数字3D技术在胸外科中的发展及应用

doi:10.3877/cma.j.issn.1674-6899.2021.06.014

计算机技术已经经历了70余年的发展，在20世纪90年代通过电视辅助胸腔镜手术(video assisted thoracic surgery, VATS)才真正与临床医学结合，尤其是在胸外科领域的应用起来，是胸外科技术发展史上具有里程碑意义的事情。此后30年来，胸外科学在以VATS为主要手术方式的引导下完成了各式手术并发展至今。近年来，计算机硬件技术和软件水平有了突破式的发展，各类专用设备、配套软件等与各医疗专科结合形成了各专业不同技术特色的，以复合型技术支撑为引导的学科技术体系，在胸外科领域的疾病诊断、小结节定位、治疗中已有大量运用和研究探索。在小结节定位方面，笔者对术前CT引导下亚甲蓝注射、术前CT引导下医用胶注射、术前CT引导下cook微弹簧圈定位、术前CT引导下Hook-Wire穿刺定位、电磁导航定位在临床上的应用进行了总结回顾，以及总结笔者所在医院在部分技术实际应用操作中的经验。在胸部疾病治疗方面，3D技术在早期肺癌小结节精准切除的运用中显现出优势，3D打印技术也通过个体化增材制造技术在胸外科(诸如完成了胸壁缺损修复、气管支架置入、骨性关节重构等)应用并取得了满意疗效。相信在未来，随着3D技术与胸外科手术技术的发展、运用和更好地结合，能更好地发挥出数字3D技术在临床应用中的价值，产生更好的社会经济效益，造福广大患者。

关键词: 数字3D技术, 胸外科手术, 肺结节定位

Computer technology has undergone more than 70 years of development. It was only in the 1990s that video assisted thoracic surgery (VATS) was truly integrated with clinical medicine, especially in the field of thoracic surgery. In the following 30 years, thoracic surgery has completed various operations under the guidance of VATS as the main surgical method and has developed to this day. In recent years, computer hardware technology and software level has undergone breakthrough development. All kinds of special equipment and supporting software have been combined with various medical specialties, forming a system with different technical characteristics of various professions with composite technology support. In the field of thoracic surgery, there have been a large number of applications and research explorations in diagnosis, small pulmonary nodules localization, and treatment. This article reviewed techniques to localize small pulmonary nodules, including CT-guided methylene blue positioning, CT-guided percutaneous puncture medical glue positioning, CT-guided cook microcoil positioning, CT-guided Hook-Wire puncture positioning, and electromagnetic navigation positioning and shared some experience in the application of some technologies in medical center the author working for. In the treatment of thoracic diseases, 3D technology has shown its advantages in precise sublobar lung resection, while 3D printing technology completed complex operations such as sternocostal reconstruction, airway stent insertion, bone joint reconstruction, etc. and achieved satisfactory results through personalized additive manufacturing technology. It is believed that, in the future, with the development, application and better combination of 3D technology and thoracic surgery technology, the value of digital 3D technology in clinical applications can be better brought into play, resulting in better social and economic benefits, and benefiting more and more patients.

Key words: Digital 3D technology, Thoracic surgery, Pulmonary nodules localization

图1 CT检查诊断技术的进步注：A.世界上第一幅由CT扫描获得的人体图像——颅脑CT，分辨力较低，矩阵像素较大；B.曲面重建及最大/最小密度投影技术处理得到的主动脉夹层图像，可以清晰看到夹层的位置和范围(箭头所示)；C.经过三维处理后可以多角度、直观对病变进行显示，诊断评估更加准确

图2 术中CT引导结节穿刺定位方案注：A.术中CT专用扫描机架，孔径较普通CT为大；B.穿刺定位用格栅；C.穿刺置入定位针Hook-Wire后再次CT扫描的影像，箭头所示为病变位置

图3 光学导航定位注：A.光学导航定位的实施场景；B.胸腔镜下术中定位实况，圆圈处为病变所在位置

图4 增强现实导航下气管镜定位小结节注：A.气管镜下现实影像与增强现实建模影像；B.运用增强现实技术进行支气管及小结节建模定位

图5 不同切除范围下的胸外科手术模式注：A.肺叶切除；B.肺段切除；C.亚段切除

图6 将二维CT图像转化为3D并经过3D打印指导手术的具体步骤注：A.右肺上叶尖段结节在CT图像位置(黄色箭头示)；B.与病变相关的气管三维重建；C.静脉的三维重建；D.全部解剖结构三维重建(箭头示病变位置)；E.经1∶1的3D打印解剖模型；F.术后切除的右上肺尖段肺组织(箭头示病变位置)

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