[Application of digital medical technology in hepatopancreatobiliary surgery:20 years' retrospective review and prospect].

Digital medicine has played a vital role in promoting the development of hepatobiliary and pancreatic surgery of China.The multidisciplinary integration of medical science and technology innovates research and development,and practice in clinical diagnosis and treatment.Digital medicine has enabled within 20 years,development from digital virtual human,three-dimensional visualization,molecular fluorescence imaging to artificial intelligence.There are four important stages of the development in China's digital medical technology:digital medicine 1.0 (2002 to 2004,digital virtual human) on digital human anatomy, digital medicine 2.0(2004 to 2014,three-dimensional(3D) visualization and 3D printing) on 3D diagnosis and treatment of complex hepatobiliary and pancreatic diseases, digital medicine 3.0(2014 to 2019,molecular fluorescence imaging) on precision navigation of tumor boundaries and micro tumors using indocyanine green molecular imaging, and digital medicine 4.0(2019 to present,digital artificial intelligence) on augmented reality-based and mixed reality-based 3D abdominal navigation hepatectomy and photoacoustic imaging of tumors.Over the past 20 years' course of development,Chinese researchers have made countless and remarkable achievements in digital medicine through continuous efforts and innovation. In the future,cutting-edge technologies such as artificial intelligence on deep machine learning,multi-mode image real-time fusion navigation surgery,photoacoustic imaging and targeted molecular probe technology will promote the development of digital medicine 4.0 in a coordinated manner,leading to the advent of digital medicine 5.0.

[From digital virtual human, three-dimensional visualization to digital intelligence in liver surgery].

Digital intelligent hepatobiliary surgery has evolved over decades.It has experienced an evolution course from digital virtual human technology to the establishment of a quality-controlled and homogeneous three-dimensional visualization system for precision diagnosis and treatment of diseases, from three-dimensional visualization to the clinical transformation of digital intelligent technology and changes in the diagnosis and treatment model, from empirical diagnosis of diseases to the application of deep learning for the intelligent diagnosis and treatment of diseases, from empirical surgery to real-time multi-modal image guidance during surgery, and from the morphological diagnosis of tumors to accurate diagnosis from molecular imaging.During the whole process, only through continuous innovation in research, theory and technology can the "life" of digital intelligent surgery be endowed with new vitality.In the future, the definition of tumor boundary from the molecular and cellular levels and the early diagnosis and treatment of liver tumor through the functional visualization of key molecules will have significant clinical value for changing the prognosis of liver cancer.In addition, in order to realize intelligent navigation for hepatectomy and break through the technical bottleneck, it is of great clinical significance to develop an intelligent robot real-time navigation hepatectomy system with automatic navigation technology, machine learning intelligent planning technology and multimodal image fusion technology.This provides unprecedented opportunities and challenges for the development of digital intelligent hepatobiliary surgery.

[Construction and application of the core technology system of digital intelligent diagnostic and treatment for hepato-biliary-pancreatic diseases].

Digital intelligent diagnostic and treatment technology is a novel technology which is based by combining modern medicine with digitalized and intelligent high-tech to form a multidisciplinary and multi-knowledge domain. This technology plays an important role in areas including precision diagnosis, preoperative planning and surgical navigation. Its core technologies are: (1) quality control research on high-quality CT imaging data acquisition; (2) quality control and homogenization research on three-dimensional (3D) reconstruction; (3) high-quality 3D printed physical models; (4) virtual reality 3D simulation platform; (5) molecular fluorescence imaging to define tumor boundaries; (6) non-rigid registration multi-mode image fusion surgical navigation system; (7) image feature extraction and prediction model establishment. The workflow of this system includes: First, CT data acquisition and 3D visualization of hepatobiliary and pancreatic diseases; followed by individualized vascular assessment, liver volume calculation and surgical planning using the 3D model; then virtual simulation surgery, 3D printing, virtual reality technology and molecular fluorescence imaging accordance to the required specific conditions. Preoperative radiomics are used to predict the risk of complications and long-term follow-up results. Intraoperative multi-modal fusion image navigation and its consistency are evaluated with the findings in actual surgery and preoperative planning. This technology, hopefully, will bring in novel strategies and approaches in the diagnosis and treatment of hepatobiliary and pancreatic diseases.

[The clinical application of three dimention printing technology].

In recent years, the three-dimentional(3D)printing technology is gradually applied in medicine.Now, the 3D printing has already play an important role in medical education, surgical device development, prosthesis implantation and so on.There are still many challenges and difficulties in the clinical overall application of 3D printing for some time, but it also contains a huge application prospect.Once with appropriate applications of this technology, it will be a major breakthrough in iatrical history once more.

[Overview of Chinese digital medicine].

Digital medicine is a newly developed interdiscipline, which is based on the rapid development of medical imaging technology and other advanced technologies in information science, such as computer and internet etc. To let academic world comprehend the history, status, mission, and prospect of this new branch of science, this comment primarily review the major events related to the booming process in Chinese digital medicine, the published milestone works, and dominating applied technology.

The urogenital-hypogastric sheath: an anatomical observation on the relationship between the inferomedial extension of renal fascia and the hypogastric nerves.

PURPOSE: The study aimed to perform an anatomical observation on the inferomedial extension of the renal fascia (RF) to the pelvis and explore its relationship with the hypogastric nerves (HGNs). METHODS: Gross anatomy was performed on 12 formalin-fixed and 12 fresh cadavers. Sectional anatomy was performed on four formalin-fixed cadavers. RESULTS: Different from the traditional concept, both the anterior and posterior RF included the outer and inner layer with different inferomedial extensions. The multiple layers of RF extended downward to form a sandwich-like and compound fascia sheath with potential and expandable spaces which was named as "the urogenital-hypogastric sheath." Below the level of the origin of the inferior mesenteric artery, the bilateral urogenital-hypogastric sheath communicated with the counterpart in front of the great vessels in the midline and the superior hypogastric plexus ran into the urogenital-hypogastric sheath which carried the HGNs, ureters, and genital vessels downward to their terminations in the pelvis. In the retrorectal space, the urogenital-hypogastric sheath surrounded the fascia propria of the rectum posterolaterally as a layer of coat containing HGNs. CONCLUSION: The multiple layers of RF with different extensions are the anatomical basis of the formation of the urogenital-hypogastric sheath. As a special fascial structure in the retroperitoneal space and the pelvis, emphasis on its formation and morphology may be helpful for not only unifying the controversies about the relationship between the pelvic fascia and HGNs but also improving the intraoperative preservation of the HGNs by dissecting in the correct surgical plane.

Three dimensional reconstruction of the pancreas based on the virtual Chinese human--female number 1.

OBJECTIVE: To study the three dimensional (3D) reconstruction and 3D visualisation of the pancreas and create anatomy of the digitalised visual pancreas so as to construct a concrete basis for virtual operation and surgical operation on pancreas. METHODS: The digital imaging data of pancreas, duodenum, common bile duct, arteries, and veins were obtained from the virtual Chinese human--female 1 (VCH-F1). The image data were investigated and 380 images ascertained of pancreas picked up from images numbers 2617 to 2996. Finally, the images from number 2574 to 3017 were adopted to segment and processed using ACDSee and Photoshop so as to reconstruct 3D pancreas digitally. The data of pancreatic surfaces were transformed into Visualization Toolkit (VTK). The GUI program written with VC+ was used to display this VTK file and realise 3D visualisation of the pancreas. RESULTS: 3D reconstruction and visualisation of the pancreas and the peri-pancreatic structures (the duodenum, the common bile duct,the inferior vena cava, the portal vein vessels, the aorta, the coeliac trunk vessels) was successful. The 3D and visualised pancreas manifested itself with its complete structure as well as its adjacency to other tissues. CONCLUSION: The 3D reconstruction and 3D visualisation of the pancreas based on the digital data of VCH-F1 produces a digitally visualised pancreas, which promises a novel method for virtual operation on the pancreas, clinical operation on the pancreas, and anatomy of 3D visualised pancreas.

[Progress of treatment of wrist disorder by limited intercarpal arthrodesis].

OBJECTIVE: To review the recent progress in the treatment of wrist disorder by limited intercarpal arthrodesis and the related experimental study. METHODS: Recent original articles related to limited intercarpal arthrodesis, including clinical practice and experimental study, were extensively retrieved and carefully analyzed. RESULTS: Limited intercarpal arthrodesis could relieve pain and stabilize the wrist joint with partial motion. CONCLUSION: With suitable indication and well selected operation approach, the limited intercarpal arthrodesis should be the optimal surgical intervention than total carpal athrodesis in the treatment of wrist disorder.

[Applied anatomy of the sensate latissimus dorsal muscular flap with the lateral posterior branch of the intercostal nerve].

OBJECTIVE: To provide anatomy basis for a free latissimus dorsal muscular flap with the sensate nerve. METHODS: The structure of back and lateral chest area were dissected and the origin, alignment and distribution of the intercostals nerve within the area of latissimus dorsal muscular flap were observed in 40 adult cadaver specimens. RESULTS: The 5th to 10th lateral posterior branches of the thoracic nerve pierced from respective intercostal area near the axial anterior line and run a long distance in deep fascia. They distributed mainly in lateral latissimus skin outside the scapular line and anastomosed with the lower branch near the scapular line. Among these branchs, the 6th to 8th branches had a longer nerve distribution respectively and the pedicle of nerve and artery was parallel and long. CONCLUSION: It is possible to design a sensate latissimus dorsal muscular flap with the 6th to 8th lateral posterior branch of the intercostal nerve.

Anatomic basis of iliac crest flap pedicled on the iliolumbar artery.

This paper presents the anatomy and clinical applications of an iliac crest flap pedicled on the iliolumbar artery. 54 iliolumbar arteries were filled with pink plastic in 27 adult cadavers. Their origin, course and branches, and the surroundings were investigated, and the external diameter, length of segments and terminal distribution were measured. The iliolumbar artery was constant, but with a few variations. Its length was 7.0 +/- 3.9 cm, and the outer diameter 2.0 +/- 0.4 mm at the lateral edge of the psoas major muscle. Based on the anatomic findings, the surgical technique for a bone flap based on the iliolumbar artery was designed. Its clinical applications included both free bone grafting (in 2 patients) and pedicled bone transfer (in another 2 patients). The clinical results were satisfactory. The iliac crest flap pedicled on the iliolumbar artery is a reliable bone flap for clinical usage.

Changes and implications of blood flow velocity of the vertebral artery during rotation and extension of the head.

OBJECTIVE: To study the effects of extension and extension-rotation of the head on the blood flow velocity of the vertebral artery experimentally and clinically. DESIGN: Randomized experimental clinical study. SETTING: Institute of Clinical Anatomy and Biomechanics and the Department of Ultrasound, NanFang Hospital of the First Military Medical University, Guangzhou, China. SUBJECTS: The fresh spines from T1-2 to the occipital bone were obtained from persons who died of acute brain death (n = 10). For the transcranial Doppler measurement, 27 asymptomatic subjects with routine physical examination results and 23 students from the above-mentioned university took part in the test. INTERVENTIONS: The instillation experiment in the cadavers was made. Clinical measurements of blood flow velocity in the vertebral artery in the subjects and students were taken and recorded. MAIN OUTCOME MEASURES: Changes in the drop of the vertebral artery were measured by the instillation test in the experimental sample. The blood flow velocity was measured with transcranial Doppler sonography during extension and extension-rotation of the head. RESULTS: During one-sided rotation of the head with extension of the head, measurements in the contralateral vertebral artery and the bilateral vertebral arteries were both reduced in the instillation experiment. The blood flow velocity in the bilateral vertebral arteries decreased during extension and extension-rotation of the head in the subjects and the students. The pulsatility index in the right vertebral arteries increased more than that in the left in extreme extension and that in the bilateral vertebral arteries in neutral position. CONCLUSIONS: Extreme rotation and extension are dangerous to patients who have abnormal vertebral arteries when extreme rotatory and extension manipulations are applied. Doctors should be very careful when rotating the patient's head to the right side.

[Applied anatomy of the paraumbilical flap with the lateral anterior branch of the thoracic nerve].

OBJECTIVE: To provide the anatomical basis for the free paraumbilical flap with sensory nerve. METHODS: The morphology, branch and distribution of the inferior epigastric artery and inferior intercostal nerve were dissected and measured in 20 adult cadaver specimens. RESULTS: The diameter of inferior epigastric artery at the original point was (2.3 +/- 0.3) mm, and that of its accompanying vein was (3.6 +/- 0.4) mm. The anterial branch of inferior intercostal nerves transversed through their corresponding intercostal spaces of axilla anterior line and ran out of the superficial fascia at the midclavicular line. The lateral anterior branch of the eighth to tenth intercostal nerves ran out of superficial fascia in the range of 0-7 cm above umbilicus and innervated the paraumbilical flap. CONCLUSION: It is possible to design sensory paraumbilical flap with the lateral anterior branch of the eighth to tenth intercostal nerve.

Diagnostic value on signs of subluxation of cervical vertebrae with radiological examination.

OBJECTIVE: To investigate the relationship between radiographic signs of subluxation in the cervical vertebrae and their clinical diagnostic value. DESIGN: Controlled, clinical study. SETTING: Institute of Clinical Anatomy and Biomechanics and NanFang Hospital of the First Military Medical University, Guangzhou, China. SUBJECTS: Eighty-seven subjects with cervicodynia and 21 asymptomatic volunteers. INTERVENTIONS: Radiological signs of subluxation from anteroposterior, lateral, open-mouth and dynamic radiographs of the cervical vertebrae of the subjects were measured and analyzed. MAIN OUTCOME MEASURES: The right and left odontoid lateral mass interspace, divergence of the spinous processes, sign of double contour and position of odontoid process were studied. RESULTS: The bilateral odontoid lateral mass interspaces were asymmetrical in most cases, and the divergence of spinous processes, sign of double contour and position of odontoid process were also common. Cervical vertebrae C5, C4 and C6 showed no special variations. CONCLUSION: There was little evidence to support the contention that signs of subluxation in the cervical vertebrae are of diagnostic significance. Subluxation should be defined in two ways: as a purely roentgenological diagnosis and as a combination of roentgenological signs with clinical signs.

Spinal manipulation in China.

BACKGROUND: Although there is a long history of the use spinal manipulation in China, little has been formally written on this topic. OBJECTIVE: To discuss the history and status of Chinese spinal manipulation. DISCUSSION: This article describes the history of Chinese spinal manipulation as revealed through past formal textbook publications on this topic, along with journal articles describing both the basic science foundation and clinical applications of such manipulation. In addition, the current status of Chinese spinal manipulation is described. CONCLUSION: There is a long history of the use of spinal manipulation throughout China, though some basic problems of application remain. Current research may help to resolve these problems.

The effect of cervical traction combined with rotatory manipulation on cervical nucleus pulposus pressures.

OBJECTIVE: To study experimentally the effect of cervical traction combined with rotatory manipulation on the pressure of the cervical nucleus pulposus. DESIGN: Randomized experimental study. SETTING: Institute of Clinical Anatomy and Biomechanics, the First Military Medical University, GuangZhou, China. SUBJECTS: Twelve fresh cervical spines, from C7 to occipital bone, were obtained from cadavers of patients who had died from acute brain death. INTERVENTION: State A: under different traction forces, the cervical spine was rotated. State B: the cervical spine was rotated first and then tractioned. State C: the cervical spine was tractioned and rotated simultaneously. MAIN OUTCOME MEASURES: The cervical spine was tractioned and rotated by the Material Test System (MTS), and pressures of the cervical nucleus pulposus of C3-4, C4-5 and C5-6 were measured using pressure sensors. RESULTS: (a) When the traction force increased, the pressure fell continuously in the 200-N tractioned spines; the pressure increased slightly when the sample was rotated. (b) The pressure fell to a certain extent when the state of cervical spine was restored. (c) In state A, the pressure fell obviously and increased slightly under a 200-N traction force and then the sample was rotated; in state B, the pressure first increased to a certain extent and then fell slightly and in state C, the pressure underwent no change in the main. CONCLUSIONS: The results of this research suggest that rotatory manipulation of cervical spine under traction was the safest of the three procedures and the traction force used in clinical treatment may be a little smaller.

Biomechanical characteristics of human trabecular bone.

OBJECTIVE: To evaluate the effect of strain rate (varepsilon), apparent density (rho(a)) and tissue density (rho(t)) on Young's modulus (E), strength (sigma(u)) and ultimate strain (varepsilon(u)) on intervertebral bone from a Chinese population. METHODS: Testing was performed by uniaxial compression at five strain rates on 36 human trabecular bone specimens from three male T(12) thick similar L(4) vertebrae. RESULTS: Apparent density ranged between 0.46 and 0.71 g/cm(3). Tissue density ranged between 1.02 and 1.54 g/cm(3). Non-linear regression analyses using strength, Young's modulus or ultimate strain as dependent variables (Y) and strain rate and apparent density or tissue density as independent variables were performed using the following equation: Y = arho(b)varepsilon(c). The exponent of apparent density and strain rate to Young's modulus were 1.88 and 0.07, separately (P = 0.0007). The variation of strength was explained only by apparent density with an exponent of 1.29 (P = 0.0107). The variation of Young's modulus was explained equally by the quadratic and cubic relationship to apparent density or tissue density (P < 0.01). Ultimate strain varied independently of apparent density or tissue density and strain rate.

Anatomic basis of venous drainage in donor flaps.

The venous architecture in donor flaps was observed in 17 fresh cadavers by injection of latex or ink into the vessels or by making corrosion-cast specimens. The pattern of the veins resembles that of the arteries, with the difference that there is another set of venous trunks which do not accompany the arteries. Because these trunks are of larger caliber, they are the main drainage route for flaps. There are three types of drainage based on the anatomical architecture: 1) the superficial trunk is the main drainage path; 2) the deep trunk is the main path; 3) both superficial and deep veins are involved. These morphological considerations are the basis for selection of veins for anastomosis in microsurgery. The axial veins in temporal, frontal and facial flaps on the dorsum of the hand and the foot usually loosely accompany the axial arteries. The characteristics of these vascular pedicules should be studied in transplant operation.

Behavior of axons, Schwann cells and perineurial cells in nerve regeneration within transplanted nerve grafts: effects of anti-laminin and anti-fibronectin antisera.

Wistar rats (close cloned strain) were used to investigate the effect of endogenous laminin and fibronectin on axons, Schwann cells and perineurial cells in the regenerating peripheral nervous system (PNS). Sciatic nerve grafts obtained from donor rats were frozen, thawed and treated with rabbit anti-rat laminin or anti-fibronectin antiserum. Control grafts were treated with normal rabbit serum alone. One cm long portions of the sciatic nerve of the recipient rats were replaced with grafts. At 15 days after transplantation the number of regenerated axons in the laminin- and fibronectin-depleted grafts was half of that in the control. The growing axons in the laminin-depleted grafts did not recognize the basal lamina scaffolds (BLS) remaining in the basal lamina tubes, while in the control and fibronectin-depleted grafts 90% or more of axons grew inside the BLS. Elongation of axons always preceded migration of Schwann cells with the latter subsequently adhering to and wrapping around the former. Perineurium-forming fibroblastic cells recognized the combination of axons and Schwann cells and formed perineurial fasciculi around them. These fibroblastic cells did not recognize empty BLS but responded to them only when fibronectin was depleted. Macrophages sometimes closely faced the naked axons which elongated outside the BLS. These results suggest that in the early stages of nerve regeneration endogenous laminin and fibronectin not only regulate the growth of regenerating nerve fibers, but also exert a positive influence on perineurial cells and macrophages, both of which play important roles in nerve tissue injury and repair.

Blood supply of the flexor digital tendon in the hand and its clinical significance.

An anatomical study on the blood sources and vascularity of the flexor digital tendon was conducted in the upper extremities of fresh cadavers by means of arterial injection and meticulous dissection of the transparent tendon under the microscope. According to whether or not synovial membrane surrounded the tendon, the flexor digital tendon can be divided into 2 regions: non-synovial and synovial. The major intrinsic blood supply of the digital tendon was in the form of longitudinal vascular bundles, while the transverse anastomotic branches were short and sparse. The non-synovial region of the tendon was covered by paratenon and the vascular distribution of this region was uniform. In the synovial sheath, the blood vessels distributed only on the dorsal side, while the volar side was devoid of vessels. The profundus and superficialis tendons had an avascular zone at the proximal interphalangeal and metacarpophalangeal joints respectively. It was considered that the difference of the vascular architecture might be related to the mechanical force to which the tendon was subjected. The nutrition of tendon was discussed and the selection of tendon graft at operation was suggested.