normal bile duct opening and then complete Roux-en-Y hepaticojejunostomy [23, 24]. In clinical practice, 3D visualization technology has been well applied in the perihilar resection of hilar cholangiocarcinoma [25, 26]. It is used to evaluate key anatomical landmarks such as point B and point P and to measure the anatomical depth of the hepatic hilum. In early repair surgery for high-level bile duct injury, abdominal infection is relatively aggravated, and tissue edema is significant. This increases the risk of bleeding in the hilar plate and perihilar resection, resulting in the difficulty of identifying the bile duct opening. However, the preoperative application of 3D visualization technology allows for 3D reconstruction of the primary injury of bile duct opening amount, measurement of the depth of the damaged bile duct openings at liver gate, eventually forming simulation operation scheme. Based on 3D visualization protocol, the surgeon decreased the hilar plate or perihilar resection to expose the damaged bile duct opening. In addition, when the location or number of injured bile duct openings was uncertain, the surgeon could make accurate judgment by comprehensively using 3D visualization reconstruction results, intraoperative biliary stent guidance or intraoperative cholangiography (Fig. 3D-I) to prevent the omission of tiny bile duct openings and the occurrence of bile leakage after repair surgery.
The study also has limitations. Because bile duct injury during LC is an accidental and urgent complication, sometimes the progressive aggravation of the condition does not allow a long waiting time to complete the 3D visualization reconstruction, resulting in a small number of cases that meet the research requirements. However, the application of 3D visualization technology in the early surgical repair of bile duct injury during LC has indeed achieved exploratory results. In addition, the deep mining of the application value of 3D visualization technology must rely on the joint participation of surgeons and radiologists with rich knowledge. Unfortunately, the diagnostic value of 3D visualization is limited for such minor biliary tract injuries as Strasberg-Bismuth classification A and D.
In conclusion, 3D visualization technology is safe and feasible for assisting in the early repair of bile duct injury during LC. The auxiliary effect of 3D visualization technology is primarily highlighted in the two aspects of preoperative evaluation and intraoperative navigation of bile duct injury, offering significant application and promotion value. Recent reports suggested [27] that the LC application of intraoperative indocyanine green biliary imaging can prevent biliary injury and a secondary biliary injury repair surgery [28]. The combination of multiple image techniques and 3D visualization technology may further enhance the prospects for bile duct injury repair surgery.
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