Technological developments, advances in perioperative medicine and ongoing scientific research have led to reduced rates of mortality and morbidity in patients undergoing major liver surgery. Under these conditions, the frontier of resectability is constantly in movement towards more complex cases with extended tumor spread and potentially minimized remnant liver volume. A promising technique to support oncological correct and safe liver surgery is the introduction of preoperative computer based planning models and intraoperative navigation systems. Whereas three-dimensional (3D) liver models are commercially available and have been clinically implemented, the use of navigation systems is currently under evaluation by different groups using a variety of techniques. This manuscript is meant to give the reader an overview on current developments, difficulties and future aspects of image guided liver surgery.
"The largest LN in an involved region may not always be the involved LN. To compare the preoperative image with the pathological diagnosis in node-by-node manner, data accumulated from imageguided surgery, currently used for gastric or liver cancer   are necessary. Although the detection rate of at least one LN in a region was increased when involved LNs existed, the detection rate was still 75%, not 100% (Fig. 1b). "
[Show abstract][Hide abstract] ABSTRACT: The sensitivity of the current 10mm cut-off diameter that is used to diagnose lymph node (LN) metastasis is too low. This is the first study to develop a new criterion to diagnose LN metastasis in a region-by-region manner using multi-detector computed tomography (MDCT).
1) The short-axis diameter of the LNs in MDCT images from 1-mm slices obtained immediately prior to surgery was compared with the pathological diagnosis in 78 uterine cervical cancer patients undergoing primary surgery. For the region-by-region analysis, we divided para-aortic and pelvic spaces into 13 regions. 2) In 28 cases in which patients received neoadjuvant chemotherapy (NAC) followed by surgery, we compared MDCT images before and after NAC.
1) The optimal cut-off in the region-by-region analysis was 5mm, yielding 71% sensitivity and 79% specificity. 2) NAC significantly decreased LN size (p<0.0001). NAC decreased the number of swollen LN regions (>5mm) from 51% (81/158) to 26% (41/158).
The new criterion developed using MDCT could be effective for accurately assessing LN status. It also facilitates the assessment of NAC efficacy regarding the eradication of LN metastases.
[Show abstract][Hide abstract] ABSTRACT: Advances in surgical and in imaging technology permit the performance of complex tumour resections in a safe and oncologically correct manner. To date, this has mainly implicated refined preoperative imaging methods, such as three-dimensional computer-assisted planning (3D-CASP). With the advent of modern hybrid operating rooms, intraoperative imaging has spread and various techniques of intraoperative image guidance have been developed.
We review recent advances in intraoperative image guidance. We also delineate the role of intraoperative imaging techniques such as intraoperative ultrasound and computed tomography for real-time image guidance in laparoscopic liver surgery.
Our review shows that advances in intraoperative imaging accompany the increasing use of laparoscopic approaches in visceral surgery. For the liver surgeon working laparoscopically, the loss of tactile sensation and the complex three-dimensional anatomy of the human liver make 3D-imaging techniques and intraoperative image guidance indispensable. We describe the role of 3D-CASP in preoperative surgical planning in liver surgery.
An innovative imaging strategy for identifying liver segments during laparoscopic liver surgery by applying a fluorescent imaging method is proposed.
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