Commentary on “Laparoscopic Radiofrequency Ablation in the Caudate Lobe for Hepatocellular Carcinoma Before Liver Transplantation”

This report by Di Benedetto et al. ¹ details a small case series of 3 patients undergoing laparoscopic radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) of the caudate lobe in order to downstage their disease prior to orthotopic liver transplantation. Technical pearls given in this report include the use of a non-periumbilical Hasson-type trocar placement for the initial entry into the abdomen of a patient with portal hypertension as well as the use of intraoperative ultrasound throughout the procedure. The group obtained technical and clinical success in all 3 patients who were eventually transplanted and are doing well at follow-up.

The authors highlight several of the difficulties in treating HCC in the face of cirrhosis. It is clear that liver transplantation offers the best outcomes over resection for these patients and should therefore be offered within the accepted criteria. Patients presenting outside of these criteria can be downstaged by tumor-directed therapies that are generally performed by transarterial or percutaneous methods. However, in the case of caudate lobe involvement, oftentimes neither of these approaches may be feasible, as the authors point out. Other recent reports have detailed the ability to successfully perform percutaneous RFA for HCC lesion in the caudate with the use of artificial ascites and careful ultrasonic guidance. ² However, it is important to point out that the sizes of the tumors in this current report were much larger, necessitating a direct view afforded by laparoscopy for increased safety and efficacy. Additionally, the use of laparoscopy minimizes the morbidity compared with an open abdominal operation in a patient with cirrhosis. Consequently, the authors show that with the use of laparoscopy, RFA can safely and effectively be performed under direct vision for patients with sizeable HCC of the caudate lobe in the setting of liver cirrhosis as a bridge to transplantation.