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Kościuszko et al. Hepatoma Res 2021;7:51 https://dx.doi.org/10.20517/2394-5079.2021.17 Page 3 of 16

[13]
research on surgery with mixed reality and crucial articles to create a broader search. The search strategy
is described in Table 1. It was conducted on 25 January 2021, and the initial results were screened by three
reviewers to identify relevant studies.

Inclusion and exclusion criteria
Original studies concerning liver surgery in children, preferentially hepatic tumour surgery, were included.
In addition, studies concerning virtual reality, augmented reality, mixed reality and 3D printing were
included. We excluded articles expressing individual opinions (letters or commentaries), reviews and
studies concerning adults, bioengineering and non-medical publications. Studies that did not mention
patient age were also excluded.

Data extraction and analysis
Extracted information included: type of imaging studies performed, software or service used, number of
patients, 3D imaging modality, measured outcome variables, the main results and the advantages and
disadvantages of different methods.

PLAN (RADIOLOGICAL ASSESSMENT)
Imaging is the critical components of precision medicine and precision liver surgery. The surgeon expects
[14]
exact, relevant information from the radiologist. Advances in cross-sectional imaging allow better treatment
efficacy and patient safety .
[15]

The aim of liver tumour imaging is to answer the following questions: is the tumour present, is it malignant
or benign and, most importantly, whether complete surgical resection is plausible. To answer them, one
should choose the best imaging modality.

The clinician has three main methods of cross-sectional liver evaluation available: ultrasound (US),
computed tomography (CT) and magnetic resonance imaging (MRI).

Due to the wide accessibility and patients’ small size, US is the primary diagnostic tool for assessing liver
tumours in the paediatric population. One can describe the lesion’s size, character (solid vs. cystic) and
vascularity during ultrasound examination. This assessment is quick and relatively inexpensive. It may be
difficult to establish the lesion’s extent due to the small field of view, especially when the tumour is large.
The inspection for local and distant metastases may be uncertain as well.

Radiation-free imaging, similar to US, is favourable for children as they are much more susceptible to
ionising radiation than adults and they are prone to developing radiation-associated side effects, including
[16]
cancer .

Doppler (colour, power, pulsed, etc.) mode can be used to identify the presence or absence of blood flow in
a mass, lesion or tumour thrombus in the portal vessels. The characteristics of doppler signal may suggest
the organ of origin .
[17]

Somewhat new, but supported with multiple publications (unfortunately, mainly concerning adults and
only scarcely paediatric population), contrast-enhanced ultrasound (CEUS) is emerging as a new liver
tumour evaluation method (even though it has been known for over 20 years).