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Application of three-dimensional visualization technology in early surgical repair of bile duct injury during laparoscopic cholecystectomy

BMC Surgery volume 24, Article number: 271 (2024) Cite this article

Abstract

Objective

This study aimed to explore the application value of three-dimensional (3D) visualization technology in the early surgical repair of bile duct injury during laparoscopic cholecystectomy (LC).

Methods

A retrospective analysis was conducted on the clinical data of 15 patients who underwent early surgical repair of bile duct injury during LC with the assistance of 3D visualization technology at the Hepatobiliary Surgery Department of Ningxia Hui Autonomous Region People’s Hospital from January 2019 to December 2022. Postoperative efficacy and long-term follow-up outcomes were summarized.

Results

Before the repair surgery, 15 cases of bile duct injury during LC were evaluated using 3D visualization technology according to the Strasberg-Bismuth classification: 2 cases of type C, 4 of type E1, 3 of type E2, 3 of type E3, and 3 of type E4. Intraoperative findings were consistent with the 3D visualization reconstruction results, and all patients successfully underwent hepaticojejunostomy using Roux-en-Y anastomosis guided by the 3D visualization navigation. The time interval between LC and bile duct repair surgery ranged from 5 to 28 (14.2 ± 9.7) days. The surgical time was between 120 and 190 (156.40 ± 23.92) min, and estimated blood loss ranged from 80 to 250 (119.66 ± 47.60) mL. The length of hospital stay ranged from 12 to 25 days (median: 16 days). One patient experienced mild bile leakage after the operation, which healed with conservative treatment. All patients were followed up for 12–56 months (median: 34 months) without any loss to follow-up. During the follow-up period, no complications, such as anastomotic stricture or stone formation, were observed.

Conclusion

The application of 3D visualization technology for preoperative evaluation and intraoperative navigation can accurately and effectively facilitate early surgical repair of bile duct injury during LC and has clinical value for promotion and application.

Peer Review reports

Introduction

Laparoscopic cholecystectomy (LC), when complicated by biliary injury, can cause serious physical and psychological pain for patients and lead to medical disputes and administrative penalties for physicians. Therefore, successful biliary surgery repair is crucial [1]. LC-associated biliary injuries are often detected early postoperatively, but uncertainties remain in perioperative assessment and intraoperative exploration, such as the preoperative identification of the injury site and the determination of high bile duct injuries. Over the past three decades, various imaging techniques, such as abdominal enhanced computed tomography (CT) and angiography, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous transhepatic cholangiography (PTC), have been individually applied to evaluate bile duct injury [2,3,4,5,6]. However, each of these methods has its limitations. Three-dimensional (3D) visualization technology has been widely used for preoperative evaluation and intraoperative navigation in the radical resection of liver cancer [7,8,9]. This technology can more intuitively display the positional relationship among tumors, blood vessels, and bile ducts. However, there are few reports on the clinical application of early surgical repair of iatrogenic bile duct injury. This study retrospectively analyzed the clinical data of early surgical repair of biliary injuries following LC, assisted by 3D visualization technology. The study discussed the application value of this technology in the early surgical repair of iatrogenic bile duct injuries, as reported below.

Patients and methods

This study retrospectively analyzed the clinical data of 15 patients with bile duct injury during LC who underwent early repair surgery assisted by 3D visualization technology in the Department of Hepatobiliary Surgery, People’s Hospital of Ningxia Hui Autonomous Region from January 2019 to December 2022. Among the 15 patients, 1 patient suffered from bile duct injury during LC in our center, and the other 14 patients were transferred to our center from the general surgery department of four different county-level hospitals in the province. All patients and their families signed the informed consent before surgery. This study was approved by the Ethics Committee of the People’s Hospital of Ningxia Hui Autonomous Region (Ethics [2024] -LL-027).

Reconstruction and evaluation of 3D visualization technology

All patients underwent an upper abdominal enhanced 512-slice spiral computed tomography (CT) scan (PHILIPS BRILLIANCE, the Netherlands). Before CT examination, patients need to practice deep breathing and holding their breath to avoid CT image artifacts caused by breathing movements. The enhanced CT scan was completed at a voltage of 120 kV and a current of 200mAs, and the cross-sectional scan was performed from the top of the diaphragm to the lower margin of both kidneys with a slice thickness of 0.5 mm. Enhanced scanning agent iopromide (300 mg/ml) was injected through Medrad Stellant D-CE high-pressure injection system (MEDRAD, Germany), and three phases of unenhanced, arterial and venous images were acquired. CT images were archived and exported in Digital Imaging and Communication Standard in Medicine (DICOM) format and uploaded to 3DMIS software (inlook3D Company, Hubei, China).A clinically experienced hepatopancreatobiliary surgical specialist and technical personnel finally completed the reconstruction images. The enhanced CT images of the upper abdomen were reconstructed into continuous 3D images. Automatic or semi-automatic image segmentation algorithm was used to identify and extract the liver region. Due to the fine and complex structure of the biliary tract, more advanced segmentation methods, such as deep learning-based segmentation networks, are usually used. Using the partitioned liver and biliary tract data, the three-dimensional model was generated by the surface reconstruction method of Marching Cubes algorithm. In the process of 3D reconstruction, the morphology of hepatic vessels was manually tracked according to the development characteristics of hepatic arteries and portal veins in arterial phase and venous phase, and the morphology of bile ducts was manually tracked according to the development characteristics of bile ducts in portal venous phase.

The 3D reconstructions had the following main application: (1) Before the biliary tract repair surgery, the surgical team used the 3D reconstruction analysis platform to rotate and clear different tissues, vessels, and organs in 360 degrees. They observed the location of the biliary tract injury, the relationship between biliary tract injury and hepatic artery and portal vein, the distance from the hepatic hilum, and the presence or absence of liver ischemia or atrophy. (2) During the repair operation, the 3D reconstruction report was combined to explore and determine the opening of the bile duct injury, identify variations in the bile duct, identify tissues and blood vessels around the bile duct, and clarify the type of bile duct injury under the 3D visualization technology.

Surgical strategies and procedures

The general strategy for early repair surgery after bile duct injury in this study included a detailed evaluation of the location of bile duct injury, the defect or truncation of the bile duct, and the vascular injury. Special attention was given to the overall anatomical integrity of the hepatic hilar region, the degree of inflammation, the presence or absence of active bleeding, and the blood supply to the liver and duodenum to determine the type of biliary injury. The primary surgical method was hepaticojejunostomy using Roux-en-Y anastomosis. The specific repair techniques varied depending on the type of injury damage and included single or multiple hepatic duct openings jejunum with Roux-en-Y anastomosis (with or without a biliary supporting tube), common bile duct to jejunum Roux-en-Y anastomosis (with or without a biliary T-tube).

Postoperative follow-up

The patients were followed up regularly through outpatient reviews, telephone inquiries, and medical record system inquiries. The contents of follow-up included regular liver function, abdominal color Doppler ultrasound or T-tube cholangiography within three months after the repair surgery, MRCP within six months after the repair surgery, and liver color Doppler ultrasound and liver function reexamination every year.

Statistical analysis

In this study, normally distributed data are expressed as mean ± standard deviation, while skewness distribution is expressed as a median (range). Count data are expressed as the number of cases and percentage. The accuracy of preoperative evaluation by 3D visualization technology was evaluated and described by comparing the number of patients corresponding to the Strasberg-Bismuth classification of biliary tract injury evaluated by different imaging techniques and the coincidence of intraoperative exploration.

Results

Patient characteristics

A total of 15 patients with bile duct injury during LC were enrolled in this study, including 6 males and 9 females, aged 31–62 (44.4 ± 10.3) years. The primary gallbladder diseases of 15 patients included 8 cases of cholecystolithiasis with acute cholecystitis (53.33%), 2 cases of cholecystolithiasis with chronic cholecystitis (13.33%), 1 case of Mrrinz syndrome (6.66%), 3 cases of gallbladder polyps (20%), and 2 cases of atrophic cholecystitis (13.33%). All patients were diagnosed within one week after LC. A total of 7 patients presented with bile leakage, 5 with jaundice, and 3 with both jaundice and bile leakage.

Strasberg-Bismuth classification of biliary injury with different imaging

Among the 15 cases of bile duct injury during LC, 4 cases of common hepatic duct transection, 2 cases of common bile duct transection, 1 case of common bile duct clamping, 6 cases of high bile duct injury, and 2 cases of ectopic right hepatic duct injury were initially determined by abdominal enhanced CT and MRCP after operation. Further evaluation of the Strasberg-Bismuth classification was performed using the 3D visualization technology. Consistency was finally determined by intraoperative exploration. As depicted in Table 1 and 3D visualization technology under the guidance of biliary injury Strasberg-Bismuth classification assessment of the accuracy was better than that of MRCP, with 100% consistency with intraoperative exploration results. Particularly in cases of high bile duct injury (Strasberg-Bismuth classification E) and liver hilum clamping laparoscopic ligation (titanium clip or Hemlock) in bile duct clip type of bile duct injury, 3D visualization technology provided a more intuitive preoperative evaluation (Fig. 1).

Table 1 Strasberg-Bismuth classification of biliary injury with different imaging
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Fig. 1
figure 1

Case of common bile duct clamping in CT, MRCP, and 3D visualization images.A CT only showed high density shadow in the hepatic hilar area. B MRCP indicated bravery manager transverse linear low signal shadow. C 3D visualization was close to the real state to simulate the clamping state of common bile duct

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The area of biloma distribution and the type of biliary injury guided by 3D visualization technology

Table 2 The area of biloma distribution and the type of biliary injury guided by 3D visualization technology
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Different ranges of biloma formed in the hilar region in 15 patients with bile duct injury during LC (Table 2). Biloma was confined to one side of hepatic hilar region in patients with bile duct injury diagnosed as type C, E1 and E2 of Strasberg-Bismuth classification (Fig. 2A), while biloma was widely distributed in the whole hepatic hilar area in patients with bile duct injury diagnosed as type E3 and E4 of Strasberg-Bismuth classification (Fig. 2B).

Fig. 2
figure 2

3D visualization of biloma after bile duct injury in typical cases. A 3D visualization imaging of biloma after bile duct injury as type E2 of Strasberg-Bismuth classification. B 3D visualization imaging of biloma after bile duct injury as type E4 of Strasberg-Bismuth classification

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The repair surgery of bile duct injury guided by 3D visualization technology

Implementing biliary surgery to repair 15 cases from LC time interval in 5–28 (14.2 ± 9.7) days, all smooth implementation issues of biliary surgery to repair, specific as follows: Seven patients underwent Roux-en-Y hepaticojejunostomy (including three patients with T-tube drainage of bile duct), four patients underwent Roux-en-Y hepaticojejunostomy with multiple hepatic duct openings and bile duct drainage, two patients underwent perihilar resection with Roux-en-Y hepaticojejunostomy with multiple hepatic duct openings, and two patients underwent right hepaticojejunostomy. In type, Strasberg-Bismuth E biliary injury, 3D visualization technology provided significant advantages for preoperative and intraoperative evaluation by identifying the position of the bile duct injury, the number of bile duct openings, and the relationship with adjacent blood vessels. Bile duct injury can be determined accurately using the Strasberg-Bismuth classification example (Fig. 3).

All patients with operation time was 120–190 (156.40 ± 23.92) min, the bleeding in 80–250 (119.66±47.60)mL. One patient who underwent perihilar resection and Roux-en-Y hepaticojejunostomy had mild bile leakage and was cured after continuous abdominal drainage for 20 days, which was considered to be caused by bile capillary leakage in the liver section. The hospital time of all patients was 12–25 days (median time 16 days), without perioperative deaths.

Fig. 3
figure 3

3D visualization technology in early surgical repair for Strasberg-Bismuth type E4 bile duct injury.A-B Bile duct injury in axis and coronary CT images. C MRCP images of bile duct injury. D–F 3D visualization image of bile duct injury and adjacent relationship between portal vein and hepatic artery. G Biloma in the hepatic hilar region. H Impaired bile duct openings were identified under the guidance of biliary probe. I Biliary support tube placed. J Procedure of hepaticojejunostomy with multiple hepatic duct openings. K Status after hepaticojejunostomy. L MRCP performed 6 months after surgery

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Postoperative follow-up

Until October 2023, all patients were followed up for 12–56 months (median time: 34 months) without cases lost to follow-up. More than four regular hepatic duct openings jejunum anastomosis of Roux-en-Y and bile duct supporting tube drainage in patients with bile duct supporting tubes within 3 months to fall off. Three patients who underwent hepatic duct jejunum Roux-en-Y anastomosis with T-tube drainage had their T-tubes removed 3–4 months post-surgery. All patients were not seen during the follow-up period of reflux cholangitis, complications such as anastomotic stenosis, and stone formation.

Discussion

LC is the most common cause of iatrogenic bile duct injury [10]. Some patients are identified and repaired intraoperatively, but most cases are discovered postoperatively when the damage is more severe [11, 12]. The timing of postoperative repair surgery for LC-related bile duct injury is a subject of ongoing debate [13]. Many experts consider 4–6 weeks post-LC as a critical cut-off point, dividing it into early and late (or deferred) repair [14]. By this time, infection-induced edema typically subsides, reducing the risk of infection and improving the outcomes of the repair surgery. Some studies have indicated [15] that there is no significant difference between the timing of repair surgery and the occurrence of postoperative complications. However, we believe that delaying biliary tract repair time may cause prolonged pain for patients and long-term psychological pressure for the surgeon. Accurate evaluation and early repair surgery should be the ideal strategy for the repair of LC-related biliary tract injury. Our results demonstrated that early repair of biliary tract injury in LC with the assistance of 3D visualization technology highlights certain advantages.

A total of 15 patients were diagnosed with postoperative iatrogenic bile duct injury. Despite the initial clinical physicians understanding of bile duct injury degree, referral, and repair preparation factors leading to variability in the timing of early repair surgery, the 15 cases of patients with LC implement biliary surgery to repair a distance interval in 5–28 (14.2 ± 9.7) days. All patients underwent early repair surgery after LC. We believe that the timing of LC postoperative biliary injury repair should consider the classification of bile duct injury, including clinical characteristics such as jaundice, bile leakage, and combined jaundice-type with bile leakage. This helps specialists determine the appropriate timing for the repair operation. Among the 15 patients with primary gallbladder diseases, acute cholecystitis accounted for 53.33% (8/15), and the proportion of patients with bile leakage was 66.66% (10/15). With the assistance of 3D visualization technology, we accurately evaluated the classification of bile duct injury before operation and combined the results of 3D reconstruction during operation to improve the efficiency of bile duct injury opening exploration. All 15 bile duct injury repairs were successful, demonstrating the practical application value of early surgery with 3D visualization assistance.

The value of plain CT in the diagnosis of bile duct injury is limited. The cholangiogram characteristics of enhanced CT in different periods, providing raw images for 3D visualization technology, could help radiologists to initially determine the approximate location and adjacent vessels of biliary tract injury [16, 17]. However, enhanced CT is a two-dimensional image, and only when combined with sufficient knowledge of liver anatomy and surgical experience in dealing with biliary tract injury, biliary surgeons can image the shape of bile duct tree in the brain to complete the repair of biliary tract injury. MRCP can fully display the bile duct tree and has significant diagnostic value for bile duct defects [4, 18]. The injury caused by hemlock clamping the hepatic duct only shows false lines on MRCP while the bile duct is of good continuity (as shown in Fig. 1), which is easy to cause misdiagnosis.The 3D visualization technology can intuitively, stereoscopically, and comprehensively evaluate the confluence mode and spatial conformation of hepatic hilar vessels. It can quantitatively evaluate the position of bile duct stenosis, the depth of the hepatic hilar, the rotation angle of hepatic hilar, and the volume of liver segments to determine whether there is liver atrophy. Furthermore, the team of surgeons can use 3D visualization technology to better communicate the understanding of hepatobiliary anatomy, without being limited to the abstract impression of two-dimensional images. In the preoperative evaluation of early repair of biliary tract injury during LC in this group of 15 cases, compared with abdominal enhanced CT and MRCP, 3D visualization technology proved more intuitive and comprehensive in the evaluation of iatrogenic biliary tract injury. For middle and low bile duct injury caused by transection or stenosis of the common bile duct, 3D visualization technology indicated the location and length of the bile duct injury and its relationship with the main vessels in the hepatic hilar area.For minor bile duct injury, such as bile leakage caused by minor injury of the aberrant bile duct in the gallbladder bed, because the bile duct above the injury site is in a non-dilated state, 3D visualization technology based on CT cannot directly determine the classification of bile duct injury, while ERCP [19] or PTC [5, 20] has more advantages.

In evaluating high-level bile duct injury, the advantages of 3D visualization technology lie in simulating the exposure of the bile duct opening and evaluating the need for perihilar resection. During the bile duct 3D visualization model set-up process, the distribution of biloma after laparoscopic cholecystectomy and the severity of the biliary injury may have a certain correlation. Biloma is considered to be caused by abdominal cavity fluid accumulation formed in the process of bile leakage [21]. This study showed that the distribution characteristics of biloma in the hilar region were partially correlated with the Strasberg-Bismuth classification of bile duct injury. The higher the biliary injury, the wider the distribution of biloma, which may extend through the lumen of the lesser omentum. We speculate that the reason may be that the higher the position of biliary tract injury at the level of hepatic hilar, the greater the destruction scope of minor omental cavity, which is not conducive to the aggregation of biliary effusion. A multicenter retrospective study also reported [22] a statistically significant correlation between the presence of biloma after laparoscopic cholecystectomy and the severity of bile duct injury (P = 0.02). The correlation of complicated bile duct injuries is eventually a clear diagnosis of Strasberg-Bismuth E3–E4 biliary injury risk increased 41.7 times. The existence of biloma affects the intuitive judgment of bile duct injury by abdominal CT or MRCP. By applying the 3D visualization technology to remove the biloma imaging part, we can finally visually display the 3D biliary tract imaging. However, we argue that the correlation between the distribution of hilar biloma and the degree of bile duct injury needs more refinement and verification of 3D visualization models due to the differences in the effect of abdominal tube drainage during LC.

We reported the experience of diagnosis and treatment of 30 cases of bile duct injury during LC. These cases were retrospectively analyzed with a focus on high-level damage. Among the patients, 15 cases were classified as Strasberg-Bismuth E2 or above of 9 cases of bile duct injury, accounting for 60%. The key to the successful repair of high-level bile duct injury is the exposure of the damaged bile duct opening. This often requires descending or perihilar resection to repair the normal bile duct opening and then complete Roux-en-Y hepaticojejunostomy [23, 24]. In clinical practice, 3D visualization technology has been well applied in the perihilar resection of hilar cholangiocarcinoma [25, 26]. It is used to evaluate key anatomical landmarks such as point B and point P and to measure the anatomical depth of the hepatic hilum. In early repair surgery for high-level bile duct injury, abdominal infection is relatively aggravated, and tissue edema is significant. This increases the risk of bleeding in the hilar plate and perihilar resection, resulting in the difficulty of identifying the bile duct opening. However, the preoperative application of 3D visualization technology allows for 3D reconstruction of the primary injury of bile duct opening amount, measurement of the depth of the damaged bile duct openings at liver gate, eventually forming simulation operation scheme. Based on 3D visualization protocol, the surgeon decreased the hilar plate or perihilar resection to expose the damaged bile duct opening. In addition, when the location or number of injured bile duct openings was uncertain, the surgeon could make accurate judgment by comprehensively using 3D visualization reconstruction results, intraoperative biliary stent guidance or intraoperative cholangiography (Fig. 3D-I) to prevent the omission of tiny bile duct openings and the occurrence of bile leakage after repair surgery.

The study also has limitations. Because bile duct injury during LC is an accidental and urgent complication, sometimes the progressive aggravation of the condition does not allow a long waiting time to complete the 3D visualization reconstruction, resulting in a small number of cases that meet the research requirements. However, the application of 3D visualization technology in the early surgical repair of bile duct injury during LC has indeed achieved exploratory results. In addition, the deep mining of the application value of 3D visualization technology must rely on the joint participation of surgeons and radiologists with rich knowledge. Unfortunately, the diagnostic value of 3D visualization is limited for such minor biliary tract injuries as Strasberg-Bismuth classification A and D.

In conclusion, 3D visualization technology is safe and feasible for assisting in the early repair of bile duct injury during LC. The auxiliary effect of 3D visualization technology is primarily highlighted in the two aspects of preoperative evaluation and intraoperative navigation of bile duct injury, offering significant application and promotion value. Recent reports suggested [27] that the LC application of intraoperative indocyanine green biliary imaging can prevent biliary injury and a secondary biliary injury repair surgery [28]. The combination of multiple image techniques and 3D visualization technology may further enhance the prospects for bile duct injury repair surgery.

Data availability

The datasets generated during and/or analyzed during the current study are not publicly available, due to the involvement of patients’ personal privacy, the data cannot be uploaded to the database at the moment but are available from the corresponding author on reasonable request.

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Acknowledgements

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Funding

Ningxia Hui Autonomous Region Key Research Project (2019 BEG03039).

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  1. Zhiqi Yang and Jing Liu contributed equally to this work.

Authors and Affiliations

  1. The Third Clinical Medical College of Ningxia Medical University, Yinchuan, 750002, China

    Zhiqi Yang, Yong Lan, Xiaochun Sha, Jianbin Cheng, Zhiming Ma & Minghao Li

  2. Department of Hepatobiliary Surgery, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan, 750002, China

    Zhiqi Yang, Jing Liu, Lang Wu, Yang Ding, Songbo Ma, Wentao Yan & Minghao Li

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Contributions

Zhiqi Yang and Jing Liu co-wrote the manuscript. Lang Wu performed statistical analysis. Yang Ding, Songbo Ma and Wentao Yan edited Figs. 1 and 2 and 3. Yong Lan and Xiaochun Sha collected the data. Jianbin Cheng and Zhiming Ma followed up with the patients. Minghao Li performed the surgeries and Zhiqi Yang, Jing Liu, Yang Ding, Songbo Ma and Wentao Yan participated the surgeries. All authors reviewed and approved the manuscript.

Corresponding author

Correspondence to Minghao Li.

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Ethics approval and consent to participate

The experimental protocol was established, according to the ethical guidelines of the Helsinki Declaration and was approved by the Human Ethics Committee of People’s Hospital of Ningxia Hui Autonomous Region. Informed consent was obtained from all subjects and/or their legal guardian(s). The study was approved by the Ethics Committee of People’s Hospital of Ningxia Hui Autonomous Region. Informed consent was obtained from all subjects and/or their legal guardian(s). All methods were carried out in accordance with relevant guidelines and regulations.

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The authors declare no competing interests.

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All study data were approved by the Ethics Committee of People’s Hospital of Ningxia Hui Autonomous Region.

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Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

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Yang, Z., Liu, J., Wu, L. et al. Application of three-dimensional visualization technology in early surgical repair of bile duct injury during laparoscopic cholecystectomy. BMC Surg 24, 271 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12893-024-02571-4

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12893-024-02571-4

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BMC Surgery

ISSN: 1471-2482

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