Radiofrequency Ablation for Small Hepatocellular Carcinoma by Minshan Chen Yaojun Zhang & W.Y. Lau

Author:Minshan Chen, Yaojun Zhang & W.Y. Lau
Language: eng
Format: epub
Publisher: Springer Netherlands, Dordrecht

Fig. 6.2Laparoscopic RFA

The surgical RFA approach is generally applied to patients with multiple large tumors which range from 3 to 5 cm or which are close to a large vessel. Surgical RFA allows for temporary occlusion of hepatic artery and portal vein, the Pringle’s maneuver, which practically stops all blood inflow to the liver. As the cooling effect from the blood inflow is minimized, large tumors are more likely to be completely ablated. It also facilitates bile duct cooling by using an endoscopic nasobiliary drainage (ENBD) tube during RFA for HCC close to major bile ducts. If multiple RFA ablations with overlapping ablation zones are needed for large tumors, surgical RFA is more suitable. If the patient also presents with a separate tumor that cannot undergo RFA but is suitable to be resected, it can be surgically resected during the same operation. Moreover, surgical RFA enables identification and control of bleeding after treatment of superficial tumors and avoidance of seeding along the needle track.

The disadvantages of open RFA are similar to those of other open surgeries, as it is more expensive, requires general anesthesia and longer hospital stay, and is associated with more pain. In addition, as percutaneous RFA technique has improved much in the last decade, open RFA now contributes only to a small proportion of RFA procedures in most centers. As a consequence, there are very limited data on open RFA. One non-randomized study showed percutaneous RFA to have a significantly shorter hospital stay (4.1 vs. 7.6 days) and a lower morbidity rate (2.3 % vs. 8.8 %) than open RFA [6].

Laparoscopic RFA is currently more commonly adopted than open RFA. Laparoscopic RFA combines many of the benefits of both the percutaneous and open approaches. However, a history of previous abdominal surgery with significant intraabdominal adhesions may preclude the use of the laparoscopic approach. Laparoscopic RFA is a safe treatment for liver tumors in deep locations, as well as superficial nodules adjacent to the diaphragm and organs, or for multiple lesions. The complication and mortality rates have been reported to range from 3.2 % to 27 % and from 0 % to 1.9 %, respectively [7–11]. Three non-randomized comparative studies consistently showed that laparoscopic RFA had significantly lower intraoperative blood loss, shorter operative time, and shorter postoperative hospital stay, when compared with open RFA [12–14]. In addition, laparoscopic intraoperative ultrasound during laparoscopic RFA allows a much more accurate staging than preoperative imagings. Laparoscopic intraoperative ultrasound has been reported with great accuracy during the procedure, permitting to detect 13.3–46.1 % new HCC nodules missed at preoperative imagings [15–18]. The laparoscopic approach also has the advantages of the open approach, such as applying the Pringle’s Maneuver, or to carry out concomitant resectional procedures. However, it is technically more challenging. For those tumors which are close to the dome of the liver or when the right posterior sector is shrunken in cirrhotic liver, the degree of freedom for introduction of the RFA electrodes is less than with open RFA. In expert centers, these tumors in such difficult locations can still be treated by laparoscopic RFA.

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