Surgical and Radiologic Anatomy (2021) 43:537–544

https://doi.org/10.1007/s00276-020-02631-3

ANATOMIC BASES OF MEDICAL, RADIOLOGICAL AND SURGICAL TECHNIQUES

3D‑printed anatomical models of the cystic duct and its variants,

a low‑cost solution for an in‑house built simulator for laparoscopic
surgery training
C. Casas‑Murillo2 · Alejandro Zuñiga‑Ruiz3 · Rafael Eduardo Lopez‑Barron1 · Antonio Sanchez‑Uresti1 ·
Andoni Gogeascoechea‑Hernandez2 · Gerardo Enrique Muñoz‑Maldonado3 · Matias Salinas‑Chapa2 ·
Guillermo Elizondo‑Riojas2 · Adrian A. Negreros‑Osuna2 

Received: 6 October 2020 / Accepted: 17 November 2020 / Published online: 1 January 2021
© Springer-Verlag France SAS, part of Springer Nature 2021

Abstract
Objectives  To explore a method to create affordable anatomical models of the biliary tree that are adequate for training
laparoscopic cholecystectomy with an in-house built simulator.
Methods  We used a fused deposition modeling 3D printer to create molds of Acrylonitrile Butadiene Styrene (ABS) from
Digital Imaging and Communication on Medicine (DICOM) images, and the molds were filled with silicone rubber. Thirteen
surgeons with 4–5-year experience in the procedure evaluated the molds using a low-cost in-house built simulator utilizing
a 5-point Likert-type scale.
Results  Molds produced through this method had a consistent anatomical appearance and overall realism that evaluators
agreed or definitely agreed (4.5/5). Evaluators agreed on recommending the mold for resident surgical training.
Conclusions  3D-printed molds created through this method can be applied to create affordable high-quality educational
anatomical models of the biliary tree for training laparoscopic cholecystectomy.

Keywords  3D-printed molds · 3D printing · Laparoscopic cholecystectomy · Low-cost simulator · Surgical planning ·
Surgical training · Anatomy education

Introduction increasing the hours of practice, a proved solution for flatten-

Surgical teachings in residency programs have applied
the use of simulation as part of their practice. Their aim
is to maintain the quality standard of patient safety while
* Adrian A. Negreros‑Osuna
adrian.negrerosos@uanl.edu.mx
1
Centro de Ingeniería Biomédica, Facultad de Medicina,
Universidad Autónoma De Nuevo León, Monterrey,
Nuevo León, Mexico
2
Radiology and Imaging Department, Facultad de Medicina
y Hospital Universitario “Dr. José E. González, Universidad
Autónoma de Nuevo León, Ave. Francisco I. Madero S/N,
Colonia Mitras Centro, Monterrey, Nuevo León, Mexico
3
Department of General Surgery, Facultad de Medicina y
Hospital Universitario “Dr. José E. González, Universidad
Autónoma de Nuevo León, C.P. 64460 Monterrey,
Nuevo León, Mexico
ing the learning curve without compromising patient health
[1–3].
Acquiring a magnetic resonance cholangiopancreatog-
raphy (MRCP) before a laparoscopic cholecystectomy has
been proposed to be a protective measure to prevent lesions
of the biliary tree, unfortunately, its high cost and relative
unavailability makes it a non-viable solution imaging study
for lowering the morbidity [1–7]
A 3D-printed model obtained from DICOM images rep-
resents the natural progression and evolution for anatomi-
cal visualization. The demand for these types of 3D-printed
models is increasing, especially in surgical planning [4, 5]
where it provides detailed information on different patho-
logical and anatomical scenarios.
Different techniques have been described for acquiring
soft tissue prostheses by printing molds of ABS with fuse
deposition modeling and then applying silicon. These tech-
niques allow the acquisition of low-cost complex anatomic
models with a soft consistency [6].

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538
Biliary tree anatomical variations are common, multiple
studies have classified and determined the prevalence of the
cystic duct (CD) variations where about 50% of cystic ducts
have a lateral normal insertion on the middle third of the com-
mon bile duct while other variants such as medial insertion
(16%), low insertion (9%), parallel course (7.5%), high inser-
tion (6%) and short CD (1%) have been described [8–12].
Recognizing the different anatomical variations of the
cystic duct is important for the appropriate interpretation of
pathological conditions, procedure planning and periopera-
tive decisions.
Our study aimed to apply 3D-printing techniques to develop
a low-cost in-house built simulator of anatomical variations of
the cystic duct that could be evaluated by trainees and com-
pared to their experience in the operating room.
Materials and methods
Image acquisition and 3D model rendering
For the acquisition of the cystic duct and the extrahepatic
biliary system, as well as the gallbladder, we searched retro-
spectively in our radiological archives for MR cholangiopan-
creatographies (FRFSE-XL pulse sequence, respiration trig-
gered MRCP ASSET, 256 slices with thickness of 1.4 mm
and interslice gap of 0.7 mm, FOV 29, matrix of 256 × 256,
NEX 1, TE:452 and TR:3000, acquired on an oblique plane)
made on a General Electric SIGNA HDxt 1.5T LX-MR, and
obtained 3 anatomical variants and a normal anatomical study.
The cystic duct variants were described as one distal insertion
of the cystic duct to the common bile duct with parallel trajec-
tory, one medial middle third insertion of the cystic duct and
another one with a medial distal third insertion of the cystic
duct. The DICOM images were segmented through 3D Slicer
version 4.8.0 and posteriorly converted to STL format. A post-
processing of the images was required for smoothing the edges
and correcting imperfections of the segmentation; for the
task, a computer-aided design and drafting (CADD) software
(Autodesk Meshmixer version 3.5.474) was used [4–6, 13].
The liver, duodenum and cystic artery were obtained
through an arterial phase axial tomography (slide thickness
of 1.2 mm and 0.635 mm interval) segmented with 3D Slicer
version 4.8.0, using the CADD software. We decided to
leave only the organ contours of the duodenum and the liver
to facilitate the mold assembly and to save printing material.
3D printing and fabrication of molds, casts
and mold assembly
Molds
The contours of the hepatic segments V and VI and the
second portion of the duodenum were printed with a fused
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Surgical and Radiologic Anatomy (2021) 43:537–544
deposition modeling technique using a 3D Zortrax printer,
replicas were finally colored.
Negative mold creation
The extra hepatic biliary system, the gall bladder and the
cystic artery had to be fabricated from silicone rubber to
create a realistic tissue user experience. After the acquisi-
tion of the final STL formats, a 2-part negative mold was
designed with Solid Works 2016, for this, the gallbladder
and the bile ducts had to be on a same plane, so a straight
line can be traced through the center of the structures. After
the printing of the negative molds with ABS, silicone casting
was performed by applying silicone rubber p53 mixture with
a desired colorant. After solidification, the silicone replica
was evacuated from the mold and asperities caused by the
unintentional silicone flowing were cleaved from the main
mold [14–16]. The cystic artery was obtained with the right
hepatic artery; no anatomical variants were considered for
this cast (Fig. 1).
For the medial insertion cystic duct variants, defining
negative 2-part mold of a gall bladder and bile ducts was
laborious, since the insertion of the cystic duct on this vari-
ants is characterized by a normal anatomical loop around
the common bile duct, making it non-feasible to design a
complete 2-part negative mold. As an alternative, separat-
ing the Gall Bladder with Cystic Duct and the rest of the
extra hepatic bile ducts into two different negative 2-part
casts were performed. Using the adherent properties of the
liquefied silicone rubber, the gallbladder/cystic duct cast was
created and after it solidified, it was attached to a mold of
the bile ducts, for further silicone application, as shown on
Fig. 2.
Low‑cost simulator
A low-cost simulator was designed, and a metallic box of
40 × 30 × 20 cm was adapted with three-port access on the
top and a front hole for an endoscopic USB camera, provid-
ing real time video on a computer. An internal light and
different reusable laparoscopic graspers where also required
[2, 3].
Mold assembly
Materials such as screws and wires were required to main-
tain the molds in place inside the simulator, to recreate the
normal position of the structures at the time of the laparo-
scopic surgery. The liver and intestine mold contours were
connected with the silicone casts of the extra hepatic biliary
system, keeping the gallbladder pulled by a wire over the
liver, simulating an assistant. The cystic artery was stapled
to the gallbladder, and the right hepatic artery was connected
Surgical and Radiologic Anatomy (2021) 43:537–544 539
Fig. 1  a Coronal T2 weighted MRI, normal cystic duct anatomy, gall-
bladder not shown. b ABS negative mold of the 3D processed MRI.
c Cast of with silicone rubber and green dye. d Software processing
and creation of the 2-part negative mold of the 3D model obtained
to its anatomic insertion in the liver, at the hepatic hilum
(Fig. 3).
Connective tissue
The tissue dissection is a vital part of the laparoscopic chol-
ecystectomy [7]. To correctly recreate the procedure, we
used a commercial yellow-colored slime. Different layers of
slime were place to simulate the fibrous tissue that connects
the neck of the gallbladder to the liver, the hepatoduodenal
ligament, and the tissue that is between the cystic artery and
the cystic duct. The slime must be maintained at 25 °C or
less, since at warmer temperatures, it melts over the molds
(Fig. 4).
Materials and pricing
Approximate prices of the molds and casts acquired by
3D printing and the amount of connective tissue required
are exposed in Table 1. Creating the casts of silicone on
from the MRI, note the yellow platform that represents the straight
line that separates the 3D model, allowing the 2-part negative molds
to be created
the negative molds can be repeated after the use of a cast,
making the silicone rubber the only expendable (Table 1).
Procedure testing and questionary evaluating
the molds
Between January 2019 and 2020, 13 participants with 2
or 3 years of experience on laparoscopic cholecystectomy
affiliated to the surgical department at Hospital Universi-
tario, José E. González, in Monterrey, Nuevo Leon, Mex-
ico, based on the laparoscopic cholecystectomy consensus
guidelines simulated the procedure [7]. A 5-point Likert
scale evaluating consistency, texture, overall realism and
level of mold recommendation for laparoscopic cholecys-
tectomy training was filled and quantitative results were
obtained [16–18] (Table 2). A recommendation space was
left to fill up for any feedback they would consider appro-
priate on the molds and procedure.
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540
Fig. 2  a One of the 2-parts negative mold of the gallbladder/cystic
duct. b A solidified silicone rubber gallbladder/cystic duct attached to
a 2-part negative mold of the rest of the extra hepatic bile ducts with
fresh silicone rubber in process of solidifying, enabling the print-
ing of the cystic duct medial insertion anatomical variations. MRCP
Results
Participant opinions on the 3D molds
Thirteen General surgery practitioners affiliated to our
institution at the university-hospital with 4 or 5 years of
experience agreed to participate in trying the simulator.
Qualitative analysis of the simulator texture was graded
as excellent by 7/13 (53%) and good by 6/13 (46%) evalua-
tors, an average score of 4.5. Regarding consistency, 5/13
(35%) evaluators were completely satisfied and 7/13 (53%)
were very satisfied, 1/13 (7%) was moderately satisfied,
an average score of 4.3. In terms of overall realism, 8/13
(61%) evaluators considered it far above standard, 4/13
(30%) above standard, and 1/13 (7%) considered to meet
the standard required for laparoscopic training. When the
evaluators were asked if they would recommend the sim-
ulator for laparoscopic cholecystectomy training, 12/13
(92%) strongly agreed and 1/13 (7%) agreed, an average
score of 4.6.
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Surgical and Radiologic Anatomy (2021) 43:537–544
demonstrating anatomical variants of the cystic duct with their cor-
responding silicone mold, distal third medial insertion (b, f), medial
middle third insertion (c, g), and lower cystic duct insertion with a
parallel course (d, h)
Additional comments were also obtained: 7/13 (53%)
evaluators urged to develop more anatomical variants, 5/13
(35%) suggested the need of fibrotic tissue that could simu-
late inflammatory plastron and 2/13 (15%) asked for a dis-
tended colon or fluid collections, conditions that could make
the procedure more complicated (Fig. 5).
Discussion
This study reported the methods for the creation of a
low-cost cholecystectomy laparoscopic simulator using
3D-printed molds and casts of ABS and silicon. With the
proposed workflow, it was possible to create hard plastic
and silicone models of the bile ducts and gallbladder, with
additional anatomic variants of the cystic duct. The texture,
consistency, and overall realism of the simulator mostly
satisfied the requisites of the surgeons, with most of them
strongly agreeing on recommending the simulator for lapa-
roscopic training.
Surgical and Radiologic Anatomy (2021) 43:537–544 541
Fig. 3  a Axial CT arterial phase
tomography showing the normal
disposition of the cystic artery.
b Low-cost in build simulator. c
Silicone made cystic artery con-
nected to the gallbladder by a
staple. d Final mold disposition
on the simulator
Work-hour limitations and concerns of patient safety
have cause innovation in surgical simulation to become a
part of residency education, 3D printing recent advances
are paving the way for simulators to become integral com-
ponents of medical training, even though simulation train-
ing’s ultimate goal is enhance learning, cost-effectiveness
is a critical factor [18, 19]. Our simulator is character-
ized by low-cost materials, as well as the durability of the
hard ABS molds and negative 2-face molds, making them
reusable for any new silicone rubber cast when needed,
creating an affordable solution for low-budget residency
programs, especially in developing countries around the
world [20].
The role of 3D printing of DICOM images generated and
processed for surgical planning requires a multidisciplinary
approach that manages the surgical techniques, technology
that involves the post-processing, the materials needed, and
the imaging acquisition through the image studies [4, 5].
This mold production confirms that the expertise of these
disciplines combined can create 3D models that provide
detailed and tangible information about complex anatomic
situations, and therefore, create a very recommendable mold
for training laparoscopic cholecystectomy through a low-
cost simulator.
Efficacy of procedure simulation using 3D-printed molds
has proven to be a realistic method for improving skills
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542 Surgical and Radiologic Anatomy (2021) 43:537–544

Fig. 4  a Presentation of the molds inside a low-cost simulator. b Localization of the cystic duct, exposing its insertion to the common
Visualization of the biliary ducts inside the Slime. c Dissection of bile duct, demonstrating normal anatomy
the connective tissue and isolation of the cystic artery for stapling. d

Table 1  Prices of the materials Organ Material Weight (g) or Price (US $)

used approximated to its weight volume (cc)

Liver (segments V and VI) ABS 53 g 4.4 $

Duodenum (second portion) ABS 11 g 0.9 $
Gall bladder and bile duct cast P53 Silicone Rubber 26 g 0.7 $
Cystic artery P53 Silicone Rubber 9 g 0.3 $
Connective tissue Elmer’s Slime 142 cc 1.2 $
2-Part negative mold of the gall bladder and ABS 140 g 11.7 $
bile ducts with normal anatomy
2-Part negative mold of the cystic artery ABS 15 g 1.3 $

without any risk to patients in previous studies [14–18].
Similarly, our simulator provides a realistic model of the
biliary system, in which trainees can gain experience of
laparoscopic manipulation.
As shown in other medical areas, the techniques that
require hard material molds, like ABS, for the later
application of silicone rubber, can create low-consistency
complex anatomical molds [6, 13, 14, 21]; this evaluation
of the gall bladder and bile duct silicon casts is consistent
with other studies where experts have qualitatively validated
the 3D printing for the simulation of surgical procedures and
their training [15–17].

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Surgical and Radiologic Anatomy (2021) 43:537–544 543

Table 2  Likert-5 scale used for the evaluation of the simulator

Characteristic 1 2 3 4 5

Texture Very poor Poor Fair Good Excellent

Consistency Not at all satisfied Slightly satisfied Moderately satisfied Very satisfied Completely satisfied
Overall realism Far below standard Below standard Meets standard Above standard Far above standard
Recommend the simulator Strongly disagree Disagree Neither agree or disagree Agree Strongly agree

Fig. 5  Bar graph showing the evaluation given by the 13 participants to the simulator

Multiple advantages of using CAD software for the post-
processing of DICOM images has been previously described
by studies in other medical fields that explored simulation
[14, 15]; the ability to provide rare anatomical variants or
pathological situations, as well as rare scenarios, is one of
the main strengths of this in-house built simulator. The raw
data of the DICOM images could be processed to create a
wide range of theoretical situations, providing possible novel
experiences and reinforcing decision making, as educational
residency programs have declared the need of acquiring new
competencies and surgical abilities to the operation room by
the trainees [1–3]. Our results showed participants mostly
agreed on recommending the molds for training, and recom-
mendations were based on adding more difficult scenarios,
like rare-cystic duct variations that were not visualized on
MRI, adding fibrotic tissue to simulate inflammatory plas-
tron of simulate fluid collections.
Even though current evidence suggests that skills
acquired by simulation with virtual reality (VR) technolo-
gies or synthetic materials, like the ones we used in this
study, are positively transferred to clinical settings and may
improve patient outcome, the major challenge is based in
proving if this in-house built simulator, molds, and silicon
casts will positively affect patient surgical outcomes and
resident practice, and not bias resident experience, creating a
possible negative effect on patient outcomes [1–3]. Trainees
that evaluated the simulator had a 2- or 3-year experience on
the procedure, and the opinion of more advanced surgeons,
as well as non-experienced residents or medical students, is
still unknown.

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544
Conclusion
There are different 3D-printing tools useable to acquire ana-
tomic models for surgical simulation. Silicone casts from
negative 2-part molds are a viable possibility for low-cost
soft tissue structure representation. For this type of proce-
dure, a multidisciplinary team must get involved, been the
radiologist an indispensable asset for image acquisition and
post-processing.
This methodology of printing low-cost silicone molds
can be used in a variety of procedures and disciplines. A
prospective study designed to prove if this method can
positively develop surgical skills, to eventually decrease the
morbidity of the laparoscopic cholecystectomy is required.
Acknowledgements  The study was supported by the 3D laboratory and
its members of the Radiological department of the Hospital Universi-
tario “Jose Eleuterio Gonzalez” in Monterrey, Nuevo León.
Author contributions  CCM: project development, data collection,
manuscript writing, and data analysis. AZR: project development, data
collection, and manuscript writing. RELB: project development, data
collection, and manuscript writing. ASU: project development, data
collection, and manuscript writing. AGH: project development, data
collection, and manuscript writing. GEMM: project development, data
collection, and manuscript writing. MSC: project development, data
collection, and manuscript writing. GER: project development, data
collection, and manuscript writing. AANO: project development, data
collection, manuscript writing, and data analysis.
Compliance with ethical standards  tomical variations of cystic ducts in magnetic resonance cholan-
Conflict of interest  No potential conflict of interest relevant to this ar-
ticle.
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