Application of Three-dimensional Visualization Technology in Early Surgical Repair of Bile Duct Injury During Laparoscopic Cholecystectomy

Application of Three-dimensional Visualization Technology in Early Surgical Repair of Bile Duct Injury During Laparoscopic Cholecystectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Application of Three-dimensional Visualization Technology in Early Surgical Repair of Bile Duct Injury During Laparoscopic Cholecystectomy Zhiqi Yang, Jing Liu, Lang Wu, Yang Ding, Songbo Ma, Wentao Yan, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4639600/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Sep, 2024 Read the published version in BMC Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Objective: This study aimed to explore the application value of three-dimensional (3D) visualization technology in the early surgical repair of bile duct injury during laparoscopic cholecystectomy (LC). Methods: A retrospective analysis was conducted on the clinical data of 15 patients who underwent early surgical repair of bile duct injury during LC with the assistance of 3D visualization technology at the Hepatobiliary Surgery Department of Ningxia Hui Autonomous Region People's Hospital from January 2019 to December 2022. Postoperative efficacy and long-term follow-up outcomes were summarized. Results: Before the repair surgery, 15 cases of bile duct injury during LC were evaluated using 3D visualization technology according to the Strasberg-Bismuth classification: 2 cases of type C, 4 of type E1, 3 of type E2, 3 of type E3, and 3 of type E4. Intraoperative findings were consistent with the 3D visualization reconstruction results, and all patients successfully underwent hepaticojejunostomy using Roux-en-Y anastomosis guided by the 3D visualization navigation. The time interval between LC and bile duct repair surgery ranged from 5 to 28 (14.2 ± 9.7) days. The surgical time was between 120 and 190 (156.40 ± 23.92) min, and estimated blood loss ranged from 80 to 250 (119.66 ± 47.60) mL. The length of hospital stay ranged from 12 to 25 days (median: 16 days). One patient experienced mild bile leakage after the operation, which healed with conservative treatment. All patients were followed up for 12–56 months (median: 34 months) without any loss to follow-up. During the follow-up period, no complications, such as anastomotic stricture or stone formation, were observed. Conclusion: The application of 3D visualization technology for preoperative evaluation and intraoperative navigation can accurately and effectively facilitate early surgical repair of bile duct injury during LC and has clinical value for promotion and application. Bile duct injury Three-dimensional visualization Early repair Laparoscopic cholecystectomy Figures Figure 1 Figure 2 Figure 3 Introduction Laparoscopic cholecystectomy (LC), when complicated by biliary injury, can cause serious physical and psychological pain for patients and lead to medical disputes and administrative penalties for physicians. Therefore, successful biliary surgery repair is crucial [ 1 ]. LC-associated biliary injuries are often detected early postoperatively, but uncertainties remain in perioperative assessment and intraoperative exploration, such as the preoperative identification of the injury site and the determination of high bile duct injuries. Over the past three decades, various imaging techniques, such as abdominal enhanced computed tomography (CT) and angiography, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography, and percutaneous transhepatic cholangiopancreatography, have been individually applied to evaluate bile duct injury[ 2 – 6 ]. However, each of these methods has its limitations. Three-dimensional (3D) visualization technology has been widely used for preoperative evaluation and intraoperative navigation in the radical resection of liver cancer [ 7 – 9 ]. This technology can more intuitively display the positional relationship among tumors, blood vessels, and bile ducts. However, there are few reports on the clinical application of early surgical repair of iatrogenic bile duct injury. This study retrospectively analyzed the clinical data of early surgical repair of biliary injuries following LC, assisted by 3D visualization technology. The study discussed the application value of this technology in the early surgical repair of iatrogenic bile duct injuries, as reported below. Patients and methods This study retrospectively analyzed the clinical data of 15 patients with bile duct injury during LC who underwent early repair surgery assisted by 3D visualization technology in the Department of Hepatobiliary Surgery, People's Hospital of Ningxia Hui Autonomous Region from January 2019 to December 2022. All patients and their families signed the informed consent before surgery. This study was approved by the Ethics Committee of the People's Hospital of Ningxia Hui Autonomous Region (Ethics [2024] -LL-027). Reconstruction and evaluation of 3D visualization technology All patients underwent a conventional 512 abdominal enhanced CT examination. The data in digital imaging and communications in medicine format were imported into 3D reconstruction software. A clinically experienced GanDanYi surgical specialist and professional and technical personnel completed the reconstruction images and produced the final report. The 3D reconstructions had the following main application: (1) Before the biliary tract repair surgery, the surgical team used the 3D reconstruction analysis platform to rotate and clear different tissues, vessels, and organs in 360 degrees. They observed the location of the biliary tract injury, the relationship between biliary tract injury and hepatic artery and portal vein, the distance from the hepatic hilum, and the presence or absence of liver ischemia or atrophy. (2) During the repair operation, the 3D reconstruction report was combined to explore and determine the opening of the bile duct injury, identify variations in the bile duct, identify tissues and blood vessels around the bile duct, and clarify the type of bile duct injury under the 3D visualization technology. (3) The application value of 3D visualization technology in the early repair of bile duct injury during LC was comprehensively evaluated by assessing the consistency between the types of bile duct injury and intraoperative exploration, the success rate of bile duct repair, and the occurrence of postoperative complications. Surgical strategies and procedures The general strategy for early repair surgery after bile duct injury in this study included a detailed evaluation of the location of bile duct injury, the defect or truncation of the bile duct, and the vascular injury. Special attention was given to the overall anatomical integrity of the hepatic hilar region, the degree of inflammation, the presence or absence of active bleeding, and the blood supply to the liver and duodenum to determine the type of biliary injury. The primary surgical method was hepaticojejunostomy using Roux-en-Y anastomosis. The specific repair techniques varied depending on the type of injury damage and included single or multiple hepatic duct openings jejunum with Roux-en-Y anastomosis (with or without a biliary supporting tube), common bile duct to jejunum Roux-en-Y anastomosis (with or without a biliary T-tube). Postoperative follow-up The patients were followed up regularly through outpatient reviews, telephone inquiries, and medical record system inquiries. The contents of follow-up included regular liver function, abdominal color Doppler ultrasound or t-tube angiography within three months after the repair surgery, MRCP within six months after the repair surgery, and liver color Doppler ultrasound and liver function reexamination every year. Statistical analysis In this study, normally distributed data are expressed as mean ± standard deviation, while skewness distribution is expressed as a median (range). Count data are expressed as the number of cases and percentage. The accuracy of preoperative evaluation by 3D visualization technology was evaluated and described by comparing the number of patients corresponding to the Strasberg-Bismuth classification of biliary tract injury evaluated by different imaging techniques and the coincidence of intraoperative exploration. Results Patient characteristics A total of 15 patients with bile duct injury during LC were enrolled in this study, including 6 males and 9 females, aged 31–62 (44.4 ± 10.3) years. The primary gallbladder diseases of 15 patients included 8 cases of cholecystolithiasis with acute cholecystitis (53.33%), 2 cases of cholecystolithiasis with chronic cholecystitis (13.33%), 1 case of Mrrinz syndrome (6.66%), 3 cases of gallbladder polyps (20%), and 2 cases of atrophic cholecystitis (13.33%). All patients were diagnosed within one week after LC. A total of 7 patients presented with bile leakage, 5 with jaundice, and 3 with both jaundice and bile leakage. Strasberg-Bismuth classification of biliary injury with different imaging Among the 15 cases of bile duct injury during LC, 4 cases of common hepatic duct transection, 2 cases of common bile duct transection, 1 case of common bile duct clamping, 6 cases of high bile duct injury, and 2 cases of ectopic right hepatic duct injury were initially determined by abdominal enhanced CT and MRCP after operation. Further evaluation of the Strasberg-Bismuth classification was performed using the 3D visualization technology. Consistency was finally determined by intraoperative exploration. As depicted in Table 1 , 3D visualization technology under the guidance of biliary injury Strasberg-Bismuth classification assessment of the accuracy was better than that of MRCP, with 100% consistency with intraoperative exploration results. Particularly in cases of high bile duct injury (Strasberg-Bismuth classification E) and liver hilum clamping laparoscopic ligation (titanium clip or Hemlock) in bile duct clip type of bile duct injury, 3D visualization technology provided a more intuitive preoperative evaluation (Fig. 1 ). Table 1 Strasberg-Bismuth classification of biliary injury with different imaging. Strasberg-Bismuth classification MRCP Three-dimensional visualization technology Intraoperative exploration Transection Defect Clamping down Transection Defect Clamping down transection Defect Clamping down C 2 2 2 E1 3 4 4 E2 4 0 2 1 2 1 E3 4 3 3 E4 2 3 3 The repair surgery of bile duct injury guided by 3D visualization technology Implementing biliary surgery to repair 15 cases from LC time interval in 5–28 (14.2 ± 9.7) days, all smooth implementation issues of biliary surgery to repair, specific as follows: Seven patients underwent Roux-en-Y hepaticojejunostomy (including three patients with T-tube drainage of bile duct), four patients underwent Roux-en-Y hepaticojejunostomy with multiple hepatic duct openings and bile duct drainage, two patients underwent perihilar resection with Roux-en-Y hepaticojejunostomy with multiple hepatic duct openings, and two patients underwent right hepaticojejunostomy. In type, Strasberg-Bismuth E biliary injury, 3D visualization technology provided significant advantages for preoperative and intraoperative evaluation by identifying the position of the bile duct injury, the number of bile duct openings, and the relationship with adjacent blood vessels. Bile duct injury can be determined accurately using the Strasberg-Bismuth classification example (Fig. 2 ). All patients with operation time was 120–190 (156.40 ± 23.92) min, the bleeding in 80–250 mL (119.66–47.60). One patient who underwent perihilar resection and Roux-en-Y hepaticojejunostomy had mild bile leakage and was cured after continuous abdominal drainage for 20 days, which was considered to be caused by bile capillary leakage in the liver section. The hospital time of all patients was 12–25 days (median time 16 days), without perioperative deaths. Postoperative follow-up Until October 2023, all patients were followed up for 12–56 months (median time: 34 months) without cases lost to follow-up. More than four regular hepatic duct openings jejunum anastomosis of Roux-en-Y and bile duct supporting tube drainage in patients with bile duct supporting tubes within 3 months to fall off. Three patients who underwent hepatic duct jejunum Roux-en-Y anastomosis with T-tube drainage had their T-tubes removed 3–4 months post-surgery. All patients were not seen during the follow-up period of reflux cholangitis, complications such as anastomotic stenosis, and stone formation. Discussion 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 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. 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. 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 bile duct injury after liver hilum biliary tumor and the severity of the biliary injury may have a certain correlation. Biliary tumors of bile leakage are considered to be caused by abdominal cavity fluid accumulation [ 16 ]. The higher the biliary injury, the wider the distribution of liver mun biliary tumor, which may extend through the lumen of the lesser omentum (Fig. 3 ). A multicenter retrospective study also reported [ 17 ] a statistically significant correlation between the presence of biliary tract tumors 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 E3–5 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. We believe 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 [ 18 – 19 ]. In clinical practice, 3D visualization technology has been well applied in the perihilar resection of hilar cholangiocarcinoma [ 20 – 21 ]. 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 reduces 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 the liver door, and appropriate intraoperative decreased liver door or gate resection. Combined with intraoperative bile duct support tube detection or biliary imaging, this approach helps accurately identify bile duct openings, preventing small bile duct opening omissions and causing bile leakage to occur after surgery to repair. 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 [ 22 ] that the LC application of intraoperative indocyanine green biliary imaging can prevent biliary injury and a secondary biliary injury repair surgery [ 23 ]. The combination of multiple image techniques and 3D visualization technology may further enhance the prospects for bile duct injury repair surgery. Declarations Acknowledgments No. Authors’ contributions Zhiqi Yang and Jing Liu co-wrote the manuscript. Lang Wu performed statistical analysis. Yang Ding, Songbo Ma and Wentao Yan edited Fig.1, Fig.2. and Fig.3. Yong Lan and Xiaochun Sha collected the data. Jianbin Cheng and Zhiming Ma followed up with the patients. Minghao Li performed the surgeries and Zhiqi Yang, Jing Liu, Yang Ding, Songbo Ma and Wentao Yan participated the surgeries. All authors reviewed and approved the manuscript. Funding Ningxia Hui Autonomous Region Key Research Project (2019 BEG03039). Data Availability The datasets generated during and/or analyzed during the current study are not publicly available, due to the involvement of patients' personal privacy, the data cannot be uploaded to the database at the moment but are available from the corresponding author on reasonable request. Competing interests The authors have declared that no competing interests exist. Ethics approval and consent to participate The experimental protocol was established, according to the ethical guidelines of the Helsinki Declaration and was approved by the Human Ethics Committee of People's Hospital of Ningxia Hui Autonomous Region. Informed consent was obtained from all subjects and/or their legal guardian(s). The study was approved by the Ethics Committee of People's Hospital of Ningxia Hui Autonomous Region. Informed consent was obtained from all subjects and/or their legal guardian(s). All methods were carried out in accordance with relevant guidelines and regulations. Consent for publication Not applicable. Human Ethics All study data were approved by the Ethics Committee of People's Hospital of Ningxia Hui Autonomous Region. Animal Ethics Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. References de'Angelis N, Catena F, Memeo R, et al. 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg. 2021 Jun 10;16(1):30. Linhares BL, Magalhães Ada G, Cardoso PM, et al. Bile duct injury following cholecystectomy. Rev Col Bras Cir. 2011 Mar-Apr;38(2):95-9. English, Portuguese. Jabłońska B, Lampe P. 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Surg Endosc. 2023 Aug;37(8):5836-5846. Tokuda S, Fujita A, Takagi A, Kanemoto H, Oba N. Repair of Bile Duct Injury Using Indocyanine Green Following Laparoscopic Cholecystectomy. Cureus. 2023 Nov 23;15(11):e49312. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 27 Sep, 2024 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 12 Jul, 2024 Reviews received at journal 11 Jul, 2024 Reviews received at journal 11 Jul, 2024 Reviewers agreed at journal 03 Jul, 2024 Reviewers agreed at journal 01 Jul, 2024 Reviewers invited by journal 01 Jul, 2024 Editor invited by journal 01 Jul, 2024 Editor assigned by journal 30 Jun, 2024 Submission checks completed at journal 30 Jun, 2024 First submitted to journal 25 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4639600","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":326114073,"identity":"86546d3a-c36a-4329-a0be-4eebbdccfee1","order_by":0,"name":"Zhiqi Yang","email":"","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhiqi","middleName":"","lastName":"Yang","suffix":""},{"id":326114074,"identity":"992c07b7-cb43-4dc7-bad7-b7199722c6dc","order_by":1,"name":"Jing Liu","email":"","orcid":"","institution":"Ningxia Hui Autonomous Region Peoples Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Liu","suffix":""},{"id":326114075,"identity":"52668723-cdfe-48bb-b06b-da34b525702e","order_by":2,"name":"Lang Wu","email":"","orcid":"","institution":"Ningxia Hui Autonomous Region Peoples Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lang","middleName":"","lastName":"Wu","suffix":""},{"id":326114076,"identity":"35df18e8-78f9-41a9-96dd-049b772c9ad2","order_by":3,"name":"Yang Ding","email":"","orcid":"","institution":"Ningxia Hui Autonomous Region Peoples Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Ding","suffix":""},{"id":326114077,"identity":"3968c915-e835-4917-a5ad-833ba2527842","order_by":4,"name":"Songbo Ma","email":"","orcid":"","institution":"Ningxia Hui Autonomous Region Peoples Hospital","correspondingAuthor":false,"prefix":"","firstName":"Songbo","middleName":"","lastName":"Ma","suffix":""},{"id":326114078,"identity":"f17351fb-f113-481d-98a5-adc80e0e2816","order_by":5,"name":"Wentao Yan","email":"","orcid":"","institution":"Ningxia Hui Autonomous Region Peoples Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wentao","middleName":"","lastName":"Yan","suffix":""},{"id":326114079,"identity":"0e95e475-dae1-4b12-ba90-5b91496f3f1d","order_by":6,"name":"Yong Lan","email":"","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Lan","suffix":""},{"id":326114081,"identity":"006fe375-84a9-4e01-ad25-b4d60aa0c45c","order_by":7,"name":"Xiaochun Sha","email":"","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiaochun","middleName":"","lastName":"Sha","suffix":""},{"id":326114085,"identity":"50169882-fc12-4815-9f09-dbf07f7b6891","order_by":8,"name":"Jianbin Cheng","email":"","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jianbin","middleName":"","lastName":"Cheng","suffix":""},{"id":326114088,"identity":"8391cdc2-4af8-489a-b21f-7b701262a0db","order_by":9,"name":"Zhiming Ma","email":"","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhiming","middleName":"","lastName":"Ma","suffix":""},{"id":326114090,"identity":"0244bff3-5fe6-4336-a7f7-560309111740","order_by":10,"name":"Minghao Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIie3PsQqCQBjA8e8QdOj01qKhV7gIosHqWUSwxaFHOBFykVr1LYReQPuorb2h2TlokXBIDKKpcwy6Pwe3fD/uPgCV6gezNIC8PSyIqhu3F1Kiv0kfxSBZe66cvK6GwEoM6e1AhJQYPQfXj+uIQSEmNs81MPCYff+YmWG6LcdpGAjX51cLqOddpMSMkWR5IdDnpQZ9Ou1EllnuBOGMIxGdCK3QaUioQWdiCnTTpNiQmHuuLtuFsfP+Tmuc71hUQlXbC2bg6StpI5vPd6XjbXW3MZVKpfrTnsfIULcipaKzAAAAAElFTkSuQmCC","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":true,"prefix":"","firstName":"Minghao","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-06-26 03:29:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4639600/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4639600/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-024-02571-4","type":"published","date":"2024-09-27T15:57:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60912249,"identity":"02de4e86-5ff5-40bc-9dbf-aad59a492257","added_by":"auto","created_at":"2024-07-23 13:01:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":314150,"visible":true,"origin":"","legend":"\u003cp\u003eExample of common bile duct clamping in CT, MRCP, and 3D visualization images.\u003c/p\u003e\n\u003cp\u003eA. CT only showed high density shadow in the hepatic portal area. B. MRCP indicated bravery manager transverse linear low signal shadow. C. 3D visualization was close to the real state to simulate the clamping state of common bile duct.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4639600/v1/01c296f4c705065baaef6bca.png"},{"id":60913273,"identity":"da03d06b-f7f6-438a-beb7-d6834c7d474d","added_by":"auto","created_at":"2024-07-23 13:09:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":834647,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e3D visualization technology in Strasberg-Bismuth E4 type biliary injury repair surgery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA-B. The evaluation of bile duct injury in axial and coronal CT images before repair surgery. Panel C indicates MRCP before repair surgery. D–F. Biliary repair hand biliary 3D reconstruction of high damage and direction relations between hepatic artery and portal vein. G. In the abdominal cavity detection. H. Exposure of hepatic hilar area and determination of injured bile duct opening (guided by biliary probe). I. A biliary stent was placed. J. In heterogeneous hepatic duct jejunum anastomosis after fitting line right front and left hepatic duct were dry-jejunum anastomosis. K. Postoperative status of multi-opening hepaticojejunostomy. MRCP was reexamined six months after operation.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4639600/v1/04bd9bc8d6d7d1e8fc134d77.png"},{"id":60912251,"identity":"62a366da-3da2-42a5-9026-d9779a22bf88","added_by":"auto","created_at":"2024-07-23 13:01:26","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":82997,"visible":true,"origin":"","legend":"\u003cp\u003eHilar biloma after high bile duct injury. The yellow section shows the distribution of biloma, the gray part is the abdominal drainage tube.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4639600/v1/ba022fce6a7ffe3f7ed6d7b8.png"},{"id":65627108,"identity":"8faa5caf-d469-4fbb-8640-2588ac685b76","added_by":"auto","created_at":"2024-09-30 16:11:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1901184,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4639600/v1/052cacfc-1d34-4db8-90b3-e5c043ba4233.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Application of Three-dimensional Visualization Technology in Early Surgical Repair of Bile Duct Injury During Laparoscopic Cholecystectomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLaparoscopic cholecystectomy (LC), when complicated by biliary injury, can cause serious physical and psychological pain for patients and lead to medical disputes and administrative penalties for physicians. Therefore, successful biliary surgery repair is crucial [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. LC-associated biliary injuries are often detected early postoperatively, but uncertainties remain in perioperative assessment and intraoperative exploration, such as the preoperative identification of the injury site and the determination of high bile duct injuries. Over the past three decades, various imaging techniques, such as abdominal enhanced computed tomography (CT) and angiography, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography, and percutaneous transhepatic cholangiopancreatography, have been individually applied to evaluate bile duct injury[\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, each of these methods has its limitations. Three-dimensional (3D) visualization technology has been widely used for preoperative evaluation and intraoperative navigation in the radical resection of liver cancer [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This technology can more intuitively display the positional relationship among tumors, blood vessels, and bile ducts. However, there are few reports on the clinical application of early surgical repair of iatrogenic bile duct injury. This study retrospectively analyzed the clinical data of early surgical repair of biliary injuries following LC, assisted by 3D visualization technology. The study discussed the application value of this technology in the early surgical repair of iatrogenic bile duct injuries, as reported below.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003eThis study retrospectively analyzed the clinical data of 15 patients with bile duct injury during LC who underwent early repair surgery assisted by 3D visualization technology in the Department of Hepatobiliary Surgery, People's Hospital of Ningxia Hui Autonomous Region from January 2019 to December 2022. All patients and their families signed the informed consent before surgery. This study was approved by the Ethics Committee of the People's Hospital of Ningxia Hui Autonomous Region (Ethics [2024] -LL-027).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eReconstruction and evaluation of 3D visualization technology\u003c/h2\u003e \u003cp\u003eAll patients underwent a conventional 512 abdominal enhanced CT examination. The data in digital imaging and communications in medicine format were imported into 3D reconstruction software. A clinically experienced GanDanYi surgical specialist and professional and technical personnel completed the reconstruction images and produced the final report. The 3D reconstructions had the following main application: (1) Before the biliary tract repair surgery, the surgical team used the 3D reconstruction analysis platform to rotate and clear different tissues, vessels, and organs in 360 degrees. They observed the location of the biliary tract injury, the relationship between biliary tract injury and hepatic artery and portal vein, the distance from the hepatic hilum, and the presence or absence of liver ischemia or atrophy. (2) During the repair operation, the 3D reconstruction report was combined to explore and determine the opening of the bile duct injury, identify variations in the bile duct, identify tissues and blood vessels around the bile duct, and clarify the type of bile duct injury under the 3D visualization technology. (3) The application value of 3D visualization technology in the early repair of bile duct injury during LC was comprehensively evaluated by assessing the consistency between the types of bile duct injury and intraoperative exploration, the success rate of bile duct repair, and the occurrence of postoperative complications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical strategies and procedures\u003c/h2\u003e \u003cp\u003eThe general strategy for early repair surgery after bile duct injury in this study included a detailed evaluation of the location of bile duct injury, the defect or truncation of the bile duct, and the vascular injury. Special attention was given to the overall anatomical integrity of the hepatic hilar region, the degree of inflammation, the presence or absence of active bleeding, and the blood supply to the liver and duodenum to determine the type of biliary injury. The primary surgical method was hepaticojejunostomy using Roux-en-Y anastomosis. The specific repair techniques varied depending on the type of injury damage and included single or multiple hepatic duct openings jejunum with Roux-en-Y anastomosis (with or without a biliary supporting tube), common bile duct to jejunum Roux-en-Y anastomosis (with or without a biliary T-tube).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative follow-up\u003c/h2\u003e \u003cp\u003eThe patients were followed up regularly through outpatient reviews, telephone inquiries, and medical record system inquiries. The contents of follow-up included regular liver function, abdominal color Doppler ultrasound or t-tube angiography within three months after the repair surgery, MRCP within six months after the repair surgery, and liver color Doppler ultrasound and liver function reexamination every year.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eIn this study, normally distributed data are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, while skewness distribution is expressed as a median (range). Count data are expressed as the number of cases and percentage. The accuracy of preoperative evaluation by 3D visualization technology was evaluated and described by comparing the number of patients corresponding to the Strasberg-Bismuth classification of biliary tract injury evaluated by different imaging techniques and the coincidence of intraoperative exploration.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eA total of 15 patients with bile duct injury during LC were enrolled in this study, including 6 males and 9 females, aged 31\u0026ndash;62 (44.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3) years. The primary gallbladder diseases of 15 patients included 8 cases of cholecystolithiasis with acute cholecystitis (53.33%), 2 cases of cholecystolithiasis with chronic cholecystitis (13.33%), 1 case of Mrrinz syndrome (6.66%), 3 cases of gallbladder polyps (20%), and 2 cases of atrophic cholecystitis (13.33%). All patients were diagnosed within one week after LC. A total of 7 patients presented with bile leakage, 5 with jaundice, and 3 with both jaundice and bile leakage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStrasberg-Bismuth classification of biliary injury with different imaging\u003c/h2\u003e \u003cp\u003eAmong the 15 cases of bile duct injury during LC, 4 cases of common hepatic duct transection, 2 cases of common bile duct transection, 1 case of common bile duct clamping, 6 cases of high bile duct injury, and 2 cases of ectopic right hepatic duct injury were initially determined by abdominal enhanced CT and MRCP after operation. Further evaluation of the Strasberg-Bismuth classification was performed using the 3D visualization technology. Consistency was finally determined by intraoperative exploration. As depicted in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, 3D visualization technology under the guidance of biliary injury Strasberg-Bismuth classification assessment of the accuracy was better than that of MRCP, with 100% consistency with intraoperative exploration results. Particularly in cases of high bile duct injury (Strasberg-Bismuth classification E) and liver hilum clamping laparoscopic ligation (titanium clip or Hemlock) in bile duct clip type of bile duct injury, 3D visualization technology provided a more intuitive preoperative evaluation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStrasberg-Bismuth classification of biliary injury with different imaging.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e 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\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe repair surgery of bile duct injury guided by 3D visualization technology\u003c/b\u003e \u003c/p\u003e \u003cp\u003eImplementing biliary surgery to repair 15 cases from LC time interval in 5\u0026ndash;28 (14.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7) days, all smooth implementation issues of biliary surgery to repair, specific as follows: Seven patients underwent Roux-en-Y hepaticojejunostomy (including three patients with T-tube drainage of bile duct), four patients underwent Roux-en-Y hepaticojejunostomy with multiple hepatic duct openings and bile duct drainage, two patients underwent perihilar resection with Roux-en-Y hepaticojejunostomy with multiple hepatic duct openings, and two patients underwent right hepaticojejunostomy. In type, Strasberg-Bismuth E biliary injury, 3D visualization technology provided significant advantages for preoperative and intraoperative evaluation by identifying the position of the bile duct injury, the number of bile duct openings, and the relationship with adjacent blood vessels. Bile duct injury can be determined accurately using the Strasberg-Bismuth classification example (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAll patients with operation time was 120\u0026ndash;190 (156.40 \u0026plusmn; 23.92) min, the bleeding in 80\u0026ndash;250 mL (119.66\u0026ndash;47.60). One patient who underwent perihilar resection and Roux-en-Y hepaticojejunostomy had mild bile leakage and was cured after continuous abdominal drainage for 20 days, which was considered to be caused by bile capillary leakage in the liver section. The hospital time of all patients was 12\u0026ndash;25 days (median time 16 days), without perioperative deaths.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative follow-up\u003c/h2\u003e \u003cp\u003eUntil October 2023, all patients were followed up for 12\u0026ndash;56 months (median time: 34 months) without cases lost to follow-up. More than four regular hepatic duct openings jejunum anastomosis of Roux-en-Y and bile duct supporting tube drainage in patients with bile duct supporting tubes within 3 months to fall off. Three patients who underwent hepatic duct jejunum Roux-en-Y anastomosis with T-tube drainage had their T-tubes removed 3\u0026ndash;4 months post-surgery. All patients were not seen during the follow-up period of reflux cholangitis, complications such as anastomotic stenosis, and stone formation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eLC 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\u0026ndash;12]. The timing of postoperative repair surgery for LC-related bile duct injury is a subject of ongoing debate [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Many experts consider 4\u0026ndash;6 weeks post-LC as a critical cut-off point, dividing it into early and late (or deferred) repair [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e15\u003c/span\u003e] 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.\u003c/p\u003e \u003cp\u003eA 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\u0026ndash;28 (14.2 \u0026plusmn; 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.\u003c/p\u003e \u003cp\u003eThe 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. 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. 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 bile duct injury after liver hilum biliary tumor and the severity of the biliary injury may have a certain correlation. Biliary tumors of bile leakage are considered to be caused by abdominal cavity fluid accumulation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The higher the biliary injury, the wider the distribution of liver mun biliary tumor, which may extend through the lumen of the lesser omentum (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A multicenter retrospective study also reported [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e17\u003c/span\u003e] a statistically significant correlation between the presence of biliary tract tumors and the severity of bile duct injury (P\u0026thinsp;=\u0026thinsp;0.02). The correlation of complicated bile duct injuries is eventually a clear diagnosis of Strasberg-Bismuth E3\u0026ndash;5 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. We believe 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.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWe 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 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In clinical practice, 3D visualization technology has been well applied in the perihilar resection of hilar cholangiocarcinoma [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. 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 reduces 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 the liver door, and appropriate intraoperative decreased liver door or gate resection. Combined with intraoperative bile duct support tube detection or biliary imaging, this approach helps accurately identify bile duct openings, preventing small bile duct opening omissions and causing bile leakage to occur after surgery to repair.\u003c/p\u003e \u003cp\u003eIn 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 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e22\u003c/span\u003e] that the LC application of intraoperative indocyanine green biliary imaging can prevent biliary injury and a secondary biliary injury repair surgery [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The combination of multiple image techniques and 3D visualization technology may further enhance the prospects for bile duct injury repair surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZhiqi Yang and Jing Liu co-wrote the manuscript. Lang Wu performed statistical analysis. Yang Ding, Songbo Ma and Wentao Yan edited Fig.1, Fig.2. and Fig.3. Yong Lan and Xiaochun Sha collected the data. Jianbin Cheng and Zhiming Ma followed up with the patients. Minghao Li performed the surgeries and Zhiqi Yang, Jing Liu, Yang Ding, Songbo Ma and Wentao Yan participated the surgeries. All authors reviewed and approved the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNingxia Hui Autonomous Region Key Research Project (2019 BEG03039).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current study are not publicly available, due to the involvement of patients\u0026apos; personal privacy, the data cannot be uploaded to the database at the moment but are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors have declared that no competing interests exist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe experimental protocol was established, according to the ethical guidelines of the Helsinki Declaration and was approved by the Human Ethics Committee of\u0026nbsp;People\u0026apos;s Hospital of Ningxia Hui Autonomous Region. Informed consent was obtained from all subjects and/or their legal guardian(s). The study was approved by the Ethics Committee of People\u0026apos;s Hospital of Ningxia Hui Autonomous Region. Informed consent was obtained from all subjects and/or their legal guardian(s). All methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll study data were approved by the Ethics Committee of People\u0026apos;s Hospital of Ningxia Hui Autonomous Region.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnimal Ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnimal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003ede\u0026apos;Angelis N, Catena F, Memeo R, et al. 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg. 2021 Jun 10;16(1):30.\u003c/li\u003e\n \u003cli\u003eLinhares BL, Magalh\u0026atilde;es Ada G, Cardoso PM, et al. Bile duct injury following cholecystectomy. Rev Col Bras Cir. 2011 Mar-Apr;38(2):95-9. English, Portuguese.\u003c/li\u003e\n \u003cli\u003eJabłońska B, Lampe P. Iatrogenic bile duct injuries: etiology, diagnosis and management. World J Gastroenterol. 2009 Sep 7;15(33):4097-104.\u003c/li\u003e\n \u003cli\u003eMungai F, Berti V, Colagrande S. Bile leak after elective laparoscopic cholecystectomy: role of MR imaging. J Radiol Case Rep. 2013 Jan;7(1):25-32.\u003c/li\u003e\n \u003cli\u003eFidelman N, Kerlan RK Jr, Laberge JM, Gordon RL. Accuracy of percutaneous transhepatic cholangiography in predicting the location and nature of major bile duct injuries. J Vasc Interv Radiol. 2011 Jun;22(6):884-92.\u003c/li\u003e\n \u003cli\u003eMcGahan JP, Stein M. Complications of laparoscopic cholecystectomy: imaging and intervention. AJR Am J Roentgenol. 1995 Nov;165(5):1089-97.\u003c/li\u003e\n \u003cli\u003eProcopio F, Cimino M, Vigan\u0026ograve; L, et al. Prediction of remnant liver volume using 3D simulation software in patients undergoing R1vasc parenchyma-sparing hepatectomy for multiple bilobar colorectal liver metastases: reliability, clinical impact, and learning curve. HPB (Oxford). 2021 Jul;23(7):1084-1094.\u003c/li\u003e\n \u003cli\u003eTakamoto T, Ban D, Nara S, et al. Automated Three-Dimensional Liver Reconstruction with Artificial Intelligence for Virtual Hepatectomy. J Gastrointest Surg. 2022 Oct;26(10):2119-2127.\u003c/li\u003e\n \u003cli\u003eZeng X, Tao H, Dong Y, et al. Impact of three-dimensional reconstruction visualization technology on short-term and long-term outcomes after hepatectomy in patients with hepatocellular carcinoma: a propensity-score-matched and inverse probability of treatment-weighted multicenter study. Int J Surg. 2024 Mar 1;110(3):1663-1676.\u003c/li\u003e\n \u003cli\u003eAlexander HC, Bartlett AS, Wells CI, et al.Reporting of complications after laparoscopic cholecystectomy: a systematic review. HPB (Oxford). 2018 Sep;20(9):786-794.\u003c/li\u003e\n \u003cli\u003eStrasberg SM, Gouma DJ. \u0026apos;Extreme\u0026apos; vasculobiliary injuries: association with fundus-down cholecystectomy in severely inflamed gallbladders. HPB (Oxford). 2012 Jan;14(1):1-8.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBrunt LM, Deziel DJ, Telem DA, et al. Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy. Ann Surg. 2020 Jul;272(1):3-23.\u003c/li\u003e\n \u003cli\u003eWang X, Yu WL, Fu XH, et al. Early Versus Delayed Surgical Repair and Referral for Patients With Bile Duct Injury: A Systematic Review and Meta-analysis. Annals of surgery. 2020;271(3):449-59.\u003c/li\u003e\n \u003cli\u003eEl Nakeeb A, Sultan A, Ezzat H, et al. Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury: A multicenter study. Hepatobiliary Pancreat Dis Int. 2021;20(1):53-60.\u003c/li\u003e\n \u003cli\u003eSchreuder AM, Busch OR, Besselink MG, et al. Long-term impact of iatrogenic bile duct injury[J]. Dig Surg, 2020, 37(1):10-21.\u003c/li\u003e\n \u003cli\u003eWalker AT, Shapiro AW, Brooks DC, et al. Bile duct disruption and biloma after laparoscopic cholecystectomy: imaging evaluation. AJR Am J Roentgenol. 1992;158(4):785-789.\u003c/li\u003e\n \u003cli\u003eConde Monroy D, Torres G\u0026oacute;mez P, Rey Chaves CE, et al. Early versus delayed reconstruction for bile duct injury a multicenter retrospective analysis of a hepatopancreaticobiliary group.Sci Rep. 2022;12(1):11609.\u003c/li\u003e\n \u003cli\u003eWiboonkhwan NA, Pitakteerabundit T, Thongkan T. Total Hilar Exposure Maneuver for Repair of Complex Bile Duct Injury. Ann Gastroenterol Surg. 2021 Sep 3;6(1):176-181.\u003c/li\u003e\n \u003cli\u003eOtto W, Sierdziński J, Smaga J, et al. Actuarial Patency Rates of Hepatico-Jejunal Anastomosis after Repair of Bile Duct Injury at a Reference Center. J Clin Med. 2022 Jun 13;11(12):3396.\u003c/li\u003e\n \u003cli\u003eEndo I, Shimada H, Sugita M, et al. Role of three-dimensional imaging in operative planning for hilar cholangiocarcinoma. Surgery. 2007 Nov;142(5):666-75.\u003c/li\u003e\n \u003cli\u003eFang C, An J, Bruno A, et al. Consensus recommendations of three-dimensional visualization for diagnosis and management of liver diseases. Hepatol Int. 2020 Jul;14(4):437-453.\u003c/li\u003e\n \u003cli\u003eXu C, Yin M, Wang H, Jiang P, et al. Indocyanine green fluorescent cholangiography improves the clinical effects of difficult laparoscopic cholecystectomy. Surg Endosc. 2023 Aug;37(8):5836-5846.\u003c/li\u003e\n \u003cli\u003eTokuda S, Fujita A, Takagi A, Kanemoto H, Oba N. Repair of Bile Duct Injury Using Indocyanine Green Following Laparoscopic Cholecystectomy. Cureus. 2023 Nov 23;15(11):e49312.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bile duct injury, Three-dimensional visualization, Early repair, Laparoscopic cholecystectomy","lastPublishedDoi":"10.21203/rs.3.rs-4639600/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4639600/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eThis study aimed to explore the application value of three-dimensional (3D) visualization technology in the early surgical repair of bile duct injury during laparoscopic cholecystectomy (LC).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective analysis was conducted on the clinical data of 15 patients who underwent early surgical repair of bile duct injury during LC with the assistance of 3D visualization technology at the Hepatobiliary Surgery Department of Ningxia Hui Autonomous Region People's Hospital from January 2019 to December 2022. Postoperative efficacy and long-term follow-up outcomes were summarized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eBefore the repair surgery, 15 cases of bile duct injury during LC were evaluated using 3D visualization technology according to the Strasberg-Bismuth classification: 2 cases of type C, 4 of type E1, 3 of type E2, 3 of type E3, and 3 of type E4. Intraoperative findings were consistent with the 3D visualization reconstruction results, and all patients successfully underwent hepaticojejunostomy using Roux-en-Y anastomosis guided by the 3D visualization navigation. The time interval between LC and bile duct repair surgery ranged from 5 to 28 (14.2 ± 9.7) days. The surgical time was between 120 and 190 (156.40 ± 23.92) min, and estimated blood loss ranged from 80 to 250 (119.66 ± 47.60) mL. The length of hospital stay ranged from 12 to 25 days (median: 16 days). One patient experienced mild bile leakage after the operation, which healed with conservative treatment. All patients were followed up for 12–56 months (median: 34 months) without any loss to follow-up. During the follow-up period, no complications, such as anastomotic stricture or stone formation, were observed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The application of 3D visualization technology for preoperative evaluation and intraoperative navigation can accurately and effectively facilitate early surgical repair of bile duct injury during LC and has clinical value for promotion and application.\u003c/p\u003e","manuscriptTitle":"Application of Three-dimensional Visualization Technology in Early Surgical Repair of Bile Duct Injury During Laparoscopic Cholecystectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-23 13:01:21","doi":"10.21203/rs.3.rs-4639600/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-12T11:05:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-11T10:08:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-11T04:41:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"216103123955878672295684822307191225325","date":"2024-07-03T12:47:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"236486245666815362683250902327992706188","date":"2024-07-01T12:53:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-01T12:34:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-01T11:04:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-30T11:48:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-30T11:48:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2024-06-26T03:28:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6bc9700a-bae2-41e0-a963-acb7c0a26790","owner":[],"postedDate":"July 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-30T15:59:57+00:00","versionOfRecord":{"articleIdentity":"rs-4639600","link":"https://doi.org/10.1186/s12893-024-02571-4","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2024-09-27 15:57:04","publishedOnDateReadable":"September 27th, 2024"},"versionCreatedAt":"2024-07-23 13:01:21","video":"","vorDoi":"10.1186/s12893-024-02571-4","vorDoiUrl":"https://doi.org/10.1186/s12893-024-02571-4","workflowStages":[]},"version":"v1","identity":"rs-4639600","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4639600","identity":"rs-4639600","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}