Laparoscopic ablation therapy for hepatocellular carcinoma. Clinical significance of a newly developed laparoscopic sector ultrasonic probe

Abstract

Background: Although a laparoscopic approach for local ablation plays an important role in treating hepatocellular carcinoma (HCC) near the liver surface, precise targeting ablation has been difficult using a conventional linear ultrasonic probe. We have recently developed a sector ultrasonic probe with a guiding tract for precisely targeting tumors. Methods: Since 1996, 349 HCC cases have been treated with either microwave or radiofrequency ablation. A percutaneous approach was selected in 298 cases, and a laparoscopic approach was selected in 51 cases. The laparoscopic approach was selected in the cases in which serious complications due to the tumors being located on the surface or protruding from the liver, or adjacent to the gallbladder or intestine made it difficult to treat percutaneously. In the latest 21 cases, the sector ultrasonic probe was used. Results: All the cases were safely and successfully treated by laparoscopic ablation with an exception by an extensive HCC case with portal vein tumor thrombus. Survival after the treatment by laparoscopic ablation was 95.2% in 1 year, and 82.4% in 3 years. The tumor stage was a significant prognostic factor (P < 0.0001). There was no local recurrence within 6 months of treatment in the successfully treated cases. The use of the sector probe widened indications for the laparoscopic approach for treating HCC. Conclusion: Laparoscopic ablation can result in a satisfactory outcome in difficult‐to‐treat cases by the percutaneous approach. The newly developed sector ultrasonic probe has allowed us more therapeutic choices in the treatment of HCC.

Novel Non-Trocar Technique for Laparoscopic Radiofrequency Ablation

“…Asahina et al [4,5] have developed a sector type ultrasonic probe (end-fire type), which is inserted through a 12-mm trocar, and although safe and accurate ablation is possible therewith, a 20-cm needle is difficult to handle. When a cool-tip type probe is used, a 25-cm long needle is requisite; however, such a needle may carry the risk of unnecessary overablation of small HCC, in that it can ablate only nodules 3 cm in diameter.…”

“…The former is superior to the latter because of its minimally invasive surgical procedure and the cosmetically more esthetic surgical scar [3]. When a laparoscopic ultrasound probe is inserted through a trocar, it is difficult to use the insertion point made by the probe or to attach and slide an ablation needle along the groove of the probe into the abdominal cavity because of the longitudinal dissociation between the needle and the probe [4,5]. We have developed a novel insertion method, a non-trocar technique (NTT), for laparoscopic RFA with the use of a convex scanning probe, whereby an ablation needle accurately and easily punctures the target tumor in the liver.…”

Laparoscopic Radiofrequency Ablation for Hepatocellular Carcinoma

“…Hence, the laparoscopic approach is well indicated in superficial or extrahepatic protrusive HCC, and HCC adjacent to the gastrointestinal tract, gallbladder, bile duct or heart 35,36 . In cases of paracholecystic HCC, the laparoscopic procedure allows for a cholecystectomy and enables a direct approach through the gallbladder fossa to ablate the tumor 24,37 . The laparoscopic approach with a positive‐pressure pneumoperitoneum has a distinct advantage over the percutaneous approach because liver blood flow is reduced by approximately 40% 38 …”

“…The laparoscopic approach also offers the ability to carry out an intraoperative high‐frequency ultrasound examination. Using laparoscopic ultrasound during the procedure can help identify the treatable lesion, detect new HCC lesions that were not identified by preoperative imaging, 39–44 and aid RF‐needle placement for more accurate targeting 37,45–50 . Initially, laparoscopy and laparoscopic ultrasound were found to be useful for staging and detecting new HCC that could not be identified preoperatively 39–44,48 .…”

“…Despite its good image resolution, a linear probe requires skill and experience, 45,51–53 or the development of special navigation technology, 47–50 to precisely target a tumor for ablation. This clinical obstacle has been overcome by new types of ultrasonic probes; the sector type (Aloka Co.) 37 and the convex scan type (PVM‐787LA; Toshiba Medicals, Tokyo, Japan) 46 . These probes are designed to target intrahepatic tumors because they have a guiding tract on the shaft that allows the user to see an ablation needle advancing into a tumor on a real‐time ultrasonographic image.…”