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INDICATIONS

Radiofrequency ablation (RFA) of liver tumors can be performed percutaneously, laparoscopically, or through a traditional open incision. The most common indication for RFA is unresectable primary or metastatic hepatic cancer. RFA can also be applied to a potentially resectable hepatic neoplasm in a patient with a prohibitive operative risk secondary to severe medical comorbidities or compromised hepatocellular reserve (cirrhosis). The role of RFA in non-neuroendocrine neoplasms with extrahepatic metastases is unclear. RFA can provide effective symptomatic palliation for unresectable functional neuroendocrine neoplasms.

RFA is currently considered a form of hepatic directed palliative therapy. Heat produced during RFA induces local tissue destruction by inducing coagulative necrosis. The effectiveness of RFA is limited by the size and the location of the lesion(s). When performed correctly, RFA is effective at destroying hepatic neoplasms up to 5 cm in diameter. Lesions located near a vessel greater than 3 mm in diameter may not be adequately ablated because of a “heat sink” effect in which optimum targeted temperature cannot be achieved due to perivascular heat dissipation. Neoplasms located near the hilar plate must be approached with caution because of the potential for bile duct injury.

PREOPERATIVE PREPARATION

Triple-phase contrast-enhanced computed tomography (CT) scan of the abdomen provides critical anatomical information on the number and location of hepatic masses and their relation to major vessels and ductal structures.

Preoperative medical evaluation for cardiopulmonary disease and fitness for surgery are essential. In patients with cirrhosis, laboratory investigation and clinical assessment must be performed to assess the hepatocellular reserve. The model of end-stage liver disease (MELD) score is an objective method to evaluate the hepatic reserve. The MELD score is calculated by measuring serum creatinine, total bilirubin, and the international normalized (coagulation) ratio (INR). The MELD score has been demonstrated to be predictive of perioperative mortality in patients undergoing abdominal and hepatic surgery.

Patients with a metastatic “functional” neuroendocrine neoplasm should have their symptoms appropriately controlled preoperatively, usually with octreotide. Adequate hydration, preoperative antibiotic, and deep venous thrombosis (DVT) prophylaxis are all indicated. Essential equipment includes 30- and 45-degree laparoscopes, a 10-mm flexible laparoscopic ultrasound probe, an ultrasonic dissector, a 10-mm clip applier, and a laparoscopic radiofrequency ablation system with a 5-cm array electrosurgical probe.

ANESTHESIA

General anesthesia with endotracheal intubation and complete neuromuscular blockade is required for this operation.

OPERATIVE PREPARATION

A dose of prophylactic IV antibiotic is administered per routine. A Foley catheter and nasogastric tube are placed after the induction of anesthesia. The upper abdomen of the patient is shaved from the nipple line to the pubis if necessary. The abdomen is sterilely prepped and draped.

PATIENT POSITION

Laparoscopic RFA of a hepatic mass is performed with the patient in the supine position. The upper and lower extremities are well ...

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