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Minimally invasive liver surgery: indications and contraindications 249
49 Andreou A, Vauthey JN, Cherqui D, et al. Improved long-term
survival after major resection for hepatocellular carcinoma: a
multicenter analysis based on a new definition of major hepatectomy. J Gastrointest Surg 2013; 17(1):66–77; discussion 77.
50 Reddy SK, Barbas AS, Turley RS, et al. A standard definition of
major hepatectomy: resection of four or more liver segments.
HPB (Oxford) 2011; 13(7):494–502.
51 Postriganova N, Kazaryan AM, Rosok BI, Fretland AA, Bar-
khatov L, Edwin B. Margin status after laparoscopic resection
of colorectal liver metastases: does a narrow resection margin
have an influence on survival and local recurrence? HPB
(Oxford) 2014; 16(9):822–829.
52 Cherqui D, Husson E, Hammoud R, et al. Laparoscopic liver
resections: a feasibility study in 30 patients. Ann Surg 2000;
232(6):753–762.
53 Nguyen KT, Geller DA. Outcomes of laparoscopic hepatic
resection for colorectal cancer metastases. J Surg Oncol
2010; 102(8):975–977.
54 Cho JY, Han HS, Yoon YS, Shin SH. Feasibility of laparoscopic
liver resection for tumors located in the posterosuperior segments
of the liver, with a special reference to overcoming current
limitations on tumor location. Surgery 2008; 144(1):32–38.
55 Costi R, Capelluto E, Sperduto N, Bruyns J, Himpens J,
Cadiere GB. Laparoscopic right posterior hepatic bisegmentectomy (Segments VII–VIII). Surg Endosc 2003; 17(1):162.
56 Gumbs AA, Gayet B. Totally laparoscopic left hepatectomy.
Surg Endosc 2007; 21(7):1221.
57 Chang S, Laurent A, Tayar C, Karoui M, Cherqui D. Laparos-
copy as a routine approach for left lateral sectionectomy.
Br J Surg 2007; 94(1):58–63.
58 Belli G, Gayet B, Han HS, et al. Laparoscopic left hemihepa-
tectomy a consideration for acceptance as standard of care.
Surg Endosc 2013; 27(8):2721–2726.
59 Mala T, Edwin B, Gladhaug I, et al. A comparative study of the
short-term outcome following open and laparoscopic liver
resection of colorectal metastases. Surg Endosc 2002; 16
(7):1059–1063.
60 Farges O, Jagot P, Kirstetter P, Marty J, Belghiti J. Prospective
assessment of the safety and benefit of laparoscopic liver
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61 Schultz NA, Larsen PN, Klarskov B, et al. Evaluation of a fast-
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62 Vibert E, Perniceni T, Levard H, Denet C, Shahri NK, Gayet B.
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63 Koffron A, Geller D, Gamblin TC, Abecassis M. Laparoscopic
liver surgery: shifting the management of liver tumors. Hepatology 2006; 44(6):1694–1700.
64 Ardito F, Tayar C, Laurent A, Karoui M, Loriau J, Cherqui D.
Laparoscopic liver resection for benign disease. Arch Surg
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65 Vanounou T, Steel JL, Nguyen KT, et
clinical and economic impact of laparoscopic versus open
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67 Lee KF, Cheung YS, Chong CN, et al. Laparoscopic versus
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68 Sarpel U, Hefti MM, Wisnievsky JP, Roayaie S, Schwartz ME,
Labow DM. Outcome for patients treated with laparoscopic
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69 Gigot JF, Glineur D, Santiago Azagra J, et al. Laparoscopic liver
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70 O’Rourke N, Shaw I, Nathanson L, Martin I, Fielding G.
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71 Kaneko H, Takagi S, Otsuka Y, et al. Laparoscopic liver resection
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72 Chen HY, Juan CC, Ker CG. Laparoscopic liver surgery for
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al. Comparing the
Videos 1–20 will be of interest to readers of this chapter.
Visit the companion website at:
www.wiley.com\go\conrad\liver-pancreas-biliary-laparoscopic-surgery
CHAPTER 17
Laparoscopy (hybrid) and hand-assisted
laparoscopy in liver surgery: why, when,
and how?
Yasushi Hasegawa1and Go Wakabayashi
1
Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
2
Department of Surgery, Ageo Central General Hospital, Ageo City, Japan
EDITOR COMMENT
This chapter, by expert laparoscopic liver surgeons, allows the reader to learn the important indications for hybrid and hand-assisted
approaches to advanced laparoscopic liver resection. We believe that there are important yet selected indications with clear advantages
of a hybrid technique. These include the beginning of a surgical experience where placement of a surgical laparotomy pad inside the
abdomen early in the case allows for manual compression with the pad in case of bleeding and subsequent safe conversion to open
surgery. Hand-assisted approaches can be important when preoperative imaging and intraoperative ultrasound are not sufficient to
ensure complete tumor removal and palpation of the liver is required. When a hand-assisted approach is performed, placement of the
assistant’s hand rather than the operating surgeon’s hand in the abdomen can improve ergonomics and facilitate graduation to a purely
laparoscopic approach. Another important indication for hand-assisted or hybrid approaches are patients with significant abdominal
adhesions. The placement of a hand-assist access port allows for the creation of a working space through this access port from which the
remainder of the case can be performed purely laparoscopically.
Keywords: hand-assisted laparoscopic liver surgery, hybrid laparoscopic liver surgery
17.1 Introduction
Laparoscopic liver resection was first reported in the
1990s and since then, laparoscopic liver resection has
been established as a safe and feasible treatment option
for both benign and malignant liver tumors [1–4]. Despite
the clinical benefits of laparoscopic liver resection (e.g.
reduced blood loss, pain, and analgesic requirements;
shorter hospital stays; and improved cosmetic results),
its application remains limited because of insufficient
hepatic and laparoscopic surgical experience among
surgeons.
Laparoscopic liver resection can be divided into pure
laparoscopy, hand-assisted laparoscopy, and the hybrid
technique [2]. In the pure laparoscopic procedure, the
2
entire resection of the liver is completed through laparoscopic ports; hand-assisted laparoscopy is defined by the
placement of a hand port to facilitate the procedure; and
the hybrid technique is defined as a procedure that is
started as a pure or hand-assisted laparoscopy but in
which the final resection is performed through a minilaparotomy incision.
There is no evidence that any of these three approaches
is superior to the others; however, hand-assisted laparoscopy and the hybrid technique may help overcome certain difficulties associated with pure laparoscopy, and
may be less invasive than open laparotomy [3].
The role of these two methods compared with pure
laparoscopy and open laparotomy is discussed in this
chapter.
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
250
Laparoscopy (hybrid) and hand-assisted laparoscopy in liver surgery 251
17.2 The hybrid technique
(laparoscopy-assisted method)
As mentioned earlier, the hybrid technique consists of
two parts: it has an initial component in which limited
laparoscopic skills are required (usually liver mobilization) and a subsequent part that is technically more
challenging and performed open through a mini-laparotomy (the actual liver resection) [2]. The hybrid technique
is also frequently called the “laparoscopy-assisted”
method. The main feature of this method is that the
only laparoscopic skill required is liver mobilization,
and it can thus be relatively easily performed by most
liver surgeons [5,6].
17.2.1 Surgical procedure
There are two stages to the hybrid technique: first, the
liver mobilization is performed through a laparoscope,
followed by parenchymal transection being performed
through a small laparotomy incision.
The patient is fixed in a semi-left lateral decubitus
position that allows an intraoperative change from the
supine to the left lateral position by rotating the operative
table. A laparoscopic trocar is inserted from the umbilicus
in an open procedure and an expected small incision line
of up to 12 cm is drawn at the upper midline or right
subcostal region. The trocar position is shown in
Figure 17.1.
First, the liver is mobilized using the laparoscopic technique. When right liver mobilization is performed, the
operating table is rotated to have the patient in the left
lateral position. Sufficient mobilization of the liver
ensures the safety of the subsequent hepatic parenchymal
transection through a smaller incision.
After the mobilization is completed, a minimal incision
is made along the expected line in the upper midline or
right subcostal region. A wound protector is used, and
retraction is performed at the incision site in the cranial
direction with a Kent retractor.
The liver hanging maneuver is an essential procedure
that allows handling through the smaller surgical incision
to be performed safely [6,7]. For the liver hanging
maneuver through a small incision, the authors prefer
the use of Nitta forceps (commercially available forceps
with a long, blunt, highly curved tip) (Figure 17.2). To
perform the liver hanging maneuver, the tissue between
the middle hepatic vein and the right hepatic vein is
dissected. The Nitta forceps are inserted beginning at
the 11 o’clock position on the inferior vena cava (IVC)
and are used to carefully dissect the tissue between the
liver and the anterior surface of the IVC. When the
tissue between the IVC and liver is passed through, a
Penrose drain is clamped with the Nitta forceps and placed
there for the liver hanging maneuver.
Hepatic parenchymal transection through a small incision can be performed with the same procedures by open
laparotomy. Various devices are available for hepatic
parenchymal transection, and a surgeon may choose
devices that are suitable to his/her preferred method
(Figure 17.3).
Figure 17.1 (a,b) Trocar placement and incision for laparoscopy-assisted liver resection.
252 Chapter 17
Figure 17.2 Nitta forceps for liver hanging maneuver with long
blunt, highly curved tip.
morbidity and enhancing their well-being postoperatively, when compared with open laparotomy.
When liver mobilization is performed laparoscopically,
not only the operator but also the assistants have the
opportunity to obtain a clear view of the posterior side of
the liver, owing to laparoscopic magnification. This view
can assist the surgeons in mobilizing the right liver more
safely.
Transection of the liver parenchyma, dividing of the
hepatic hilum, and dissection of the hepatic vein are
performed though the mini-laparotomy incision under
direct vision. These procedures are typically more challenging to perform using pure laparoscopy to the requirement for advanced laparoscopic skills. In particular, the
liver parenchymal transection has the potential to prolong the operation time when performed laparoscopically. When using the hybrid technique, this subset of
challenging procedures is carried out using standard open
laparotomy techniques, which may be easier for many
liver surgeons.
In addition, the hybrid technique is also useful for cases
requiring reconstruction of the biliary tract, such as hilar
cholangiocarcinomas. Reconstruction of the biliary tract
under pure laparoscopy is very difficult and highly technical, whereas under mini-laparotomy, it is much more
easily achieved.
Figure 17.3 Liver parenchymal transection in laparoscopy-
assisted liver resection.
17.2.2 Advantages of the hybrid
technique
The biggest advantage of the hybrid technique is the
smaller incision compared with open laparotomy. In
open hepatectomy, a subcostal incision with midline
incision, i.e. reversed T incision or reversed L incision,
is usually needed to mobilize the liver, because the liver is
fixed by ligaments behind the ribcage. However, if the
mobilization is performed by laparoscopy, a large incision
is not needed. Some studies have reported that laparoscopic liver resection is associated with less pain and fewer
analgesic requirements than open surgery. Smaller incisions should theoretically result in less pain, so the hybrid
technique thus also contributes to reducing patient
17.2.3 Disadvantages of the hybrid
technique
The principal difference between pure laparoscopy and
the hybrid technique is the method of liver parenchymal
transection. The pneumoperitoneum induced during laparoscopic surgery has a tendency to reduce bleeding at the
surgical site. Because the hybrid technique does not allow
for peritoneal insufflation, the benefits of pneumoperitoneum-induced reduction in hepatic venous back bleeding are not present in the hybrid technique.
In addition, the patient’s body habitus has a larger effect
on the difficulty of surgery in the hybrid technique
compared with pure laparoscopy. When a patient’s anterior–posterior trunk diameter is long, the operative field
becomes difficult to see, and the technique is associated
with an increased risk of hemorrhage deep in the abdominal cavity (i.e. of the IVC or hepatic vein).
17.2.4 Why and when?
The hybrid technique has some advantages over pure
laparoscopy, but we believe that these advantages
Laparoscopy (hybrid) and hand-assisted laparoscopy in liver surgery 253
diminish when surgeons overcome the difficulties in pure
laparoscopic procedure with proper laparoscopic training [3,8]. There are two main motives for selecting the
hybrid technique over a full laparoscopic procedure.
The first reason, as noted above, is when a surgeon has
insufficient experience in performing the full laparoscopic proced ure available. Laparoscopic liver parenchymal transection commonly takes a great deal of
investment in both effort and education, in order to be
able to perform the procedure effectively. However,
having experience in liver mobilization in laparoscopyassisted hepatectomy is helpful for learning how to
perform it stepwise.
The other main motive for using the hybrid technique is
for biliary reconstruction (i.e. choledochojejunostomy).
While this procedure can be done using the full laparoscopic procedure, the level of mastery for this procedure,
including the reconstruction using a pure laparoscopic
technique, requires a great deal of experience and time
investment by the surgeon. Particularly in facilities where
this procedure is done infrequently, it is preferable to
use the hybrid method, to allow as many advantages as
possible from the laparoscopic technique, while assuring
that the more complex aspects of the surgery are managed
in a safe and oncologically sound way.
17.3 Hand-assisted laparoscopy
can also be used in the hybrid technique (laparoscopyassisted liver resection). In this section, the former
method is described, which is useful mainly in cases of
tumors located in the right liver, especially in segments
VII or VIII.
In HALS, for ergonomic reasons, it is important to
correctly position the surgeon (i.e. on the left side of
the patient, between the patient’s legs, or on the right
side of the patient), the hand-access device, and the
trocars. There is no definite “right way” to do this, and
the positions are decided on a case-by-case basis according to the operator’s preferences. If the correct setting is
misjudged when placing the hand-assist access port, the
surgeon is forced to remain in a nonergonomic position
during the entire operation, which can contribute to
operator fatigue.
A laparoscopic trocar is inserted at the umbilicus in an
open fashion. A small incision (5–8 cm, depending on the
surgeon’s hand size), which is where the hand is inserted
in hand-assisted situations, is marked out at the right
lateral abdominal region. Two 12 mm trocars are inserted
at both ends of this expected small midline incision,
and two more trocars are inserted at the epigastric region
and right subcostal region (Figure 17.4).
The right liver mobilization is usually performed by
the pure laparoscopic technique, and the parenchymal
transection is performed by HALS. After the mobilization is completed, a small incision along the previously
In the Louisville Statement, hand-assisted laparoscopy
was defined as the elective placement of a hand port
during laparoscopic liver resection to facilitate the procedure, and this technique is frequently called handassisted laparoscopic surgery (HALS) [2,9,10]. The
main feature of this method is that the surgeon’s hand
is in the abdominal cavity, as for open laparotomy, and
this is associated with a number of both advantages and
disadvantages.
17.3.1 Surgical procedure
There are two main positions for inserting the hand
during the procedure. One is the right lateral abdomen
of the patient and the other is the upper midline abdominal area. In the former method, the operator inserts the
hand into the abdominal cavity and uses it for liver
parenchymal transection, whereas in the latter method,
the assistant inserts the hand and uses it for liver mobilization. Moreover, the upper midline abdominal incision
Figure 17.4 Trocar placement and incision for hand-assisted
liver resection.
254 Chapter 17
Figure 17.5 Technique for inserting the hand. (a) The surgeon wears two gloves on the left hand. (b) Insert the hand into abdomen
through the wound retractor. (c) Loop the outside glove around the wound retractor.
marked line in right lateral a bdominal region is crea ted.
A hand -port device or wound retractor with double
surgical groves is used, and the operator’slefthandis
inserted into the abdominal cavity (Figure 17.5). During the parenchymal transection, t he hand can be used
for retracting and moving the liver, and the fingers can
be used for opening the liver cut surface (Figure 17.6).
Aside fr om the advantage of palpation and tactile feedback, the parenchymal transection is carried out in a
similar manner to pure laparoscopic liver resection.
17.3.2 Advantages of HALS
A disadvantage of laparoscopic surgery is the restriction
of movement, and HALS is helpful in avoiding this
problem. Additionally, HALS can facilitate the retraction and moving of the liver. Moving the liver using a
hand can help in various stages of a liver resection such
as during parenchymal transection, mobilization, and
dissecting vessels.
During the laparoscopic parenchymal transection of
the liver, there can be some difficulty in directing the
transection plane towards the operating surgeon, because
the trocar position is fixed. However, this can be overcome by repositioning the liver using the hand to allow for
an optimal orientation of the parenchymal transection
line towards the surgeon’s instruments. To dissect the
liver parenchyma effectively, tension created by countertraction plays an important role. During HALS, tension on
the cut surface is created not only by laparoscopic forceps
but also by the surgeon’s fingers through the HALS port.
During liver surgery there is the risk of significant blood
loss. To control bleeding requires compression of the
bleeding point. Intra-abdominally, the surgeon’s hand
can compress the bleeding point more easily and sometimes more effectively than is possible using only laparoscopic instruments. Once the bleeding point is found, it
can be stopped by an energy device or by suturing.
Furthermore, continuous bleeding from the liver parenchyma can be controlled by raising the liver with the
hand, when the HALS method is used. To accomplish this,
the right or middle hepatic vein is raised, resulting in the
intrahepatic venous pressure being reduced, thereby
lessening the bleeding from the hepatic vein. This technique is easier in HALS than in pure laparoscopy, where
Laparoscopy (hybrid) and hand-assisted laparoscopy in liver surgery 255
17.3.3 Disadvantages of HALS
Hand-assisted laparoscopic surgery has some crucial disadvantages. First, the surgeon’s hand sometimes interferes with the view of the surgical field provided by the
laparoscopic camera. The hand takes up a very large space
in the abdominal cavity, in comparison with other laparoscopic instruments, and this can impede visibility if
the positioning of the camera trocar is not managed
effectively.
The second concern is one of ergonomics. Because the
operator’s hand is confined in position by the HALS port,
the operator can experience poor body positioning,
resulting in muscle ache and increased risk of operator
fatigue, especially when the surgical time is prolonged.
Additionally, special care should be taken to be sufficiently careful and gentle with activities undertaken
within the abdominal cavity through the HALS port, as
the procedure of hand-assisted liver resection can be less
refined than that of pure laparoscopy, which tends to
allow small and delicate movements through the abdominal field.
Figure 17.6 (a,b) Hand-assisted extended posterior
sectionectomy.
all movement must be accomplished using only the
laparoscopic forceps.
Pneumoperitoneum is an advantage of laparoscopic
surgery, compared with the hybrid technique or open
surgery. Bleeding from the hepatic vein is decreased by
the pressure of the pneumoperitoneum, and because
HALS uses a port that seals the abdominal cavity, allowing
for insufflation, HALS is thus associated with less potential blood loss than the hybrid technique or open laparotomy method during parenchymal transection.
Good tactile feedback is another advantage of HALS,
with direct palpation of tumors being possible. It is crucial
to achieve negative surgical margins for the resection of
malignancies, and concerns have been raised about the
positive margin rate observed in laparoscopic surgery
potentially being higher than with the other techniques.
Tactile feedback aids in the identification of tumor margins
and of the correct direction in parenchymal transection.
17.3.4 Why and when?
The pros and cons of HALS are described above. The
advantages of HALS may be overcome by proper training
in the pure laparoscopic technique, and HALS can function as a bridge to pure laparoscopic liver resection [3]. For
surgeons training in laparoscopic hepatectomy, HALS
may be helpful, especially during posterior sectionectomy
and wedge resection for tumors located at segment VII or
VIII. Moreover, cirrhotic livers are hard to move and lift,
so HALS may be useful for these cases. When there is
delayed or little progress in obtaining adequate hemostasis, conversion to HALS from pure laparoscopy may be an
answer.
17.4 Conclusion
We believe that, although most liver resections can be
successfully performed by pure laparoscopy, both the
hybrid technique and HALS play important roles in minimal invasive hepatectomy. The appropriate procedure
should be selected depending on the experience of the
surgeon, the tumor location, and the quality of the underlying liver parenchyma.
256 Chapter 17
KEY POINTS
• There are important yet selected indications with advantages of a hybrid technique.
• Manual compression with a laparotomy pad through a hand port in case of bleeding and subsequent safe conversion to open
surgery can be life saving.
• Specific oncological cases might demand manual palpation of the liver.
• The placement of a hand-assist access port allows for the creation of a working space through the port from which the remainder
of the case can be performed purely laparoscopically.
References
1 Gagner M, Rheault M, Dubuc J. Laparoscopic partial hepa-
tectomy for liver tumor. Surg Endosc 1992; 6:97–98.
2 Buell JF, Cherqui D, Geller DA, et al. The international
position on laparoscopic liver surgery: the Louisville Statement, 2008. Ann Surg 2009; 250:825–830.
3 Wakabayashi G, Cherqui D, Geller DA, et al. Recommenda-
tion for laparoscopic liver resection: a report from the second
international consensus conference held in Morioka. Ann
Surg 2015; 261:619–629.
4 Lin NC, Nitta H, Wakabayashi G. Laparoscopic major hepa-
tectomy: a systematic literature review and comparison of
3 techniques. Ann Surg 2013; 257:205–213.
5 Koffron AJ, Kung RD, Auffenberg GB, et al. Laparoscopic liver
surgery for everyone: the hybrid method. Surgery 2007;
142:463–468.
Videos 1–20 will be of interest to readers of this chapter.
Visit the companion website at:
6 Nitta H, Sasaki A, Fujita T, et al. Laparoscopy-assisted major
liver resections employing a hanging technique: the original
procedure. Ann Surg 2010; 251:450–453.
7 Wakabayashi G. Laparoscopy-assisted donor right hepatec-
tomy employing a hanging technique. In: Asbun H, Geller D
(eds) ACS Multimedia Atlas of Surgery: Liver Volume.
Chicago: American College of Surgeons, 2014.
8 Takahara T, Wakabayashi G, Hasegawa Y, et al. Minimally
invasive donor hepatectomy: evolution from hybrid to pure
laparoscopic techniques. Ann Surg 2015; 26 (1):e3–4.
9 Fong Y, Jarnagin W, Conlon KC, et al. Hand-assisted laparo-
scopic liver resection: lessons from an initial experience. Arch
Surg 2000; 135 (7): 854–859.
10 Cuschieri A. Laparoscopic hand-assisted surgery for
hepatic and pancreatic disease. Surg Endosc 2000; 14 (11):
991–996.
www.wiley.com\go\conrad\liver-pancreas-biliary-laparoscopic-surgery
CHAPTER 18
Ablation strategies for tumors of the liver
and pancreas
Danielle K. DePeralta and Kenneth K. Tanabe
Division of Surgical Oncology, Harvard Medical School, Massachuset ts General Hospital, Boston, Massachusetts, USA
EDITOR COMMENT
In this very comprehensive chapter on nonresective approaches to hepatocellular carcinoma and secondary liver cancers, the authors
explain the technical aspects, indications, and expected outcomes for common liver-directed therapies. These include radiofrequency
ablation, microwave ablation, irreversible electroporation, cryoablation, and transarterial chemoembolization. The authors further detail
key considerations for the ablation of hepatocellular carcinoma, colorectal, neuroendocrine, and breast liver metastases. Advantages and
disadvantages of the various approaches such as percutaneous, open or laparoscopic are explained. Laparoscopic ablation probe
placement has become more precise with advances in intraoperative ultrasound and ablation probe placement.
While RFA is the standard of care for small unresectable HCCs, with greater experience in the minimally invasive resection of
hepatocellular carcinoma in cirrhotic livers, it has become an option that combines the benefits of ablation and resection. A laparoscopic
resection of early HCC can be performed with the low morbidity of ablation, but tumor removal allows for assessment of the most
important predictor of oncological outcome in HCC: vascular invasion.
Among the newer ablation technologies, irreversible electroporation is a nonthermal ablation that spares surrounding vasculature and
bile ducts and may even be an option for some patients with locally advanced pancreatic cancer.
This chapter on liver-directed strategies is important for all advanced minimally invasive hepatopancreatobiliary surgeons treating a
wide spectrum of patients with early and advanced, primary and secondary liver cancer.
Keywords: ablation of hepatocellular carcinoma, ablation of of liver metastases, cryoablation, irreversible electroporation, liver ablation,
microwave ablation, postembolization syndrome radiofrequency ablation, transarterial chemoembolization
Surgical extirpation, via either hepatic resection or 18.1 Overview of modalities
transplantation, remains the best option for potentially
curable liver tumors. However, since many patients are
not candida tes for surgical resection or tr ansplanta tion,
there has been increasing focus on locoregional therapies, which generally include transarterial and ablative
strategies, as both palliative and in some cases curative
techniques. In this chapter, we will focus on local
ablative strategies (Box 1) for hepatocellular carcinoma
(HCC), metastatic liver tumors, and t o a lesser e xtent
pancreatic cancers.
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
The options for local ablation have grown in recent years
and while radiofrequency ablation remains the most
clinically useful, the surgeon must have a thorough
understanding of the therapeutic options. Each of the
strategies discussed below may be performed percutaneously, laparoscopically, or during an open operation, depending on both patient functional status and
tumor characteristics. We focus on the most relevant
techniques here.
257
258 Chapter 18
Box 18.1 Ablation strategies for liver tumors
• Radiofrequency ablation
• Microwave ablation
• Cryoablation
• Ethanol ablation
• Acetic acid ablation
• Irreversible electroporation
• High-intensity ultrasound
• Interstitial laser ablation
18.1.1 Radiofrequency ablation (RFA)
Jacques-Arsène d’Arsonval first described the thermal
effects of radiofrequency (RF) energy on tissue in
1891 [1] and in 1928 the Bovie knife, a crude monopolar
RF electrode, was incorporated into the surgical repertoire [2]. After gaining experience in animal models, RFA
was first performed in patients with liver tumors in the
early 1990s, initially in Europe and later in the United
States [3]. No other locoregional therapy has gained the
same acceptance among surgeons or interventional radiologists, or has been as well studied.
Radiofrequency ablation induces cell death by coagulative necrosis. A simple circuit is created using an RF generator, grounding pad, and the interstitial electrode(s) placed
within the liver tumor. Electrode(s) are carefully positioned
within the tumor under direct visualization or with image
guidance, and rapidly alternating RF current leads to ion
agitation and heat generation at the site of the electrode,
with subsequent coagulation necrosis (Figure 18.1). The
greatest heat is generated at the site of the electrode and
extends peripherally by thermal conduction.
Irreversible cellular injury and death occur as tissues
are heated beyond 60 °C. Most current systems can reliably generate a 3 cm ablation zone. For larger tumors, the
electrode can be repeatedly repositioned to generate an
approximately 1 cm margin around the tumor.
Radiofrequency electrodes (Figure 18.2) are commercially available with expandable multitined, clustered,
and straight insulated needles with a metallic tip.
Figure 18.1 (a) Explanted liver resected immediately following radiofrequency ablation. (b) Central area of coagulation necrosis.
(c) Surrounding margin of incompletely ablated liver with a majority of cells that are histologically abnormal and would undergo
apoptosis if left in situ.
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