Published online Oct 27, 2026. doi: 10.4254/wjh.121142
Revised: April 30, 2026
Accepted: September 10, 2026
Published online: October 27, 2026
Processing time: 218 Days and 13.2 Hours
Accurate estimation of graft size is essential in liver transplantation to ensure adequate functional liver mass. Computed tomography (CT) volumetry is widely used for this purpose; however, alternative imaging approaches, such as three-dimensional (3D) surface scanning, may provide complementary advantages.
To compare CT volumetry and 3D surface scanning for liver graft size estimation, using explant liver mass as the reference standard.
A total of 19 liver explants were analyzed. CT volumetry and 3D surface-derived volumetry were quantitatively compared with the explant liver mass. Correlation analysis, regression-based calibration, absolute error, and reliability [intraclass correlation coefficient (ICC)] were assessed.
Both methods showed strong correlation with explant liver mass (r = 0.94 for 3D surface volumetry and r = 0.938 for CT volumetry, both P < 0.001). Regression analysis demonstrated proportional calibration for both methods, with slopes of 1.01 (R2 = 0.761) for 3D surface volumetry and 1.04 (R2 = 0.820) for CT volumetry. CT volumetry showed significantly lower absolute estimation error compared with 3D surface volumetry (P = 0.011). Reliability analysis revealed excellent agreement between CT volumetry and explant liver mass (ICC = 0.90) and good-to-excellent agreement for 3D surface volumetry (ICC = 0.87).
Both CT volumetry and 3D surface scanning provide quantitatively consistent estimates of liver graft size. However, CT volumetry remains more precise, while 3D surface scanning may serve as a complementary method in this pilot methodological study.
Core Tip: Liver transplantation requires accurate estimation of graft size to optimize postoperative outcomes, with computed tomography (CT) volumetry currently the clinical standard. In this pilot methodological validation study, CT volumetry was compared with three-dimensional surface scanning using explant liver mass as the reference standard. While CT volumetry demonstrated higher precision, three-dimensional surface scanning showed strong correlation and good measurement reliability, supporting its potential role as a complementary method for ex vivo liver volumetry.
- Citation: Jaya LOI, Rykowski P, Bartkowiak M, Kruk E, Chodurska M, Lewandowski Z, Krasnodębski M, Grąt M. Computed tomography volumetry vs three-dimensional surface scanning for liver graft size estimation using explant liver mass. World J Hepatol 2026; 18(10): 121142
- URL: https://www.wjgnet.com/1948-5182/full/v18/i10/121142.htm
- DOI: https://dx.doi.org/10.4254/wjh.121142
Liver transplantation is a life-saving treatment for patients with acute and chronic end-stage liver disease, offering substantial gains in survival and quality of life[1-3]. Recent syntheses estimate that liver disease causes approximately 2 million deaths annually - about 4% of all deaths worldwide - largely from cirrhosis and hepatocellular carcinoma, confirming its status as a major global cause of mortality[4-6]. In addition, chronic liver diseases, such as hepatitis B virus infection, hepatitis C virus infection, metabolic dysfunction-associated steatosis liver disease, and cirrhosis, remain highly prevalent. Data from the Global Burden of Disease Study 2021 demonstrate age-standardized prevalence rates per 100000 population of 3584 for hepatitis B virus, 1718 for hepatitis C virus, 15018 for metabolic dysfunction-associated steatosis liver disease, and 20303 for cirrhosis[4,7]. Furthermore, contemporary registry and cohort studies consistently dem
In liver transplantation, computed tomography (CT)-based volumetry is the gold standard for preoperative estimation of liver graft volume, as numerous studies have established its strong correlation with actual graft weight and its role in predicting perioperative complications associated with graft size[11,12]. However, CT volumetry is sensitive to imaging parameters and segmentation practices, including contrast phase, slice thickness, and operator experience, and may be unavailable when donors are referred from centers without routine abdominal CT imaging, thereby limiting pre-procurement volumetric assessment. These limitations have motivated the exploration of alternative volumetric approaches[13-15]. A recent systematic evaluation of mobile three-dimensional (3D) scanning applications, including models generated using Polycam (Polycam, Inc., San Francisco, CA, United States), has reported substantial variability in reconstruction accuracy across anatomical models. For example, reconstruction of a breast phantom showed that the 3D scanner application exhibited the highest mean error (21.4 mm) and the greatest variability among the tested platforms[16]. In practical workflows, reconstructed surface meshes are routinely post-processed using Blender (Blender Foun
Accurate assessment of graft size is critical in liver transplantation. However, most previous studies have focused on the correlation between imaging-derived liver volumes and graft weight, which does not fully capture clinical agreement, calibration, or measurement reliability. Comparative evaluations of CT-based volumetry methods against intraoperative graft weight have not only demonstrated good correlations but also revealed systematic error, underscoring the need for more comprehensive measurement frameworks[15,19,20]. A clinically critical setting in which accurate volumetric estimation appears to be essential is the large-for-size (LFS) problem, now recognized as an important determinant of early post-transplant outcomes in selected recipients. LFS is not simply “a large graft” but a mismatch between graft volume and the recipient’s abdominal domain and hemodynamic tolerance, potentially predisposing to graft com
Given the clinical importance of accurate volumetry, 3D surface-scanning technologies validated in other anatomical regions may provide a foundation for assessing liver grafts. The system has demonstrated high accuracy, low median volume error, and excellent reliability in applications such as upper-limb volumetry for breast cancer-related lymph
This study addressed this gap by quantitatively comparing 3D liver volumetry with CT volumetry, using explant liver mass as the reference standard. Given the relatively small sample size, this study should be considered a pilot methodological validation study, and the findings should be interpreted accordingly.
This retrospective observational study was conducted at the Department of General, Transplantation, and Liver Surgery, University Clinical Center of the Medical University of Warsaw, Poland. Liver explants obtained during routine liver transplantation from 30 November 2024 to 6 February 2026 were prospectively weighed and underwent 3D surface scanning according to a standardized protocol, while preoperative CT volumetry data were retrieved from routine clinical imaging. Nineteen consecutive liver explants obtained during routine liver transplantation procedures were included. No formal exclusion criteria were predefined, and no specimens required exclusion owing to technical issues (e.g., damage during handling or incomplete imaging data). This study was reviewed by the Bioethics Committee of the Medical University of Warsaw.
Immediately after procurement, each liver explant was gently dried with sterile gauze and weighed using a calibrated surgical scale. Explant mass served as the reference standard for all volumetric analyses, based on the assumption that liver tissue density approximates 1 g/cm3, thereby allowing mass to serve as a clinically relevant surrogate for organ volume. However, this approximation may not fully account for variations in tissue composition, perfusion status, and post-explant changes, potentially introducing systematic differences between mass- and volume-based measurements, particularly given the in vivo vs ex vivo conditions under which these measurements were obtained.
Following mass measurement, each liver explant underwent 3D surface scanning using the Polycam photogrammetry mobile application (iOS/Android) (Polycam, Inc., San Francisco, CA, United States). Multiple circumferential image sweeps were performed to ensure complete surface coverage. Image acquisition was performed under standardized lighting and background conditions. Mesh construction, refinement, and volumetric analysis were performed by an investigator who was blinded to the CT volumetry and explant liver mass measurements. The scans were exported in STL format and reconstructed using Blender version 5.0.0. Mesh refinement included surface smoothing, artifact removal, gap closure, and dimensional calibration. To ensure measurement reliability, volumetric estimates for each 3D mesh were obtained twice per explant (n = 2), and the results were averaged to yield a single representative 3D volume for each sample. This approach minimized operator-dependent variability in mesh selection and region-of-interest definition.
Preoperative CT volumetry was obtained from contrast-enhanced abdominal CT scans performed as part of the transplant evaluation protocol. Volumetric measurements were performed using AW Server 3.2 EXT 4.0 (GE Healthcare, Chicago, IL, United States) with the Hepatic VCAR module, which provides semi-automated liver segmentation and quantitative volumetric analysis. Manual corrections were applied when necessary by an experienced radiologist.
Continuous variables are presented as mean ± SD or median with interquartile range (IQR), as appropriate. Explant liver mass was used as the reference standard for all analyses. Imaging-based graft size estimates obtained from CT volumetry and 3D surface scanning were initially evaluated for their association with explant liver mass using Pearson correlation analysis. Assumptions underlying the analysis, including linearity and distribution of residuals, were assessed before analysis. Calibration of imaging-based graft size estimates was assessed using linear regression analysis, with explant liver mass as the dependent variable and imaging-derived estimates as independent variables. Regression coefficients, coefficients of determination (R2), and intercepts were evaluated to assess the degree of correspondence and potential systematic offset between estimated graft size and explant mass.
Agreement between imaging-derived estimates and explant liver mass was further evaluated using Bland-Altman analysis. Mean bias and 95% limits of agreement were calculated to assess the magnitude and distribution of differences across the range of graft sizes. Absolute estimation error for each modality was defined as the absolute difference between imaging-based estimates and explant liver mass. Differences in absolute error between CT volumetry and 3D surface volumetry were compared using the Wilcoxon signed-rank test for paired samples.
Reliability and agreement between imaging-derived estimates and explant liver mass were quantified using intraclass correlation coefficients (ICCs). ICC (3, 1) values derived from a two-way fixed-effects model with absolute agreement were reported. This model was selected as it reflects absolute agreement between measurement methods applied to the same subjects in a fixed-effects framework. All statistical analyses were performed using R version 4.5.2 (R Foundation for Statistical Computing, Vienna, Austria). A two-sided P < 0.05 was considered statistically significant.
In total, 19 liver explants (13 males and 6 females) were included in the study, with baseline demographics summarized in Table 1. The cohort had a median (IQR) age of 54.0 (40.0-63.5) years, height of 172.0 (163.0-181.0) cm, and body weight of 80.0 (65.5-96.0) kg, corresponding to a median (IQR) body mass index of 26.3 (22.7-32.0) kg/m2. Median (IQR) thoracic and abdominal circumferences were 93.0 (85.0-103.5) cm and 97.0 (86.5-107.5) cm, respectively, reflecting baseline demographic and anthropometric characteristics typical of liver transplant candidates. All liver explants were cirrhotic, and all patients underwent elective liver transplantation.
| Parameters | Study group, n = 19 |
| Sex | |
| Male | 13 |
| Female | 6 |
| Age in years | 54.0 (40.0-63.5) |
| Height in cm | 172.0 (163.0-181.0) |
| Weight in kg | 80.0 (65.5-96.0) |
| BMI in kg/m2 | 26.3 (22.7-32.0) |
| Thoracic circumference | 93.0 (85.0-103.5) |
| Abdominal circumference | 97.0 (86.5-107.5) |
Explant liver mass demonstrated a strong correlation with 3D surface-derived volumetry [r = 0.94, 95% confidence interval (CI): 0.84-0.98, P < 0.001; n = 19] and with CT-based volumetry (r = 0.938, 95%CI: 0.84-0.98, P < 0.001; n = 19). Corresponding scatter plots are presented in Figure 1.
Linear regression analysis was performed with explant liver mass as the dependent variable and 3D surface volumetry as the independent variable. The model demonstrated good fit (R2 = 0.775; adjusted R2 = 0.761), with a residual SE of 248.9 g (n = 19; df = 17). The regression coefficient was β = 1.01 (95%CI: 0.73-1.30; P < 0.001), indicating proportional agreement between 3D surface-derived volumetry and explant liver mass (Table 2).
| Variable | β coefficient (95%CI) | SE | P value |
| Intercept | 299.7 (-129.40 to 728.77) | 203.38 | 0.16 |
| 3D surface estimate | 1.01 (0.73 to 1.29) | 0.13 | < 0.001 |
Linear regression analysis was performed using explant liver mass as the dependent variable and CT volumetry as the independent variable. The model demonstrated good fit (R2 = 0.830; adjusted R2 = 0.820), with a residual SE of 216.4 g (n = 19; df = 17). The estimated regression coefficient was β = 1.04 (95%CI: 0.79-1.29; P < 0.001), indicating proportional agreement between CT-derived volumetry and explant liver mass (Table 3).
| Variable | β coefficient (95%CI) | SE | P value |
| Intercept | 221.86 (-157.08 to 600.79) | 179.60 | 0.234 |
| CT volumetry | 1.04 (0.80 to 1.28) | 0.11 | < 0.001 |
Bland-Altman plots comparing imaging-based graft size estimates with explant liver mass are shown in Figure 2. For CT volumetry, the mean bias was -284.1 g, with 95% limits of agreement ranging from -697.9 g to 129.8 g (Figure 2A). For 3D surface-derived volumetry, the mean bias was -315.7 g, with 95% limits of agreement ranging from -789.9 g to 158.4 g (Figure 2B).
Absolute error distributions for CT volumetry and 3D surface-derived volumetry relative to explant liver mass are shown in Figure 3. The median absolute percentage error was 18.45% (IQR: 9.72%) for CT volumetry and 21.26% (IQR: 12.87%) for 3D surface-derived volumetry. The median paired difference in absolute percentage error (3D minus CT) was 2.44% (95%CI: 0.00%-3.9%; Wilcoxon signed-rank test, P = 0.011), indicating significantly greater error for 3D surface-derived volumetry (Table 4).
| Method | Median absolute error (%) | IQR (%) |
| CT volumetry | 18.45 | 9.72 |
| 3D surface-derived volumetry | 21.26 | 12.87 |
| Paired comparison (3D-CT) | ||
| Statistic | Value | |
| Median paired difference (%) | 2.44 | |
| 95%CI | 0.00-3.9 | |
| Wilcoxon signed-rank P value | 0.011 | |
ICCs for agreement between imaging-based graft size estimates and explant liver mass are summarized in Table 5. The ICC (3, 1) was 0.90 (95%CI: 0.76-0.96; n = 19) for CT volumetry vs explant mass and 0.87 (95%CI: 0.7-0.95; n = 19) for 3D surface-derived volumetry vs explant liver mass.
| Method | ICC (3, 1) | 95%CI | n |
| CT volumetry vs explant liver mass | 0.90 | 0.76-0.96 | 19 |
| 3D surface-derived volumetry vs explant liver mass | 0.87 | 0.70-0.95 | 19 |
The study cohort consisted of adult transplant recipients with moderate body size and normal variability in body measurements, reflecting patients typically encountered in routine clinical practice. This is particularly relevant to LFS syndrome analysis, because graft size matching inherently depends on the recipient’s anatomy and the available intra-abdominal space. Therefore, volumetric estimates should be interpreted in the context of the recipient’s anatomical constraints and physiological tolerance, underscoring the need for consistent and reliable techniques for assessing graft size. Although the cohort reflects a typical transplant population, given the small sample size, the findings should be considered exploratory and primarily methodological.
CT volumetry exhibited a strong association with liver explant mass, consistent with its established role as the reference standard for clinical graft volumetry. Prior studies have shown that 3D CT-based volumetry not only improves the accuracy of graft size estimation compared with traditional 2D techniques but also provides more consistent information for size matching in liver transplantation[27]. The observed strong performance of 3D surface-derived volumetry in correlating with explant mass emphasizes its potential as an accessible complementary method[28]. This approach may be particularly advantageous within multimodal 3D planning frameworks that integrate internal CT-derived anatomy with external surface models, thereby supporting surgical simulation, preoperative planning, and education.
Calibration analyses indicated that both approaches maintained appropriate proportional scaling with explant liver mass, as evidenced by regression slopes approaching 1.0 and minimal systematic bias. This behavior suggests that both techniques yield consistent quantitative estimates across the evaluated graft-size spectrum. From a clinical perspective, preservation of proportional calibration is critical, because even modest systematic deviations at the extremes of graft size may influence graft selection and perioperative planning. Collectively, these results support the use of both imaging modalities for consistent graft size estimation, extending their utility beyond simple relative comparisons.
Measurement differences relative to explant liver mass showed moderate deviation for both modalities. CT-based estimates exhibited narrower dispersion, while surface-based measurements displayed greater variability, particularly at higher volumes (Figure 2). Notably, error magnitude did not systematically increase with graft size, arguing against the presence of substantial proportional bias. From a clinical perspective, dispersion rather than mean bias often determines the utility of a measurement method for individual patients. Accordingly, the narrower limits of agreement observed with CT-based volumetry indicate greater measurement precision compared with surface-based methods. At the same time, the lack of progressive divergence across the graft-size range demonstrates that surface-based scanning yields stable, size-independent estimates, supporting its use as a complementary or confirmatory tool rather than indicating inconsistent performance. This pattern is consistent with findings from CT-based liver volumetry studies, where CT methods demonstrate strong agreement with actual graft weight but retain non-negligible dispersion on Bland-Altman analysis, with differences in precision often being more clinically relevant than mean bias.
For example, Mohapatra et al[15] reported similar IQR percentage errors for conventional CT and 3D liver volumetry, with slightly narrower error distribution observed for 3D methods, thereby improving overall accuracy without elim
CT volumetry demonstrated lower variability and narrower error dispersion compared with 3D surface scanning (Figure 3). Conceptually, these two modalities assess the liver under fundamentally different physiological conditions. CT volumetry represents the in vivo organ, with its apparent volume affected by perfusion, venous filling, and the timing of image acquisition, whereas 3D surface scanning is usually performed ex vivo on a graft that is no longer perfused and may have been flushed and drained. As a result, systematic differences between these modalities can be anticipated a priori, even when segmentation and reconstruction are performed with high technical accuracy. Although CT volumetry exhibited slightly lower variability compared with 3D surface scanning, the magnitude of disagreement between techniques remained within a range that may be acceptable for routine graft size estimation. Thus, the key consideration is not only the strength of correlation but also whether the level of agreement is sufficient to support specific clinical decisions.
Both CT and 3D surface volumetry demonstrated high reliability for estimating explant mass, as summarized in Table 3. While CT volumetry achieved slightly superior agreement, 3D surface scanning yielded consistent and clinically acceptable results. These findings support the integration of 3D surface scanning as a complementary modality to CT for quantitative graft evaluation. Accurate volumetric assessment is essential for graft-recipient size matching and perioperative planning, and the observed concordance reinforces its role in multimodal 3D surgical workflows.
Several limitations of this study should be acknowledged. First, the sample size was relatively small, reflecting the exploratory and pilot nature of this analysis; therefore, the findings require validation in larger cohorts and with alternative scanning methods. Second, explant liver mass was used as the reference standard rather than true graft volume; however, it represents a direct and clinically meaningful surrogate for graft size assessment (Figure 2). Finally, the analysis focused on methodological performance and did not evaluate post-transplant clinical outcomes, which will be important to address in future studies to determine the clinical impact of these measurement approaches.
Accurate graft size estimation remains a critical component of liver transplantation. Both CT volumetry and 3D surface scanning provided graft size estimates consistent with explant liver mass, demonstrating quantitative consistency within the studied cohort. CT volumetry exhibited greater precision and consistency, supporting its established role as the reference standard for assessing graft size. Nevertheless, 3D surface scanning showed reliable performance and acceptable agreement, suggesting its potential utility as a complementary approach in selected transplant settings. These findings provide a methodological basis for future studies evaluating imaging-based assessment of graft size within the liver transplantation workflow; however, they should be interpreted with caution, given the limited sample size and the exploratory nature of the study.
The authors thank the transplant surgical team and radiology staff at the University Clinical Center of the Medical University of Warsaw for their support in data acquisition and technical assistance. The authors also acknowledge the contributions of all personnel involved in graft handling and data management.
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