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International Archives of the Photogrammetry, Remote Sensing and Spatial Information Sciences, Vol XXXV, Part B5. Istanbul 2004
COMPUTER-BASED SURGERY PLANNING
FOR LIVING LIVER DONATION
H.-P. Meinzer^', P. Schemmer", M. Schobinger”, M. Nolden®, T. Heimann',
B. Yalcin?, G.M. Richter“, T. Kraus", M. W. Büchler^, M. Thorn?
* Div. Medical and Biological Informatics, German Cancer Research Center, 69120 Heidelberg, Germany
° Dept. of Surgery, Ruprecht-Karls-University, 69120 Heidelberg, Germany
* Dept. of Radiology, Ruprecht-Karls-University,69120 Heidelberg, Germany
Comission WG V/3
KEYWORDS: Living donor live transplantation, operation planning, computer based planning, volumetry, anatomical evaluation
ABSTRACT:
The aim of this project is computer-based planning of a partial organ resection for three dimensional visualisation of anatomical
structures and volumetric estimations. Using quantitative parameters for the estimation of the operation risk, the selection of patients
can be further objectified. Another important effect of this project is support for surgical interventions by predefinition of different
operation scenarios. All preoperative analysis results are based on tomographic images acquired during the clinical routine. In the
end, the integration of planning results into the operation theater as well as into the clinical workflow is part of this project. Surgical
strategy is determined by the exact location of the tumor, the respective donor liver part, and the proximity of supporting and
draining vessels. Depending on the acquired images, the portal, hepatic, arterial and biliary systems may be analyzed. Therefore,
fundamentals for the qualitative and quantitative analysis of images have been developed and implemented since the beginning of
the project. The qualitative aspects are, e.g., the three dimensional visualisation of vessel structures, tumors, the security margin and
the organ itself. These were evaluated for use in the clinical routine. Preoperatively, the operation strategy is planned by segmenting
the important anatomical structures and defining the different vessel systems using a special operation planning software. The
visualisation and volumetric results can be visualised and adapted during surgical intervention with the help of a beamer and a touch-
screen monitor installed above the patient. In living donor liver transplantation (LDLT) the mostrimportant factor is to ensure that the
anatomy of the donor patient allows surgical splitting of the liver. Also, a volumetric analysis of the donor liver is of interest to
achieving less complicated surgery. Actually, all LDLTs performed in our Surgical Clinic are supported by this operation planning
System.
I. INTRODUCTION
Live donor liver transplantation was first initiated in children in
1989 in response to the severe shortage of pediatric organ
donors (Raia, 1989; Broelsch 1990). Improvements in surgical
technique resulted in superior survival compared with cadaveric
transplantations (Broelsch, 1991; Otte 1999). The expansion of
live donor liver transplantation to the adult population initially
began in countries where the availability of cadaveric donors
was scarce and in some cases totally unavailable (Lo 1996a; Lo.
1996b; Kawasaki 1998). Severe shortages of cadaveric organs
along with the exponential growth in the number of patients
with cirrhosis secondary to the epidemic of hepatitis C have
resulted in an increasing acceptance of live donor adult liver
transplantation (LDLT) in Europe and the United States
(Marcos, 2000a; Malago, 1999).
The donor selection is normally done in three phases (Pomfret
2001). In the first phase a potential donor is identified by
obtaining demographic data and documenting the relationship
between the donor and the recipient. After explanation of the
surgical procedure and description of the evaluation process a
laboratory estimation of blood compatibility and normal
screening is done.
After passing the first phase the anatomical conditions of the
donor are clarified in the second phase. For that reason CT
images are acquired for the survey of the different vessel
systems (portal vein, liver vein, bilary duct and arteries) within
the donor liver. With the help of these images the feasibility and
complexity of the surgical procedure is estimated. After the
anatomical analysis a psychological estimation of the donor
himself and his familiar setting is performed.
After the declarative statement of the laboratory, the radiology,
internists, psychologists and ethical commission that the
surgical intervention is possible for the donor the evaluation
process gets into the third phase. In that last phase the recipient
is re-evaluated to ensure that he has not become too sick for
LDLT:
The process chain, especially the second phase, reflects one of
the main problems in donor evaluation: the anatomical
examination. The analysis of the vascular structures is done
with the help of two-dimensional CT-images showing the
vessels a highlighted dots. Only very experienced radiologists
are able to verify the three dimensional structures of all vessels.
A risk-aggravating factor is the fact that no images exist
showing all different vessel-systems in one visualisation.
Additionally a valid volumetric estimation of the donor graft
size and the remaining liver tissue can’t be done directly on the
primary data.
To close that gap in donor evaluation we developed a computer-
based operation-planning system, evaluated the volumetric
estimation function and integrated this system in the clinical
workflow.
2. MATERIAL AND METHODS
Different approaches have been made for the planning (Selle,
2000a) or the training and education (Marescaux, 1998) in this
field of research. Using the computer-based operation planning
system developed in Heidelberg it is possible to preoperatively
