LIVER SURGICAL DISEASES

ANATOMY
• The liver is the largest organ in the body : 1200-1600 g
• Regarded as a paired organ which is fused along a line which
can be drawn between the gallbladder fossa and IVC.
• Each lobe receives a full branch of the portal vein, hepatic
artery and bile duct.
• By further division of the vascular supply- each lobe is
composed of 4 segments which are numbered 1 to 4 for the
left and 5 to 8 for the right liver.
• Recognition of the segmental nature of the liver can be
ascribed to the French surgeon, Couinaud.
ANATOMY
 CLASSICAL ANATOMY
The classical description of the liver
anatomy is based on the external
appearance.
On the diaphragmatic surface, the
ligamentum falciforme divides
the liver into the right and left
anatomic lobes, which are very
different from the functional right
and left lobes
In this classical description, the
quadrate lobe belongs to the
right lobe of the liver, but
functionally it is part of left lobe.
Segmental anatomy according to Couinaud
Clockwise numbering of the segments
On a frontal view of the liver the posteriorly
located segments 6 and 7 are not visible.
 ANATOMY
• Hepatic veins of surgical importance are three:
– the right hepatic vein which drains segments 6-8 by a
short vessel directly into the suprahepatic vena cava,
– the middle hepatic vein which drains from both
hepatic lobes and empties directly into the vena cava
or the left hepatic vein
– the left hepatic vein which drains segment 2, 3, 4.
• Segment 1 or caudate lobe drains by several small
hepatic veins directly into the infrahepatic vena
cava.
 SEGMENTECTOMY
• A careful identification of the vessels and
ducts supplying each segment can be achieved
by dissection above the portal hilum

• Each set may be ligated separately prior to an

attempt at resection.
 PORTAL VEIN, CBD, CHA
• In the portal hilum the portal vein which has formed
behind the head of the pancreas by the junction of
splenic and mesenteric veins, passes along the edge
of the lesser omentum.
• In front of and to the right, common bile duct drains
both liver lobes and receives the cystic duct at a
variable point of its course and on either side.
• To the left of the common bile duct runs the common
hepatic artery giving off the main cystic artery and
branches to the common bile duct prior to division
into right and left branches.
PORTAL SYSTEM
 LIVER FUNCTION
1. Bile formation and excretion
• About 500-1000 ml. of bile are secreted each day.
• The liver synthesizes bile acids from cholesterol. Almost all of
the bile acids are reabsorbed by the terminal ileum and enter
the enterohepatic circulation.
• Bile pigments are derived from the breakdown of hemoglobin
to biliverdin then bilirubin. In the liver unconjugated bilirubin
is conjugated and then secreted into the bile canaliculi and
transported to the gastrointestinal tract.
• Bile contains cholesterol in micellar form, bile acids,
phospholipids, electrolytes, mucin and water.
 JAUNDICE

• Jaundice due to unconjugated bilirubinemia results from

increased hemoglobin breakdown or diminished conjugation.

• Jaundice due to conjugated bilirubinemia is commonly

associated with intrahepatic and extrahepatic bile duct
obstruction and with hepatocyte damage.
 JAUNDICE
• Jaundice is caused by a
build up of bilirubin in
the blood resulting
in a yellow tinge to the
skin and the whites of
the eyes
 LIVER FUNCTION

2. Protein metabolism
• The liver is a major sourse of beta and gamma-globulins and
the only site of production of albumin and alpha-globulin.
• Hepatocytes are capable of protein synthesis from
aminoacids. The liver is also the major site of urea synthesis.
Most of coagulation factors are synthesized within the liver.

3. Carbohydrate metabolism
 LIVER FUNCTION
4. Lipid metabolism
• Cholesterol levels decrease markedly with hepatocellular
failure.

• Conversely, a rise in cholesterol is usually seen in intra-

and extrahepatic obstruction.
 LIVER FUNCTION
5. Enzyme secretion by the liver
• TGO (glutamic oxalacetic transaminase ) is found in high levels in
hepatocellular damage.
• Alkaline phosphatase is excreted through the biliary tree so that
biliary obstruction is accompanied by a rise in the serum alkaline
phophatase.
• However, most liver disorders including hepatic abscess, trauma,
metastases and diffuse liver disease (hepatitis) are associated with
an elevated value.
• A rise in the serum gamma-glutamyl transpeptidase (TGP) is
increased in both cholestasis and hepatocellular disease.
 INVESTIGATIONS
1. Plain abdominal X-ray
2. Ultrasonography
3. CT scanning of the liver
4. Scintiscanning of the liver parenchyma
5. Portography and arteriography.
6. Needle biopsy of the liver
 Plain abdominal X-ray
• May give helpful information in terms of:
– liver size and the position of the overlying
diaphragm.
– rarely a small gas/fluid level may be seen within an
abscess
– hydatic cysts are well shown due to calcification
within the cyst wall.
 Ultrasonography

• In patients with cholestasis, dilated IH-BD clearly pinpoint the

presence of duct obstruction.
• Gallstones may be diagnosed with an accuracy of 95% in the
best hands.
• Well shown are liver cysts and abscesses
• Primary liver tumours and multifocal MTS are readily seen.
• Intraoperative US of the liver can demonstrate precisely the
anatomy of vascular structures, the boundaries of palpable
liver tumours and the presence of impalpable foci enabling a
more appropriate resection line.
 Case report
• A 16-year-old girl presented to the emergency room of
pediatrics department with complaints of abdominal pain,
nausea and vomiting.

• Physical examination revealed tenderness on the right upper

quadrant of the abdomen.
• Blood analysis showed increased white blood count with left
shift, an ESR of 78 mm/h and CRP 279 mg/l.

• Liver enzimes- increased levels

 On abdominal X-ray, a metallic linear radio opaque
image compatible with a foreign body was seen on right
hepatic lobe localization
 USS examination revealed a 3cm long linear
echogeneity in segment 5 surrounded by an irregularly
contoured heterogeneous hyper echoic area of 10x7cm
in size -? migration of a swallowed foreign body into the
liver accompanied by an abscess formation
 Case report
• The patient remembered that she could have swallowed a
sewing needle approximately a month ago while drinking
water. She told that she saw a number of sewing needles in
the water glass which she noticed after drinking some water.

• On further examination with abdominal computed

tomography (CT), the metallic foreign body and surrounding
inflammation were better demonstrated
CT- foreign body in the right lobe of
the liver
 Case report

• The patient underwent surgical operation for the excision of

the foreign body, but it could not be reached.

• The patient went home with antibiotherapy for the

surrounding inflammation.
 Case report
• Two and a half months later the patient presented
again with abdominal pain

• Control CT examination demonstrated the migration

of the foreign body near to the gallbladder

• The surrounding inflammatory changes were

disappeared.
Foreign body near to the gallbladder.
 Case report
• On reoperation with open abdominal surgery,
the sewing needle was found easily due to its
migration nearby the gallbladder, and it was
removed from the liver.

• The patient recovered successfully after the

operation.
 CT scanning of the liver

• Normally the procedure is combined with contrast meal to

define the stomach and duodenum and iv contrast to outline
the vessels and focal lesions within the liver.

• The procedure is expensive and time-consuming but it is

consistent and leads to relatively easy interpretation.

• Furthermore surrounding structures are also well shown,

particularly the diaphragm, lung bases and suprahepatic vena
cava.
Big liver abscess and other three small liver
abscesses
Chest X-ray with free air sickle and local drainage
between diaphragm and liver
 Case report
• The 58-year-old male patient was acutely admitted to
emergency unit because of fever and diffuse
abdominal tenderness and pain mainly in the right
upper abdomen since two weeks.

• One year before the patient had undergone a

Whipple's procedure in our hospital because of an
pT4, N1-Adenocarcinoma of the Vater's papilla.
 Case report
• Investigations including: gastroscopy,
ultrasonography abdominal CT-scan showed only an
urinary tract infection.
• Blood culture - escherichia coli infection,
• The patient was treated in accordance to the
microbiological results with ciprofloxacin.
• Due to the rapid aggravation of the health condition
the patient was finally transferred to another
hospital.
 Case report
• At admission - diffuse tenderness of the abdomen
without any bowel sounds and a distinct pain in the
upper abdomen.
• There were no abdominal guarding or peritonitis signs.
• The blood analysis showed a marked increase of the
liver enzymes (ALT: 2769 IU/L, AST: 10561 IU/L, total
bilirubin: 131,7umol/L), WBC: 34,1Gpt/L, C-reactive
protein: 52mg/L) and diffuse coagulation dysfunction
(PT: 14%, PTT: 109s, ATIII: 48%) combined with a
hypotonic cardiovascular state.
 Case report
• The abdominal USS was not reliable because
of the diffuse gas concentration in the upper
abdomen.
• The chest X-ray showed a free air sickle
between the diaphragm and the liver.
Chest X-ray with free air sickle and local drainage
between diaphragm and liver
 Case report
• A brownish fluid mixed with gas was drained by CT
guidance.
• A few hours later, the patient presented the clinical
symptoms of a multiple organ failure.
• Despite maximal intensive care treatment, the
patient died 24 hours after admission.
• The microbiological presence of clostridium
perfringens was revealed in the drainage fluid.
CT-scan with an inserted percutaneous pigtail catheter
into an extensive gas - producing liver abscess
 Optimist

• Someone who figures that taking a step

backward after taking a step forward is not a
disaster.. it's a cha-cha.
Scintiscanning of the liver parenchyma

• Technetium scintiscann may detect focal

lesions greater than 2 cm. in diameter in
about two-thirds of cases.
• Generalized liver disease is demonstrated as
reduced or patchy uptake with increased
uptake of the spleen and bone marrow.
• Gallium citrate is concentrated in neoplastic
foci and abscesses
• Hemangiomas concentrate isotope indium.
The use of 99mTc labelled red blood cells (RBC) for the diagnosis of
suspected cavernous haemangioma in the liver.
Note the discordant accumulation indicated by the arrow.
 Portography and arteriography
• The portal venous system may be
demonstrated by splenic puncture using an
intercostal route. Injection of contrast medium
outlines the splenic and portal veins.
• Celiac axis is approached by a Seldinger
catheter. This technique has considerable value
in planning operability of liver tumours and
may be diagnostic of multifocal neoplasia when
all other techniques have failed
 Needle biopsy of the liver
Indications:
- alcoholic liver disease
- unexplained hepatomegaly-
- space-occupying lesions of the liver
- drug-related liver disease
It is contraindicated in patients with:
- coagulopathies,
- tense ascites and
- suspected hemangiomas.
 Pyogenic abscesses

Pathogenesis
• The main etiological factor is bile-duct infection with ascending cholangitis
commonly due to E. Coli and anaerobic organisms.
• Other sourses of infection include an ascending pylephlebitis- it arises
particularly with complicated diverticulitis.
• Some hepatic abscesses of staphylococcal and streptococcal origin arise as
a complication of generalized septicemia
• Others arise by direct extension from suppurative cholecystitis and
subphrenic collections.
• Obviously trauma to the liver tissue and subsequent infection produces an
abscess.

All types of abscesses are found more commonly in the right lobe.
 LIVER ABSCESS
• Diagnosis: pain RH, fever,
chills, increased WBC,
secondary anemia.

• Treatment is usually a
combination of drainage
and prolonged iv antibiotic
therapy .
 Case report
• The patient was a 56-year old female: fever, vomiting
and RH pain.
• On palpation of the abdomen, there was tenderness
and a vague mass in the right hypochondrium.
• She was admitted with a diagnosis of acute
cholecystitis.
 Case report
• Lab. Tests: leukocytosis, mild anemia, normal LFT.
• CXR normal.
• USS showed a cystic mass of size 8 x 6cm in the right
hypochondrium inferior to the liver; and a part of it attached
to the liver. An opacity was also seen within the mass.
Appendix was not visualized. The gall bladder was normal.
• CT scan also confirmed the USG findings of the possibility of
a liver abscess. Due to doubtful diagnosis - diagnostic
laparoscopy.
 Case report
• There was an inflammatory mass
consisting of small bowel, cecum
and omentum adherent to the
inferior border of the liver.
• The liver was normal.
• The mass was separated from the
liver with blunt dissection.
• Gentle nudging with the tip of a
suction probe resulted in
outpouring of pus from the mass
 Case report
• This was sucked out and
further blunt dissection was
carried out with the suction
probe.
• Along with the pus came
fecoliths
• It was an appendicular abscess
arising from a perforated
subhepatic appendix.
 Case report
• Once the appendix was identified,
appendectomy was done.
• The abscess cavity was drained with a
wide-bore drainage tube.
• She had purulent discharge through
the drainage tube that gradually
stopped on the 4th postoperative day.
• The patient was discharged on the 7th
POD, totally symptom-free.
 Clinical features of hepatic abscesses
• The clinical picture may be dominated by the primary disorder
(ascending cholangitis, diverticulitis, suppurative cholecystitis).
• Characteristically there is a high fever, rigors, profuse sweating,
anorexia and vomiting with pain as a relatively late symptom.
• An abscess may reach a very large size before causing pain if it is
directed through the bare area of the liver.
• Hepatomegaly is common.
• On investigation an anemia and leucocytosis may be found. ESR is
elevated.
• Blood cultures are usually positive with pyogenic abscesses when
taken during the height of pyrexia and anaerobic infection should be
considered.
 Imaging investigations

• Clinical suspicion of hepatic abscess may be confirmed by a

technetium scintiscan or by ultrasonic or CT scanning of the
liver which may also demonstrate the presence of pus.

• A plain film of the abdomen and chest may rarely show an

air/fluid level within the liver substance and usually an
elevated immobile diaphragm with loss of the anterior
costophrenic angle is found.
 Liver abscess
• CT demonstrates a heterogeneous
lesion with irregular margins and
possibly peripheral contrast
enhancement. Internal septations are
common.
• The radiologic differential diagnosis
includes cystic or necrotic metastases
and hydatid cysts.
• Often the diagnosis of a bacterial
abscess is suggested clinically.
• Treatment consists of percutaneous or
surgical drainage and antibiotics.
• The mortality rate is almost 100% if the
abscess remains untreated.
Amebic liver abscess is a collection of pus in the
liver brought on by an intestinal parasite
Causes
• Amebic liver abscess is caused by Entamoeba histolytica, the same
organism that causes amebiasis, an intestinal infection also called amebic
dysentery. The organism is carried by the blood from the intestines to the
liver.
• The disease spreads through ingestion of amebic cysts in food or water
contaminated with feces
• The infection occurs worldwide, but is most common in tropical areas
where crowded living conditions and poor sanitation exist.
Risk factors for amebic liver abscess include: Alcoholism , Cancer ,
Homosexual activity, particularly in men, Immunosuppression,
Malnutrition, Old age, Recent travel to a tropical region, Steroid use.
 Symptoms

Symptoms may include:

• Abdominal pain
– Particularly in the right, upper part of the abdomen
– Intense, continuous, or stabbing pain
• Chills
• Diarrhea
• Fever
• General discomfort or ill feeling (malaise)
• Jaundice
• Joint pain
• Loss of appetite
• Sweating
• Weight loss
 Exams and Tests

Tests that may be done include:

• Abdominal ultrasound
• Abdominal CT scan or MRI
• Complete blood count
• Liver function tests
• Serology for amebiasis
• Stool testing for amebiasis
 Treatment
• An antibiotic medicine called metronidazole (Flagyl)
is the usual treatment for liver abscess.
• A medication such as iodoquinol must also be taken
to get rid of all the amebas in the intestine.
• This can usually be delayed until after the abscess has
been treated.
• The abscess may need to be drained to help relieve
some of the abdominal pain.
Gross Pathology of amoebic liver
abscess
Dysentery showing diffuse
ulceration of mucosa
• Ultrasound image of a large liver
abscess in a child shows a typical
hypoechoic collection within a
rough/ shaggy walled cavity in
the liver.
• It is likely that this lesion is due to
amebic infection of the liver, a
common condition in parts of
India.
• As the disease progresses,
sonography of the liver may
reveal a fluid-debris layering and
even later may cause an almost
totally anechoic collection.
 Complications of the liver abscess

• recurrent septicemia
• extension and rupture of the abscess may occur in
any direction:
- peritoneal rupture results in peritonitis or
subphrenic collection
- extension through the diaphragm may lead to
thoracic empyema or to a rupture into the
bronchus with expectoration of large volumes of
pus.
- rarely, the abscess ruptures into the pericardium
with high mortality.
 Treatment

- Antibiotics according to bacterial sensitivity;

- Precise microbiological identification may result from aspiration of
the abscess with ultrasonic control.

- Drainage of the abscess cavity by repeated needle aspiration or

fine-bore catheter directed under ultrasonic control.
- Antibiotics may be instilled into the cavity.
- Progress is monitored by repeated ultrasound scan examinations.

- Surgical drainage if: - deterioration in the general condition of the

patient
- repeated episodes of septicemia
- failure of the abscess to decrease in size.
 
 
 
 Liver cysts

• Most cysts are asymptomatic

• When the cysts reach sufficient size to exert pressure
on adjacent viscera, produce non-specific symptoms
of vomiting, upper abdominal pain.
• Clinical examination reveals a non-tender liver tumour.
• Plain film of the abdomen may show displacement of
the colon or stomach
• The lesion may be confirmed by ultrasonography and
scintiscanning.
 Liver cysts
• The main differential diagnosis is parasitic
cysts and solid tumours.
• With exception of the complications of
rupture and intracystic hemorrhage, the
operative treatment is confined to large
solitary cysts which are usually completely
extirpated or removed by limited hepatic
resection.
 Hydatid cysts of the liver
• This infestation is endemic in certain countries, particularly
the southern half of South America, Australia, New
Zeeland, France.

• Man is the secondary host and becomes infected by

ingesting vegetables and water fouled by dogs or more
directly by handling the parasite-infested dogs as pets.

• After ingestion the shell of the egg is destroyed by gastric

acid and hatched within the duodenum. The liberated
embryos migrate through the gut wall into the mesenteric
circulation and lodge within the liver.
 Hydatic cyst of the liver

• 80% of hydatic cysts are ultimatelly found in the liver parenchyma.

• The unilocular hydatic cyst is caused by Echinoccocus granulosus and

the alveolar type is caused by Echinococcus multilocularis.
 Clinical features

• Since the growth of the parasite is slow, many

years elapse before the cyst reaches significant
size.
• On physical examination an anteriorly located
cyst presents as a smooth rounded tense mass.
• Secondary infection results in tender
hepatomegaly, rigors and pyrexia associated
with a deep-seated continuous pain.
 Further clinical features are the result
of cyst complications
• Intrabiliary rupture may give biliary colic and usually
causes jaundice and fever.
• Intraperitoneal rupture produces severe pain and
shock classically associated with pruritus and urticaria.
• Intrathoracic rupture may be preceded by symptoms of
diaphragmatic irritation and rupture into bronchus
leads to a partly bloodstained sputum which
frequently becomes bile stained.
Hydatic allergy is manifested by urticaria or very rare
anaphylactic shock.
 Investigations

• The appearance of a painless liver swelling in a patient living in an

endemic area gives a high index of suspicion.
• An unruptured cyst may show on plain radiograph as a calcified
reticulated shadow if not calcified by displacement of the
diaphragm or a barium-filled stomach.
• Scintiscanning shows a large filling defect and ultrasonography
reveals an echogenic cyst.
• Although the cyst is isolated from the liver by an adventitial layer,
there is an absorption of parasitic products which acts as an
antigenic stimulus.
• This reflects in an eosinophilia in 25% of patients, a complement-
fixation test which is accurate in 93% of patients.
Multivesicular Hydatid Hepatic Cyst
Univesicular uncomplicated cyst
Multivesicular hydatid with multiple daughter cysts giving a
septated appearance to the cyst
 Old hypermature liver hydatid. Non-contrast CT shows
calcification in the cyst wall and matrix and fluid within the cyst
 Complications
Rupture. Three types of ruptures are possible:
contained, communicating and direct.

1. Contained rupture
• This occurs when the endocyst ruptures in the lesion and biliary ducts do not
penetrate the pericyst. This is asymptomatic and is diagnosed when sectional
imaging (USS, CT) shows floating membranes within the hydatic lesion. Contained
rupture does not predispose to secondary bacterial infection.
2. Communicating rupture.
• This is possible when biliary ducts perforate the pericyst, allowing fluid and formed
elements to escape into the biliary tree. Sectional imaging of liver cysts which have
undergone communicating rupture demonstrates detached endocyst floating in the
remaining cyst fluid and there may be evidence of downstream biliary obstruction.
The bile that floods the pericystic cavity probably always kills the parasite but
secondary infection is almost the rule.
 Surgical treatment

• Involves removing the cyst without contamining the patient.

• The initial stage involves protection of the operative field against live
cysts using multiple coloured towels soaked in hypertonic saline
which isolate the main cyst from the exposed peritoneal cavity.

• Since hydatid fluid is under high pressure the cyst is decompressed by

aspiration and injected with 20% saline and left 5 min. after which
the cyst is opened and all daughter cysts removed as well as the
germinal layer of the cyst.
 Surgical treatment
• Spillage of cyst content during surgery is a cause of
recurrence.

• The cavity is drained for a variable period of time

depending on the presence of fluid drainage.

• Jaundice after intrabiliary rupture requires

choledochotomy and clearance of cysts followed by
T-tube drainage
 Hemangiomas

• Hemangiomas are the commonest benign tumour but only

rarely produce symptoms.
• Histologically the lesion is composed of blood-filled
endothelial lined spaces separated by a varible degree of
fibrous tissue.
• These tumours, having grown to significant size will eventually
produce pain or dyspepsia and develop a palpable abdominal
mass.
• Rupture is rare but leads to a major intra-abdominal
hemorrhage with shock and collapse.
 Hemangiomas
• CT scann is usually quite diagnostic.
• Where the diagnosis remains doubtful, arteriography will
demonstrate the lesion.
• A biopsy is not indicated.
• The preferred treatment for clinically significant hemangiomas is
wedge excision where possible.
• Lobectomy is reserved for large lesions confined to one lobe.
• The residual liver may contain further hemangiomas.
• Scintiscanning and angiography will demonstrate the lesion and if
there appears to be a major feeding vessel from the hepatic artery,
it may be worthwhile ligating this vessel or the main hepatic artery.
 USS-hemangiomas
• This is the commonest primary
tumour of the liver and is usually a
solitary lesion.

• This ultrasound image shows a

hyperechoic, homogenous, well-
circumscribed mass of the liver.
Primary malignant tumours of the liver

• Although primary malignant tumours of the liver are

uncommon in European and North American populations, the
condition is very common in African, Chinese and Indian
communities.
• The incidence of liver cancer in a community is directly
proportional to the incidence of viral hepatitis.
Risk factors:
• - alcohol intake, micronodular cirrhosis
• - chronic liver disease. The incidence of hepatoma in cirrhosis
may reach 25% but it is greatly elevated in patients with
antigen positive chronic active hepatitis (42%).
 Physical findings:

• - abdominal distension due to

hepatomegaly
• - ascites and sometimes is blood-stained.
• - hypoglycemia
• - hypercalcemia,
• - hyperlipidemia
• - hyperthyroidism
 Diagnosis
• Lab. studies: -abnormal liver function tests
- anemia due to intratumour hemorrhage
- polycytemia due to erythropoietin release.
- serum alphafetoprotein is a useful cancer marker
- HBS antigen should be looked for in all patients.

For patients undergoing surgery a study of the parameters of

coagulation is a sensible precaution.
Tumour localization and evaluation
• Lesions greater than 2 cm. in size can be detected as a
filling defect on a hepatic scintiscan but this mode of
investigation has little value.
• Ultrasound scanning demonstrates the size and
position.
• CXR for pulmonary metastases.
• CT scan demonstrates the lesion and its relatioship to
major structures.
• Needle biopsy under CT guidance.
• Arteriography is indicated for those patients in whom
liver resection is contempleted.
 Surgical treatment

• The object is to excise the lesion safely with a margin

of healthy liver tissue of 2 cm. or more.
• Procedures:
• - wedge resection
• - segmentectomy
• - lobectomy
• - hepatic transplantation
 Radiofrequency ablation (RF ablation)

• Minimally invasive treatment for

licer cancer

• The RF ablation team includes

radiologists, who perform the
treatment, and oncologists, who
determine whether RF ablation
tumor treatment is appropriate for
a patient.
 RF ABLATION
• Electrical energy delivered through this
needle heats and destroys the tumor.
• Over the following months, dead cells
turn into a harmless scar.
• During the short RF ablation treatment,
patients are under general anesthesia.
• In most cases, a tumor can be adequately
treated with one treatment session.
• Typically, RF ablation creates a zone of
tissue destruction uptill 6 centimeters in
size.
• After treatment, patient is observed and
the procedure can be repeated if new
cancer appears
CT scan of colon cancer spread to the liver,
2 hours post RF treatment
2.5 years post RF treatment
 INDICATIONS
• Tumors are less than 6 cm
• No more than three tumors
• No evidence of metastatic disease
elsewhere
 Results
• RF ablation is safe and effective and has a very low
rate of complications.
• Reported preliminary survival curves are encouraging
for small, solitary colorectal carcinoma (less than 2
cm) and hepatomas (less than 6 cm).
• Recent reports indicate that RF ablation results in
complete cell death in the majority of hepatomas of
6 cm in size.
• Patients who have residual tumors can be re-treated
if necessary
 Non surgical management

• - chemotherapy- doxorubicine
• - intra- arterial embolization
• - radiotherapy