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Kościuszko et al. Hepatoma Res 2021;7:51 https://dx.doi.org/10.20517/2394-5079.2021.17 Page 9 of 16

transplant (while the graft was still functioning).

[54]
Su et al. described a study conducted on 26 children aged 22 days to 36 months with giant liver tumours.
The Hisense CAS system was used in the reconstruction group and CT workstation examination in the
control group. Based on the reconstruction, the procedure was simulated. The 3D images were also
displayed in the operating room during the operation. It was concluded that the 3D images can precisely
locate the tumour and its vascularisation. Eight patients received blood transfusions, and the mean operative
time was shorter in the study group. The mean intraoperative blood loss was lower in the study group. Both
differences were statistically significant.

Warmann et al. designed a study that aimed at defining the role of computer-aided surgical planning in
[55]
children with advanced hepatic tumours, i.e., those affecting three or four sectors of the liver. The primary
outcome was the possibility to avoid liver transplantation. The authors used the MEVIS service. Surgical
planning is offered by MEVIS as a commercial product, and results are embedded in a 3D interactive PDF
[56]
file . Sixty-three patients were evaluated, but only 24 had computer-aided surgical planning performed.
Most of the patients had a CT-scan, but, interestingly, the authors did not see any difference in quality
between CT scans and MRI scans. The authors stated that the 14 patients with hepatoblastoma affecting
three or four liver sectors post-chemotherapy (POST-TEXT III or IV) were potential candidates for liver
transplantation, but, finally, only two patients were qualified for a liver transplant. The authors observed
close relationships between computer-aided surgical planning and intraoperative findings. Resection
margins were free of tumour cells. The authors found variations and significant differences in segmental
distribution between the patients. Variations in segment volume were presented as mean percentage and
ranges. They analysed the disease-free survival rates of the hepatoblastoma patients, and the overall survival
rate was 90% after five years.

In 2016, Zhang et al. published a cohort study comparing two groups of children who underwent
[57]
hepatectomy. Before surgery, all children had CT scans performed. CT images of eleven children were
reconstructed using Hisense CAS, and 10 children were operated on without performing 3D
reconstructions of the images. The two study groups were compared. No positive margins, no
complications and no recurrences of the disease were noted in both groups. The authors stated statistically
shorter surgery duration, less intraoperative bleeding and shorter hospital stay in the reconstruction group.

[58]
Another study was published in 2017 by Janek et al. . They also used MeVis distant services for surgical
planning. Their cohort consisted of five children diagnosed with hepatoblastoma. Post-surgical liver volume
was 28%-70%, and none of the children suffered from post-resection liver failure. Liver volumetry was
performed in OsiriX (at the time of diagnosis) and by MeVis (after neoadjuvant chemotherapy). The lowest
recorded FRL equalled 28% and was well tolerated. The authors also used OsiriX for liver volumetry but
found the analysis time-consuming. The authors also stressed that risk analysis performed by MeVis is
fundamental, and the 3D topographic-anatomical visualisation is complete. The analysis by MeVis also
contains suggested resections with calculations of liver volumes. In one of the patients, the authors used
Biliskopin™ for the analysis of the biliary tract. The price of the MeVis analysis is about 700-800 euros, as
stated by the authors.

Five children with hepatic mesenchymal hamartomas participated in a study by Zhao et al. . The children
[59]
were 8-24 months old. 3D liver reconstructions were prepared for all children based on CT examinations,
including three children using the Hisense CAS software. With this software, a virtual hepatectomy was
performed with the calculation of the residual volume. Based on the simulation, the optimal surgical