BRIEF CLINICAL REPORT
Experiences With Three-dimensional Printing in Complex
Liver Surgery
Tobias Huber, MD, Florentine Huettl, MD, Verena Tripke, MD,
Janine Baumgart, MD, and Hauke Lang, MD, MA. FACSY
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Objective: We present a series of cases where we used 3D printing in
planning of complex liver surgery.
Background: In liver surgery, three-dimensional reconstruction of the liver
anatomy, in particular of vascular structures, has shown to be helpful in
operation planning. So far, 3D printing has been used for medical applications
only rarely.
Methods and Patients: From December 2017 to December 2019, in 10 cases
where surgery was assumed to be challenging operation planning was
performed using full size 3D prints in addition to standard 3 phase CT scans.
Models included transparent parenchyma, hepatic veins, vena cava, portal
vein, hepatic artery, (biliary tree if requested), and tumors. In 7/10 cases
vascular reconstructions were needed during the procedure. Nonstructured
feedback of the surgical team revealed that the major benefit was visualization
of the critical areas of vascular reconstruction, the expected dimensions of
tangential vascular infiltration and the planning of reconstruction. In the
multifocal tumors, 3D prints were considered to be helpful for intraoperative
orientation to detect metastases and to improve planning of the resection.
Conclusions: In complex liver surgery with potential need for vascular
reconstructions operation planning may be optimized using a 3D printed
liver model. Prospective studies are needed to evaluate the clinical impact of
3D printing in liver surgery compared to other 3D visualizations.
Keywords: 3D printing, complex liver surgery, liver resection, three-
dimensional reconstruction
(Ann Surg 2021;273:e26–e27)
F or the planning of liver surgery precise knowledge of vascular
anatomy is of utmost importance due to the high variability of
liver anatomy.1 Preoperative routine imaging usually includes CT, or
MRI scans. In complex cases, three-dimensional reconstruction of
the preoperative data can be useful. For a better intraoperative
orientation, the images need to be transferred into a 3D model,
either by CT guided reconstruction or ‘‘mentally’’ by the surgeon.
This can be challenging even for experienced liver surgeons. So far,
3D printing has been used for medical applications only rarely, in
particular in hepatic surgery. Current literature on 3D printing in liver
surgery usually is casuistic focusing on preoperative planning as well
as education and training.2
From the Department of General, Visceral, and Transplantation Surgery, Univer-
sity Medical Center Mainz, Mainz, Germany.
Hauke.Lang@unimedizin-mainz.de.
TH receives intramural funding of the University Medical Center Mainz and
funding by the Federal Ministry of Education and Research (BMBF:
16SV8057 ‘‘AVATAR’’)
FH receives intramural funding of the University Medical Center Mainz
The authors have no conflicts of interests to disclose.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s Web site (www.annalsofsurgery.com).
Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/20/27301-0e26
DOI: 10.1097/SLA.0000000000004348
e26 | www.annalsofsurgery.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
PATIENTS AND WORKFLOW
From December 2017 to December 2019 we used preoperative
full size 3D printing to optimize surgical planning in 10 cases with
expected highly complex liver surgery. The Supplementary Table 1,
http://links.lww.com/SLA/C450 gives an overview on the cases and
surgical procedures. All cases received the routine high resolution 3
phased CT scans for operative planning <2 weeks before the surgery.
The reconstruction and printing were performed by Cella
Medical Solutions (Murcia, Spain). DICOM data was exported from
the local PACS system with the radiologic report and anonymized.
Patients gave consent to data transfer.
The CT sequences were coregistered using nonrigid, affine,
rigid and 3D iso-surface algorithms. The segmentation of each struc-
ture was done using active contours model and adaptive region growing
algorithms previous to noise reduction with anisotropic diffusion
algorithm. Models included parenchyma, hepatic veins, vena cava,
portal vein, hepatic artery, and tumors. 3D geometry resulting from
each structure was exported to mesh-type file (stereolithography).
A combination of material injectors with 3D printing
machines was used to print the geometric model. The materials
used included transparent polyurethane rubber for the parenchyma
and acrylonitrile butadiene styrene with pigments for gallbladder
(green) portal vein (violet), artery (red), and hepatic veins (blue).
Online virtual models were available within 4 days. Printed
models were delivered within 10 days after data transfer.
In 7/10 of these patients, vascular reconstruction was needed
during the procedure. Pathology confirmed an R0 resection in 9 of
cases and 1 R1 (vascular) resection in CRLM.
Compared to 544 liver resections in total and 163 major liver
resections during the same time period, the 3D print was thus used in
1.8% of all liver resections in our department (6.1% of major
resections). Vascular reconstruction was performed in 77 (14.2%)
cases of our liver resections compared to 70% of the printed cases.
All resections were performed by the same surgeon (HL)
Postoperative complications according to Clavien-Dindo3 are
shown in the Supplementary Table 1, http://links.lww.com/SLA/
C450. We have matched the printed cases to comparable liver
resections from our prospective institutional database according to
presence of bilioenteric diversion, vascular reconstruction, American
Society of Anesthesiologists (ASA) Score. The comparison of
postoperative complications revealed no significant difference (P
¼ 0.502, data not shown).
Nonstructured feedback of the surgical team revealed that the
major benefit was visualization of the critical areas of vascular
reconstruction, the expected dimensions of tangential vascular infil-
tration and the planning of reconstruction. In the multifocal case,
intraoperative orientation to find the metastases was considered
beneficial. The benefit for each case is listed in Supplementary
Table 1, http://links.lww.com/SLA/C450.
DISCUSSION
The new technology of 3D printing is still in its beginning.
According to the few data in literature 3D printing in surgery used for
Annals of Surgery  Volume 273, Number 1, January 2021
Annals of Surgery  Volume 273, Number 1, January 2021
FIGURE 1. Patient 9 with colorectal liver
metastases (A: preoperative CT scan; B: 3D
print; C: After resection and reconstruction
of the right hepatic vein with a peritoneal
patch (red arrow) taken from the diaphragm
(yellow line).
FIGURE 2. 3D print of multifocal tumor
burden in patient 10. Print available preop-
eratively with anterior (A) and posterior view
(B) and during surgery (C).
preoperative planning and for surgical teaching and training
mainly.2 In liver surgery, nearly half of the publications account
for preoperative planning, with the majority (87%) being case
reports.4 A recent analysis revealed that understanding of liver
anatomy is improved by the use of 3D printed models as surgical
residents were able to localize tumors in the liver faster and more
often correctly in 3D printed models compared to 3D reconstruc-
tions viewed on a 2D screen and the CT scan.5 In our series, 3D
printing was performed occasionally in highly selected cases only as
illustrated for patient 9 (Fig. 1). Preoperative planning of vascular
reconstruction was facilitated and improved according to the non-
structured feedback of the surgical team in cases with complex
vascular reconstruction. In multifocal tumors, planning of resection
plains was improved. In addition, intraoperative detection of small
and deeply located metastases was facilitated due to the availability
of the 3D model in the operating room (Fig. 2). These examples
refer to reconstruction of the vascular architecture mainly. However,
3-D-printing of biliary structures may be of even greater clinical
importance because hilar anatomy varies frequently, and a precise
knowledge of variations of the biliary tree may help to reduce
complications.
Currently, the costs for 3D printing is about 1500 to 2000s per
case. This includes the 3D reconstruction as stated in the text. In
contrast, the visualization by an external provider as a 3D PDF on a
regular screen of a liver reconstruction is about 600 to 900s per case
and does not require additional hardware. Both are not refunded, and
thus, it cannot be used in clinical routine but remains subjected to
complex cases so far.
Aside from 3D prints, Mixed Reality applications may also
provide the preoperative data in the operating room during liver
surgery.6,7 In a recently developed multi-user virtual reality applica-
tion for liver surgery planning,8 the preoperative liver anatomy can
also be well understood. 3D printed models and a Virtual Reality 3D
model have different advantages. While the virtual environment
ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Experiences With 3D Printing in Complex Liver Surgery
allows the transparency of the structures to be altered and the scaling
of the model to be enlarged or minimized according to the users’
preference, it potentially makes preoperative planning more flexible.
In contrast, the 3D printed model enables an improved resection
planning with regard to vascular reconstruction localization of
resection plains, thus reducing the risks for devascularization and
complications, and facilitates intraoperative detection of small and
deeply located tumors.
In conclusion, the potential use of 3D preoperative imaging
and in particular of 3D printing is hard to determine. Prospective
trials are needed to evaluate the best way to present liver anatomy
preoperatively to the surgical team.
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