Application of laparoscopic liver surgery techniques in laparoscopic thermal ablation of liver tumors

Application of laparoscopic liver surgery techniques in laparoscopic thermal ablation of liver tumors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Application of laparoscopic liver surgery techniques in laparoscopic thermal ablation of liver tumors Yongkun Li, Chenhao Jiang, Zheng Wang, Lei Liu, Ke Wu, Lu Zheng, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6978945/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Dec, 2025 Read the published version in BMC Gastroenterology → Version 1 posted 12 You are reading this latest preprint version Abstract Background Laparoscopic thermal ablation (LTA) of liver tumors is an increasingly performed procedure, but its application is limited when tumor location is unfavorable. This study aimed to evaluate the feasibility and safety of LTA assisted by laparoscopic liver surgery techniques (LLSTs) in challenging cases. Methods Clinical data of patients who underwent LTA with LLSTs at the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from April 2020 to December 2023 were retrospectively analyzed. Results A total of 61 lesions in 28 patients (mean age: 56.50 ± 9.65 years) with multifocal liver tumors were included. The technical success rate was 100%, with an average ablation duration of 22.32 ± 12.53 min (10.25 ± 1.29 min per lesion). Average blood loss was 85.71 ± 40.50 ml, and the average hospital stay was 4.43 ± 1.50 days. No major postoperative complications were observed, and patients with minor complications recovered after conservative treatment. During follow-up, one lesion developed local recurrence, resulting in a local control rate of 95.08%. Conclusions LTA assisted by LLSTs is a safe and feasible technique for challenging liver tumor cases, though further exploration is warranted to address remaining limitations. Laparoscopy liver surgery techniques thermal ablation liver tumors Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Thermal ablation is an effective treatment for selected liver tumors, particularly for hepatocellular carcinomas (HCC), intrahepatic cholangiocarcinoma (ICC) and colorectal liver metastases (CRLM) [ 1 – 3 ]. Although thermal ablation is primarily performed through a percutaneous approach, a laparoscopic thermal ablation (LTA) approach is increasingly used [ 4 ]. However, when tumor location is unfavorable, the application of LTA is limited [ 5 ]. Therefore, the key to addressing this problem may be searching for an appropriate method to assist LTA. With the gradual expansion of indications, laparoscopic liver surgery techniques (LLSTs) have been widely applied in the treatment of various benign and malignant liver tumors at present [ 6 ]. The primary techniques of LLSTs include Glisson's pedicle dissection [ 7 , 8 ], difficult anatomical site exposure [ 9 ], bleeding control [ 10 ], adjacent organ protection [ 11 ], etc. Specifically, the use of LLSTs for LTA can achieve Glisson pedicle dissection in advance to protect major hepatic ducts; separate ligaments, adhesions, etc., dissociate the liver and expose lesions at difficult sites to provide greater operating space and ensure successful puncture; hepatic flow occlusion prior to ablation can reduce bleeding and effectively alleviate the "Heat Sink Effect" [ 12 ]; while for lesions on the liver surface, adjacent to the diaphragm, gallbladder, intestines, etc., normal tissues can be isolated by separating and packing with wet gauze to protect surrounding tissues, the gallbladder can also be removed if necessary [ 13 ]. Through continuous learning and exploration, we have carried out LTA assisted by LLSTs and applied it to liver tumors. LTA assisted by LLSTs may be a better alternative in selected patients. This study aimed to introduce this strategy for LTA assisted by LLSTs. Methods Ethical approval The study was approved by the Ethics Committee of the Second Affiliated Hospital of Third Military Medical University (Army Medical University). This study was performed according to the Declaration of Helsinki, and written informed consent was obtained from individual participant. Patients and Data From April 2020 to December 2023, patients underwent LTA who met inclusion and exclusion criteria at our hospital were retrospectively collected. The diagnosis of HCC was based on the typical imaging appearance of contrast enhanced computed tomography (CECT) or magnetic resonance imaging (CEMRI) combined with clinical findings according to China Liver Cancer Staging (CNLC) [14], the diagnostic test of CRLM and ICC were histologically or cytological documented. The inclusion criteria in this study were as follows: (1) male or female patients aged between 18 and 75 years old; (2) liver function is graded as Child-Pugh class A or B; (3) single or multiple liver cancers with a diameter ≤ 3 cm and totaling < 3; (4) no evidence of vascular invasion, bile duct invasion, or extrahepatic metastases; (5) The patient is unable or unwilling to undergo excisional surgery; (6) patients underwent LTA assisted by LLSTs. The following exclusion criteria were applied: (1) the presence of severe organs dysfunction; (2) single or multiple liver cancers with a diameter > 3 cm and totaling > 3; (3) combined with extrahepatic metastases. Hepatitis B virus (HBV) patients received standardized antiviral treatment. Prophylactic antibiotic therapy was administered to all patients 30 min before surgery and maintained until the second postoperative day. All patients were treated with a full course of postoperative hepatic function protection, hematischesis, analgesia, rehydration and other symptomatic and supportive care. Surgical techniques Under general anesthesia, patients were placed in supine in the reverse Trendelenburg position with head up 30° and leg splitting. The monitor was located on the left front of the patient, while the surgeon stood on the right side of the patient, the camera assistant stood between the spread legs, and the assistant stood on the left side of the patient. Pneumoperitoneum was established and maintained with CO 2 at 12-14 mmHg. Low central venous pressure (lower than 5 cmH 2 O) is maintained by anesthesia to control blood loss. Five trocars are typically inserted similar to the fan shape around the operation area. A 3-mm length incision was made between left two ports to prepare for extracorporeal Pringle maneuver. According to the condition of the patients, appropriate LLSTs could be performed. Direct LTA may damage Glisson pedicle when the tumor is located adjacent to this site, highlighting the necessity of protecting Glisson pedicle at this time; Glisson pedicle dissection is feasible for dissecting and protecting adjacent Glisson pedicle to avoid its damage during LTA (Fig. 1). Difficult anatomical site exposure can be adopted to fully expose the site of ablation to facilitate surgical operation (Fig. 2). Bleeding control technique can be applied in LTA to occlude blood flow at the first hepatic hilum using Pringle maneuver to reduce bleeding and decrease the "Heat Sink Effect" (Fig. 3). Lesions on the liver surface, adjacent to the diaphragm, gallbladder, intestines and other sites can be isolated from normal tissues by separation and packing with wet gauze pads (Fig. 4); and if necessary, the gallbladder can also be removed prior to or after LTA (Fig. 5). A small incision was made in the abdominal wall above the tumor, and the thermal ablation needle was inserted into the tumor under laparoscopic and intraoperative ultrasound (IOUS) guidance. After needle placement, the ablation device was set and activated according to manufacturer in structions to achieve a complete tumor ablation, comprising a rim of adjacent liver parenchyma. In case of large lesions when IOUS showed an incompletely ablated tumour, multiple overlapping ablations and multifold cycles were performed until the lesion was judged to be totally ablated. Needle withdrawal was conducted under laparoscopic and IOUS guidance. The needle was withdrawn while cauterizing the liver, so as to reduce the risks of bleeding due to needle passage and cancer metastasis. After the surgery was completed, bleeding and bile leakage were recorded and treated accordingly. Statistical analysis Descriptive statistics was used for evaluating variants. Age, operation time, ablation time of a single lesion and follow-up time were expressed as mean ± standard deviation and blood loss and postoperative hospital stay were presented as median and interquartile range. SPSS version 22.0 (IBM SPSS, Inc, Chicago, IL) was used for all analyses. Results All 28 patients (mean age 56.50 ± 9.65 years) underwent blood biochemistry and tumor markers analyses, imaging examination, indocyanine green (ICG) clearance test, and 3-dimensional reconstruction before the operation. Of the 28 patients in this investigation, 15 patients were diagnosed with HCC, 4 diagnosed with CRLM and 9 diagnosed with ICC, 21 received ablation without surgery resection, and 7 received ablation after TACE. The average number of lesions in a single patient was 2.18 ± 1.16, the average diameter of a single lesion was 2.12 ± 0.53 cm. Of the 61 lesions, 35 were located in the anterolateral portion, 22 in the posterosuperior portion, and 4 in the paracaval portion. In addition, 38 lesions were located deep in the liver parenchyma and 23 lesions were located on the liver surface. A total of 61 tumor lesions in 28 patients completed the LTA assisted by LLSTs successfully, with a technical success rate of 100%. No patient in converted to open surgery. The average ablation duration was 22.32 ± 12.53 minutes, the average ablation time of a single lesion was 10.25 ± 1.29 min, average blood loss was 85.71 ± 40.50 ml, and no blood transfusion was performed during operation. average length of hospital stay was 4.43 ± 1.50 days. There was no mortality. According to Clavien Dindo classification, post-operative complications included Grade I complications (pleural effusion, n = 3) . No Grade II and above complications occurred. All the complications were successfully treated by conservative treatment. The clinical details of the patients are shown in Table 1. Table 1 Demographic and clinical details of study patients Variables Total (n = 28) Age, Mean ± SD 56.50 ± 9.65 Male, n (%) 21 (75.00) Body mass index, Mean ± SD 23.00 ± 2.21 N (patients/leisions) 28/61 Leisions (per patients), Mean ± SD 2.18 ± 1.16 Diagnosis HCC, n (%) 15 (53.57) ICC, n (%) 4 (14.29) CRLM, n (%) 9 (32.14) Tumor size, Mean ± SD 2.12 ± 0.53 Parenchymal location (deep/superficial) 38/23 Liver segmental location, n (%) Anterolateral 35 (57.38) Posterosuperior 22 (36.07) Paracaval portion 4 (6.56) Ablation Duration (total), Mean ± SD 22.32 ± 12.53 Ablation Duration (per Leision), Mean ± SD 10.25 ± 1.29 Blood Loss, Mean ± SD 85.71 ± 40.50 Hospital stay, Mean ± SD 4.43 ± 1.50 SD: standard deviation All 28 patients were followed, with a median follow-up time of 12.93 ± 1.34 months. During the follow-up period, none of them developed hemorrhage, bile leakage, diaphragm perforation and other complications. There was no perioperative mortality during the follow-up. As of the follow-up date, 58 lesions achieved complete ablation, the complete ablation rate reached 95.08% (58/61). One patient had a local recurrence. Discussion In recent years, LTA can serve as an alternative option because it possesses several advantages over percutaneous ablation while retaining the minimal invasiveness [15]. First, it allows for improved tumor staging by IOUS and gross examination. Second, the surgical field is clear and the operation can be conducted safely under direct laparoscopic guidance, which may reduce collateral damage to peripheral tissues. Third, the monitored treatment range and effects are more reliable in cases of multifocal liver cancer requiring multi-needle and multi-operation approaches. Moreover, LTA guarantees a safer approach to liver tumors whose locations render percutaneous approach unfeasible or extremely challenging. However, not all tumors at different locations can be successfully ablated by LTA alone, such as those in the upper segment of the right posterior lobe of the liver, adjacent to the diaphragm and located close to vital regions of the organ etc., which may affect puncture positioning. In view of the difficulty in LTA due to liver tumors in these unfavorable areas, the key to addressing this problem may be searching for an appropriate method to assist LTA. We have also carried out related research and explored feasible and safe approach. LLSTs have received extensive attention in liver surgery with the advantages of minimal surgical trauma and fast postoperative recovery LLSTs, including laparoscopic Glisson pedicle dissection, difficult anatomical site exposure, bleeding control, adjacent organ protection, and other techniques, have been increasingly widely applied and developed with the accumulation of experience related to laparoscopic hepatectomy in various liver surgery centers and the improvement of laparoscopic surgical instruments. Its application reduces surgical difficulty, improves surgical completion, and decreases intraoperative and postoperative complications [16, 17]. Therefore, we wondered whether LLSTs can assist LTA. After clinical practice, we proposed LTA assisted by LLSTs in liver tumors and made it a standardized and streamlined procedure after continuous exploration and improvement. The key technical points of LTA assisted by LLSTs can be summarized as follows: (1)Glisson pedicle dissection: Glisson pedicle dissection is a key step in LLSTs, which involves fully dissecting or ligating corresponding portal vein, hepatic artery, and bile duct branch of the target hepatic segment, region, lobe [18]. As some tumors are adjacent to the Glisson pedicle, direct ablation may directly lead to irreversible thermal damage to the Glisson pedicle during LTA. In this case, Glisson pedicle dissection can be used to dissociate and protect adjacent Glisson pedicle. This technique generally includes both extrathecal and intrathecal dissections (hepatic portal approach), and the latter one is commonly used in LTA [17]. By referring to key anatomical landmarks such as the hepatic plate system and the "6-porta" structure of the liver, anatomical structures around the liver can be identified correctly to facilitate accurate identification of the avascular space between the Laennec's capsule and the Glisson pedicle [19]. Then, the space of Laennec's capsule can be dissected safely based on precise operation under a magnified field of view of laparoscopy to promote the dissection of the Glisson pedicle [20]. At times, it is also necessary to dissect the liver parenchyma to some extent to expose Glisson pedicle. After complete dissociation of the target Glisson pedicle, it can be protected in LTA by hanging, pulling, or isolating the structure with gauze. (2) Difficult anatomical site exposure: Lesions located in segments VII, VIII and IVa, as well as the caudate lobe of the liver are considered difficult anatomical sites for LTA owing to their deep location, complex anatomical relationships, and poor surgical field of view. The challenge lies in exposure, which may further increase the difficulties of operating the major vascular structures and controlling bleeding. In case of this, a difficult anatomical site exposure technique of LLSTs can be employed to fully expose the tumor. For instance, it is feasible to adjust the patient's position and the distribution of trocar, and select an appropriate surgical approach to fully dissociate the liver according to the tumor location; and a laparoscope with a flexible viewpoint, combined with operating methods such as "retract the liver medially with gauze strip", "lifting with water bag", "elastic traction" and "held down using the hilum blood flow occlusion tube” , can be used to expose special difficult anatomical sites. In this way, it can realize sufficient surgical field exposure and reduce surgical difficulty, so that patients can benefit from LTA [21, 22]. (3) Bleeding control: Some authors feel that tumor in contact with vascular structures is a contra indication for traditional thermal ablation. Blood flow induces a cooling effect on the tumour in contact with the vascular structures, and therefore hinders the efficacy of heat transfer: this ‘‘Heat Sink Effect’’ might be the cause of a higher recurrence rate. Meanwhile, as some tumors are adjacent to the vessel, direct ablation may directly lead to damage and bleeding. To counter these effects, we recommend performing a Pringle maneuver in selected patients. Researches also confirm that LTA with Pringle maneuver in proximity to major vascular structures does not significantly increase ablation size, or cause acute vascular damage and efficiently decrease ‘‘Heat Sink Effect’’ [23]. (4) Adjacent organ protection: In principle, subcapsular tumors constitute a contra indication to radiology-guided TA. Effectively, there is an increased risk of rupture with tumour dissemination. This exposes the patient to the risk of local recurrence with the possibility of carcinomatosis and is known as the ‘‘popcorn effect’’ [13]. LTA with adjacent organ protection performed during surgery not only allows visualisation of the nodules, but also allows them to be separated from the intestinal wall or structure by surgical dissection or wet gauze pads, creating an interface between the nodule and the adjacent structure. This reduces the risk of thermal injury and tumour dissemination to these structures considerably. For the ablation of liver tumors of the diaphragm dome, the establishment of pneumoperitoneum in laparoscopic surgery can help to separate the liver from the abdominal wall, which avoids the risk of abdominal wall injury for tumors on the diaphragmatic surface. Transection of the falciform ligament can further expand the space between the liver and the abdominal wall. Transection of the coronary ligament and triangular ligament can help to separate the liver from the diaphragm. Then, saline gauze can be used to pack the bare region of the diaphragm dome to further expand the space between the liver and the diaphragm, which can also be placed on the dorsal side, i.e., the visceral surface. Consequently, an isolated zone is created in front, above, and on the dorsal side of the liver, providing a safe boundary for the ablation of tumors on the diaphragmatic and visceral surfaces of the liver. In addition, for tumors adjacent to the gallbladder, ablation can be performed prior to or after cholecystectomy [24]. There are some limitations to this investigation: First, this is a single-center retrospective investigation with a small sample size and a short follow-up time. The long-term efficacy and prognosis of LTA assisted by LLSTs in the treatment of liver tumor still needs to investigated. And due to the limited number of cases, the exploration of recurrence-related risk factors could not be carried out. Second, this investigation lacks a control group. Besides, This technique is operated in an expert center at present, which may limit the reproducibility of these results in non-expert hands. Further experience must be gained to confirm the results of this case series. Well-designed, long-term, randomized, controlled, prospective trials are still necessary to further confirm some points proposed in this study. Conclusion LTA assisted by LLSTs for the treatment of liver tumor is feasible and safe, with excellent short-term efficacy and few complications. However, further research with larger sample size and longterm follow-up may be needed to support the application of this method. Declarations Acknowledgements None. Authors’ contribution Yongkun Li: Writing - original draft, Visualization, Methodology, Formal analysis, Conceptualization. Chenhao Jiang:Writing - original draft, Validation, Data curation. Zheng Wang: Writing - review & editing, Data curation. Lei Liu: Software, Data curation. Ke Wu: Data curation, Methodology. Lu Zheng: Writing - review & editing, Validation. Nan You: Writing - review & editing, Validation, Methodology, Project administration, Conceptualization. Funding This study was supported by the general program of Chongqing medical scientific research project (Joint project of Chongqing Health Commission and Science and Technology Bureau) (2023MSXM004). Data availability The deidentified dataset can be accessed upon a reasonable request made to the corresponding author. Ethics approval and consent to participate This study was approved by the Ethics Committee of the Second Affiliated Hospital of Third Military Medical University (Army Medical University). This study was performed according to the Declaration of Helsinki, and written informed consent was obtained from individual participant. Consent for publication Not applicable. Conflict of interests The authors declare no competing interests. References Minami Y, Aoki T, Hagiwara S, Kudo M. 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Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 08 Dec, 2025 Read the published version in BMC Gastroenterology → Version 1 posted Editorial decision: Revision requested 08 Sep, 2025 Reviews received at journal 06 Sep, 2025 Reviewers agreed at journal 06 Sep, 2025 Reviews received at journal 23 Aug, 2025 Reviews received at journal 16 Aug, 2025 Reviewers agreed at journal 11 Aug, 2025 Reviewers agreed at journal 08 Aug, 2025 Reviewers invited by journal 28 Jul, 2025 Editor invited by journal 01 Jul, 2025 Editor assigned by journal 27 Jun, 2025 Submission checks completed at journal 27 Jun, 2025 First submitted to journal 25 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6978945","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":492229093,"identity":"fc40847d-4331-4baf-ac27-038ffd409f23","order_by":0,"name":"Yongkun Li","email":"","orcid":"","institution":"Xinqiao Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yongkun","middleName":"","lastName":"Li","suffix":""},{"id":492229094,"identity":"9d7cf09c-8616-43d9-90d3-ac9e89481dc8","order_by":1,"name":"Chenhao Jiang","email":"","orcid":"","institution":"Xinqiao Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chenhao","middleName":"","lastName":"Jiang","suffix":""},{"id":492229096,"identity":"a27ba863-545a-4ec5-8af8-513ecaca6ae4","order_by":2,"name":"Zheng Wang","email":"","orcid":"","institution":"Xinqiao Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zheng","middleName":"","lastName":"Wang","suffix":""},{"id":492229098,"identity":"62c16365-80e0-4e56-867b-31b642a45269","order_by":3,"name":"Lei Liu","email":"","orcid":"","institution":"Xinqiao Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Liu","suffix":""},{"id":492229101,"identity":"f54f7929-93d2-4fb3-93f8-e91d40eaff44","order_by":4,"name":"Ke Wu","email":"","orcid":"","institution":"Xinqiao Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ke","middleName":"","lastName":"Wu","suffix":""},{"id":492229102,"identity":"1d994016-396c-4dbf-b0b4-926b821dfea6","order_by":5,"name":"Lu Zheng","email":"","orcid":"","institution":"Xinqiao Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lu","middleName":"","lastName":"Zheng","suffix":""},{"id":492229103,"identity":"33be4ce0-3e0c-4061-95d7-17805ea6fedf","order_by":6,"name":"Nan You","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuUlEQVRIiWNgGAWjYPACGyjNRryWNAmStRwmQYvB8R6zBz93nK/TnXbGgOFD2WEG/tkNBLScOWNu2HvmtoTZ7RwDxhnnDjNI3DlAQMuNHDMJ3jaIFmbetsMMBhIJhLVI/m07B9Hyl1gt0rxtByBaGInRInnmWJm0bFuy5LbbaQUHe86l80jcIKCF73jzNsm3bXb8ZreTNz74UWYtxz+DgBaFA0gcEJsHv3ogkG8gqGQUjIJRMApGPAAAhfVCj3OajnEAAAAASUVORK5CYII=","orcid":"","institution":"Xinqiao Hospital","correspondingAuthor":true,"prefix":"","firstName":"Nan","middleName":"","lastName":"You","suffix":""}],"badges":[],"createdAt":"2025-06-26 02:53:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6978945/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6978945/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12876-025-04502-w","type":"published","date":"2025-12-08T15:59:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88004226,"identity":"2ea27fea-bfe5-470d-a6f6-db382dd10d98","added_by":"auto","created_at":"2025-07-31 10:35:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":17107342,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Preoperative MRI of the liver; (B) IOUS was used to determine the tumor positioning; (C) Glisson extrathecal dissection and isolation; (D) After complete dissociation of the target Glisson pedicle, it can be hung and pulled with silicone tube. IOUS was used to reconfirm tumor positioning; (E) Wet gauze was used to separate Glisson pedicle and reduce the risk of thermal injury. (F) The thermal ablation needle was inserted into the tumor under IOUS guidance.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-6978945/v1/a26804dbeb6f42ac1f6c705e.png"},{"id":88002586,"identity":"970a2a25-91b8-40da-acd3-8f0fe574d3e2","added_by":"auto","created_at":"2025-07-31 10:27:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":6233021,"visible":true,"origin":"","legend":"\u003cp\u003e(A) To better obtaining the operative field, operation began with division of liver ligaments and right liver mobilization. (B) After tumor excellent exposure was achieved, the thermal ablation needle was inserted into the tumor under IOUS guidance.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-6978945/v1/7eef44f80c51109ee8d6ebfd.png"},{"id":88002587,"identity":"3dadb2bf-2c82-4a84-8627-c20d8d9ad481","added_by":"auto","created_at":"2025-07-31 10:27:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":6063007,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Laparoscopic Pringle’s maneuver was performed. (B) The thermal ablation needle was inserted into the tumor under IOUS guidance.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-6978945/v1/c02ec7df52bb3ac99b826136.png"},{"id":88002593,"identity":"b0707510-f910-491c-86c0-5419c99ae00a","added_by":"auto","created_at":"2025-07-31 10:27:50","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":8575581,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Lesion was isolated from normal intestines by packing with wet gauze pads. (B) The thermal ablation needle was inserted into the tumor under IOUS guidance. (C) Recurrent lesion adjacent to the diaphragm can be isolated from normal tissues and ablations were performed sequentially.\u003c/p\u003e","description":"","filename":"Fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-6978945/v1/b6ec00e20a3cf2e9a455203d.png"},{"id":88004224,"identity":"48fa4978-ccd3-48db-bd6f-c914e67a05a1","added_by":"auto","created_at":"2025-07-31 10:35:50","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":14728424,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Preoperative MRI of the liver; (B) Preoperative 3D reconstruction; (C) IOUS was used to determine the tumor positioning; (D) The thermal ablation needle was inserted into the tumor under IOUS guidance; (E) Multiple overlapping ablations and multifold cycles were performed; (F) The gallbladder can also be removed after LTA.\u003c/p\u003e","description":"","filename":"Fig5.png","url":"https://assets-eu.researchsquare.com/files/rs-6978945/v1/e84b00dbd7feb584a34310e4.png"},{"id":98245596,"identity":"6c0f3f27-dc39-4f9b-a1ec-f64e13ad63ef","added_by":"auto","created_at":"2025-12-15 16:18:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":49606462,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6978945/v1/c7cf389e-fcfe-4f4f-99ab-19ca83e976bb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Application of laparoscopic liver surgery techniques in laparoscopic thermal ablation of liver tumors","fulltext":[{"header":"Background","content":"\u003cp\u003eThermal ablation is an effective treatment for selected liver tumors, particularly for hepatocellular carcinomas (HCC), intrahepatic cholangiocarcinoma (ICC) and colorectal liver metastases (CRLM) [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although thermal ablation is primarily performed through a percutaneous approach, a laparoscopic thermal ablation (LTA) approach is increasingly used [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, when tumor location is unfavorable, the application of LTA is limited [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Therefore, the key to addressing this problem may be searching for an appropriate method to assist LTA. With the gradual expansion of indications, laparoscopic liver surgery techniques (LLSTs) have been widely applied in the treatment of various benign and malignant liver tumors at present [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The primary techniques of LLSTs include Glisson's pedicle dissection [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], difficult anatomical site exposure [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], bleeding control [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], adjacent organ protection [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], etc. Specifically, the use of LLSTs for LTA can achieve Glisson pedicle dissection in advance to protect major hepatic ducts; separate ligaments, adhesions, etc., dissociate the liver and expose lesions at difficult sites to provide greater operating space and ensure successful puncture; hepatic flow occlusion prior to ablation can reduce bleeding and effectively alleviate the \"Heat Sink Effect\" [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]; while for lesions on the liver surface, adjacent to the diaphragm, gallbladder, intestines, etc., normal tissues can be isolated by separating and packing with wet gauze to protect surrounding tissues, the gallbladder can also be removed if necessary [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Through continuous learning and exploration, we have carried out LTA assisted by LLSTs and applied it to liver tumors. LTA assisted by LLSTs may be a better alternative in selected patients. This study aimed to introduce this strategy for LTA assisted by LLSTs.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of the Second Affiliated Hospital of Third Military Medical University (Army Medical University). This study was performed according to the Declaration of Helsinki, and written informed consent was obtained from individual participant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and Data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom April 2020 to December 2023, patients underwent LTA who met inclusion and exclusion criteria at our hospital were retrospectively collected. The diagnosis of HCC was based on the typical imaging appearance of contrast enhanced computed tomography (CECT) or magnetic resonance imaging (CEMRI) combined with clinical findings according to China Liver Cancer Staging (CNLC) [14], the diagnostic test of CRLM and ICC were histologically or cytological documented. The inclusion criteria in this study were as follows: (1) male or female patients aged between 18 and 75 years old; (2) liver function is graded as Child-Pugh class A or B; (3) single or multiple liver cancers with a diameter \u0026le; 3 cm and totaling \u0026lt; 3; (4) no evidence of vascular invasion, bile duct invasion, or extrahepatic metastases; (5) The patient is unable or unwilling to undergo excisional surgery; (6) patients underwent LTA assisted by LLSTs. The following exclusion criteria were applied: (1) the presence of severe organs dysfunction; (2) single or multiple liver cancers with a diameter \u0026gt; 3 cm and totaling \u0026gt; 3; (3) combined with extrahepatic metastases. Hepatitis B virus (HBV) patients received standardized antiviral treatment. Prophylactic antibiotic therapy was administered to all patients 30 min before surgery and maintained until the second postoperative day. All patients were treated with a full course of postoperative hepatic function protection, hematischesis, analgesia, rehydration and other symptomatic and supportive care. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical techniques\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnder general anesthesia, patients were placed in supine in the reverse Trendelenburg position with head up 30\u0026deg; and leg splitting. The monitor was located on the left front of the patient, while the surgeon stood on the right side of the patient, the camera assistant stood between the spread legs, and the assistant stood on the left side of the patient. Pneumoperitoneum was established and maintained with CO\u003csub\u003e2\u003c/sub\u003e at 12-14 mmHg. Low central venous pressure (lower than 5 cmH\u003csub\u003e2\u003c/sub\u003eO) is maintained by anesthesia to control blood loss. Five trocars are typically inserted similar to the fan shape around the operation area. A 3-mm length incision was made between left two ports to prepare for extracorporeal Pringle maneuver.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccording to the condition of the patients, appropriate LLSTs could be performed. Direct LTA may damage Glisson pedicle when the tumor is located adjacent to this site, highlighting the necessity of protecting Glisson pedicle at this time; Glisson pedicle dissection is feasible for dissecting and protecting adjacent Glisson pedicle to avoid its damage during LTA (Fig. 1). Difficult anatomical site exposure can be adopted to fully expose the site of ablation to facilitate surgical operation (Fig. 2). Bleeding control technique can be applied in LTA to occlude blood flow at the first hepatic hilum using Pringle maneuver to reduce bleeding and decrease the \u0026quot;Heat Sink Effect\u0026quot; (Fig. 3). Lesions on the liver surface, adjacent to the diaphragm, gallbladder, intestines and other sites can be isolated from normal tissues by separation and packing with wet gauze pads (Fig. 4); and if necessary, the gallbladder can also be removed prior to or after LTA (Fig. 5). A small incision was made in the abdominal wall above the tumor, and the thermal ablation needle was inserted into the tumor under laparoscopic and intraoperative ultrasound (IOUS) guidance. After needle placement, the ablation device was set and activated according to manufacturer in structions to achieve a complete tumor ablation, comprising a rim of adjacent liver parenchyma. In case of large lesions when IOUS showed an incompletely ablated tumour, multiple overlapping ablations and multifold cycles were performed until the lesion was judged to be totally ablated. Needle withdrawal was conducted under laparoscopic and IOUS guidance. The needle was withdrawn while cauterizing the liver, so as to reduce the risks of bleeding due to needle passage and cancer metastasis. After the surgery was completed, bleeding and bile leakage were recorded and treated accordingly. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics was used for evaluating variants. Age, operation time, \u0026nbsp;ablation time of a single lesion and follow-up time were expressed as mean \u0026plusmn; standard deviation and blood loss and postoperative hospital stay were presented as median and interquartile range. SPSS version 22.0 (IBM SPSS, Inc, Chicago, IL) was used for all analyses.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAll\u0026nbsp;28\u0026nbsp;patients (mean age 56.50\u0026nbsp;\u0026plusmn;\u0026nbsp;9.65\u0026nbsp;years) underwent blood biochemistry and tumor markers analyses, imaging examination, indocyanine green\u0026nbsp;(ICG)\u0026nbsp;clearance test, and 3-dimensional reconstruction before the operation. Of the 28 patients in this investigation,\u0026nbsp;15 patients were diagnosed with HCC, 4 diagnosed with CRLM\u0026nbsp;and\u0026nbsp;9 diagnosed with ICC,\u0026nbsp;21 received ablation without surgery resection, and 7 received ablation after TACE.\u0026nbsp;The average number of lesions in a single patient was\u0026nbsp;2.18 \u0026plusmn; 1.16, the average diameter of a single lesion was 2.12 \u0026plusmn; 0.53 cm. Of the 61 lesions, 35 were located in the anterolateral portion, 22 in the posterosuperior portion, and 4 in the paracaval portion. In addition, 38 lesions were located deep in the liver parenchyma and 23 lesions were located on the liver surface.\u003c/p\u003e\n\u003cp\u003eA total of 61 tumor lesions in 28 patients completed the\u0026nbsp;LTA assisted by LLSTs\u0026nbsp;successfully, with a technical success rate of 100%.\u0026nbsp;No patient in converted to open surgery. The average ablation duration was\u0026nbsp;22.32\u0026nbsp;\u0026plusmn;\u0026nbsp;12.53\u0026nbsp;minutes,\u0026nbsp;the average ablation time of a single lesion was 10.25 \u0026plusmn; 1.29 min, average\u0026nbsp;blood loss was 85.71\u0026nbsp;\u0026plusmn;\u0026nbsp;40.50\u0026nbsp;ml, and no blood transfusion was performed during operation.\u0026nbsp;average length of hospital stay was 4.43 \u0026plusmn; 1.50 days. There was no mortality.\u0026nbsp;According\u0026nbsp;to\u0026nbsp;Clavien\u0026nbsp;Dindo\u0026nbsp;classification, post-operative complications included Grade I complications (pleural\u0026nbsp;effusion, n = 3) . No Grade II and above complications occurred. All the complications were successfully treated by conservative\u0026nbsp;treatment. The clinical details of the patients are shown in Table 1.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"599\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 599px;\"\u003e\n \u003cp\u003eTable 1 Demographic and clinical details of study patients\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eTotal (n = 28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eAge, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e56.50 \u0026plusmn; 9.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eMale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e21 (75.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eBody mass index, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e23.00 \u0026plusmn; 2.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eN (patients/leisions)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e28/61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eLeisions (per patients), Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e2.18 \u0026plusmn; 1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eDiagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eHCC, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e15 (53.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eICC, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e4 (14.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eCRLM, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e9 (32.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eTumor size, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e2.12 \u0026plusmn; 0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eParenchymal location (deep/superficial)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e38/23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eLiver segmental location, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eAnterolateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e35 (57.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003ePosterosuperior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e22 (36.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eParacaval portion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e4 (6.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eAblation Duration (total), Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e22.32 \u0026plusmn; 12.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eAblation Duration (per Leision), Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e10.25 \u0026plusmn; 1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eBlood Loss, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e85.71 \u0026plusmn; 40.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 382px;\"\u003e\n \u003cp\u003eHospital stay, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e4.43 \u0026plusmn; 1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 599px;\"\u003e\n \u003cp\u003eSD: standard deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll 28 patients were followed, with a median follow-up time of 12.93 \u0026plusmn; 1.34 months. During the follow-up period, none of them developed hemorrhage, bile leakage, diaphragm perforation and other complications. There was no perioperative mortality during the follow-up. As of the follow-up date, 58 lesions achieved complete ablation, the complete ablation rate reached 95.08% (58/61). One patient had a local recurrence.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn recent years,\u0026nbsp;LTA can serve as an alternative option because it possesses several advantages over percutaneous ablation while retaining the minimal invasiveness\u0026nbsp;[15]. First, it allows for improved tumor staging by\u0026nbsp;IOUS\u0026nbsp;and gross examination. Second, the surgical field is clear and the operation can be conducted safely under direct laparoscopic guidance, which may reduce collateral damage to peripheral tissues. Third, the monitored treatment range and effects are more reliable in cases of multifocal liver cancer requiring multi-needle and multi-operation approaches. Moreover, LTA guarantees a safer approach to liver tumors whose locations render percutaneous approach unfeasible or extremely challenging. However,\u0026nbsp;not all tumors at different locations can be successfully ablated by LTA alone, such as those in the upper segment of the right posterior lobe of the liver, adjacent to the diaphragm\u0026nbsp;and\u0026nbsp;located close to vital regions of the organ\u0026nbsp;etc., which may affect puncture positioning.\u0026nbsp;In view of the difficulty in LTA\u0026nbsp;due to\u0026nbsp;liver tumors\u0026nbsp;in these unfavorable areas, the key to addressing this problem may be searching for an appropriate method to\u0026nbsp;assist LTA.\u0026nbsp;We have also carried out related research and explored feasible and safe approach.\u003c/p\u003e\n\u003cp\u003eLLSTs have received extensive attention in liver surgery with the advantages of minimal surgical trauma and fast postoperative recovery LLSTs, including laparoscopic Glisson pedicle\u0026nbsp;dissection, difficult anatomical site exposure, bleeding control,\u0026nbsp;adjacent organ protection, and other techniques, have been increasingly widely applied and developed with the accumulation of experience related to laparoscopic hepatectomy in various\u0026nbsp;liver surgery centers and the improvement of laparoscopic surgical instruments. Its application reduces surgical difficulty, improves surgical completion, and decreases intraoperative and postoperative complications\u0026nbsp;[16, 17].\u0026nbsp;Therefore, we wondered whether\u0026nbsp;LLSTs\u0026nbsp;can\u0026nbsp;assist\u0026nbsp;LTA.\u0026nbsp;After clinical practice, we proposed\u0026nbsp;LTA\u0026nbsp;assisted\u0026nbsp;by LLSTs in\u0026nbsp;liver tumors\u0026nbsp;and made it a standardized and streamlined procedure after continuous exploration and improvement.\u003c/p\u003e\n\u003cp\u003eThe key technical points of LTA assisted by\u0026nbsp;LLSTs\u0026nbsp;can be summarized as follows:\u003c/p\u003e\n\u003cp\u003e(1)Glisson pedicle\u0026nbsp;dissection:\u0026nbsp;Glisson pedicle\u0026nbsp;dissection is a key step in LLSTs,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ewhich involves fully dissecting or ligating corresponding portal vein, hepatic artery, and bile duct branch of the target hepatic segment, region, lobe\u0026nbsp;[18]. As some tumors are adjacent to the\u0026nbsp;Glisson pedicle, direct ablation may directly lead to irreversible thermal damage to the Glisson pedicle during LTA.\u0026nbsp;In this case,\u0026nbsp;Glisson pedicle\u0026nbsp;dissection\u0026nbsp;can be used to dissociate and protect adjacent\u0026nbsp;Glisson pedicle. This technique generally includes both extrathecal and intrathecal dissections (hepatic portal approach), and the latter one is commonly used in LTA\u0026nbsp;[17]. By referring to key anatomical landmarks such as the hepatic plate system and the \u0026quot;6-porta\u0026quot; structure of the liver, anatomical structures around the liver can be identified correctly to facilitate accurate identification of the avascular space between the Laennec\u0026apos;s capsule and the\u0026nbsp;Glisson pedicle\u0026nbsp;[19]. Then, the space of Laennec\u0026apos;s capsule can be dissected safely based on precise operation under a magnified field of view of laparoscopy to promote the dissection of the\u0026nbsp;Glisson pedicle\u0026nbsp;[20]. At times, it is also necessary to dissect the liver parenchyma to some extent to expose\u0026nbsp;Glisson\u0026nbsp;pedicle.\u0026nbsp;After complete dissociation of the target Glisson pedicle, it can be protected in LTA by hanging, pulling, or isolating the structure with gauze.\u003c/p\u003e\n\u003cp\u003e(2) Difficult anatomical site exposure: Lesions located in segments VII, VIII and\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIVa, as well as the caudate lobe of the liver are considered difficult anatomical sites for LTA owing to their deep location, complex anatomical relationships, and poor surgical field of view. The challenge lies in exposure, which may further increase the difficulties of operating the major vascular structures and controlling bleeding. In case of this, a difficult anatomical site exposure technique of LLSTs can be employed to fully expose the tumor. For instance, it is feasible to adjust the patient\u0026apos;s position and the distribution of trocar, and select an appropriate surgical approach to fully dissociate the liver according to the tumor location; and a laparoscope with a flexible viewpoint, combined with operating methods such as \u0026quot;retract the liver medially with gauze strip\u0026quot;, \u0026quot;lifting with water bag\u0026quot;, \u0026quot;elastic traction\u0026quot; and \u0026quot;held down using the hilum blood flow occlusion tube\u0026rdquo; , can be used to expose special difficult anatomical sites. In this way, it can realize sufficient surgical field exposure and reduce surgical difficulty, so that patients can benefit from LTA\u0026nbsp;[21, 22].\u003c/p\u003e\n\u003cp\u003e(3) Bleeding control: Some authors feel that tumor in contact with vascular\u0026nbsp;\u003c/p\u003e\n\u003cp\u003estructures is a contra indication for traditional\u0026nbsp;thermal\u0026nbsp;ablation. Blood flow induces a cooling effect on the tumour in contact with the vascular structures, and therefore hinders the efficacy of heat transfer: this \u0026lsquo;\u0026lsquo;Heat Sink Effect\u0026rsquo;\u0026rsquo; might be the cause of a higher recurrence rate.\u0026nbsp;Meanwhile, as some tumors are adjacent to the\u0026nbsp;vessel, direct ablation may directly lead to damage and bleeding.\u0026nbsp;To counter these effects, we recommend performing a Pringle maneuver in selected patients. Researches also confirm that LTA with Pringle maneuver in proximity to major vascular structures does not significantly increase ablation size, or cause acute vascular damage and efficiently decrease \u0026lsquo;\u0026lsquo;Heat Sink Effect\u0026rsquo;\u0026rsquo; [23].\u003c/p\u003e\n\u003cp\u003e(4) Adjacent organ protection: In principle, subcapsular tumors constitute a contra\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eindication to radiology-guided TA. Effectively, there is an increased risk of rupture with tumour dissemination. This exposes the patient to the risk of local recurrence with the possibility of carcinomatosis and is known as the \u0026lsquo;\u0026lsquo;popcorn effect\u0026rsquo;\u0026rsquo; [13]. LTA with adjacent organ protection performed during surgery not only allows visualisation of the nodules, but also allows them to be separated from the intestinal wall or structure by surgical dissection or wet gauze pads, creating an interface between the nodule and the adjacent structure. This reduces the risk of thermal injury and tumour dissemination to these structures considerably. For the ablation of liver tumors of the diaphragm dome, the establishment of pneumoperitoneum in laparoscopic surgery can help to separate the liver from the abdominal wall, which avoids the risk of abdominal wall injury for tumors on the diaphragmatic surface. Transection of the falciform ligament can further expand the space between the liver and the abdominal wall. Transection of the coronary ligament and triangular ligament can help to separate the liver from the diaphragm. Then, saline gauze can be used to pack the bare region of the diaphragm dome to further expand the space between the liver and the diaphragm, which can also be placed on the dorsal side, i.e., the visceral surface. Consequently, an isolated zone is created in front, above, and on the dorsal side of the liver, providing a safe boundary for the ablation of tumors on the diaphragmatic and visceral surfaces of the liver. In addition, for tumors adjacent to the gallbladder, ablation can be performed prior to or after cholecystectomy [24].\u003c/p\u003e\n\u003cp\u003eThere are some limitations to this investigation: First, this is a single-center retrospective investigation with a small sample size and a short follow-up time. The long-term efficacy and prognosis of LTA assisted by LLSTs in the treatment of liver tumor still needs to investigated. And due to the limited number of cases, the exploration of recurrence-related risk factors could not be carried out. Second, this investigation lacks a control group. Besides, This technique is operated in an expert center at present, which may limit the reproducibility of these results in non-expert hands. Further experience must be gained to confirm the results of this case series. Well-designed, long-term, randomized, controlled, prospective trials are still necessary to further confirm some points proposed in this study.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLTA assisted by LLSTs for the treatment of liver tumor is feasible and safe, with excellent short-term efficacy and few complications. However, further research with larger sample size and longterm follow-up may be needed to support the application of this method.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYongkun Li: Writing - original draft, Visualization, Methodology, Formal analysis, Conceptualization. Chenhao Jiang:Writing - original draft, Validation, Data curation. Zheng Wang: Writing - review \u0026amp; editing, Data curation. Lei Liu: Software, Data curation. Ke Wu: Data curation, Methodology. Lu Zheng: Writing - review \u0026amp; editing, Validation. Nan You: Writing - review \u0026amp; editing, Validation, Methodology, Project administration, Conceptualization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the general program of Chongqing medical scientific research project (Joint project of Chongqing Health Commission and Science and Technology Bureau)\u0026nbsp;(2023MSXM004).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe deidentified dataset can be accessed upon a reasonable request made to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the Second Affiliated Hospital of Third Military Medical University (Army Medical University). This study was performed according to the Declaration of Helsinki, and written informed consent was obtained from individual participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMinami Y, Aoki T, Hagiwara S, Kudo M. Tips for preparing and practicing thermal ablation therapy of hepatocellular carcinoma. Cancers. 2023;15:4763.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMasoud SJ, Rhodin KE, Kanu E, Bao J, Eckhoff AM, Bartholomew AJ, Howell TC, Aykut B, Kosovec JE, Palta M, Befera NT, Kim CY, Herbert G, Shah KN, Nussbaum DP, Blazer DG 3rd, Zani S, Allen PJ, Lidsky ME.\u0026nbsp;Comparing survival after resection, ablation, and radiation in small intrahepatic cholangiocarcinoma. Ann Surg Oncol. 2023;30:6639\u0026ndash;6646. Li J, Pang C, Liu G, Xie X, Zhang DZ, Li K, Li Z, He G, Xu E, Zhong H, Yang H, Lu M, Lou K, Xie X, Lan S, Li Q, Dai G, Yu J, Liang P.\u0026nbsp;Thermal ablation with and without adjuvant systemic therapy: a nationwide multicenter observational cohort study of solitary colorectal liver metastases. Int J Surg. 2024;110:4240\u0026ndash;4248.\u003c/li\u003e\n \u003cli\u003eMartin RCG Jr, Woeste M, Egger ME, Scoggins CR, McMasters KM, Philips P.\u0026nbsp;Patient selection and outcomes of laparoscopic microwave ablation of hepatocellular carcinoma. 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Int J Surg. 2024;110:5685\u0026ndash;5695.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eZhang C, Ma J, Zhou Y. Laparoscopic dissection of the first and second porta hepatis along Laennec\u0026apos;s capsule via \u0026quot;Hepatic Serosal Incision\u0026quot; approach: how I do it. World J Surg. 2024;48:1967\u0026ndash;1972.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShen Z, Zhang Q, Sun Z, Jiang Y, Yan S. A novel exposure maneuver in laparoscopic right hepatectomy. J Surg Oncol. 2019;120:1386\u0026ndash;1390.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKim JH. Modified liver hanging maneuver focusing on outflow control in pure laparoscopic left-sided hepatectomy. Surg Endosc. 2018;32:2094\u0026ndash;2100.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRhaiem R, Kianmanesh R, Minon M, Tashkandi A, Aghaei A, Ledoux G, Hoeffel C, Bouche O, Sommacale D, Piardi T. Microwave thermoablation of colorectal liver metastases close to large hepatic vessels under Pringle maneuver minimizes the \u0026quot;heat sink effect\u0026quot;. World J Surg. 2020;44:1595\u0026ndash;1603.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSchullian P, Weiss H, Klaus A, Widmann G, Kranewitter C, Mittermair C, Margreiter R, Bale R. Laparoscopic liver packing to protect surrounding organs during thermal ablation. Minim Invasive Ther Allied Technol. 2014;23:294\u0026ndash;301.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopy, liver surgery techniques, thermal ablation, liver tumors","lastPublishedDoi":"10.21203/rs.3.rs-6978945/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6978945/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eLaparoscopic thermal ablation (LTA) of liver tumors is an increasingly performed procedure, but its application is limited when tumor location is unfavorable. This study aimed to evaluate the feasibility and safety of LTA assisted by laparoscopic liver surgery techniques (LLSTs) in challenging cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e Clinical data of patients who underwent LTA with LLSTs at the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from April 2020 to December 2023 were retrospectively analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e A total of 61 lesions in 28 patients (mean age: 56.50 ± 9.65 years) with multifocal liver tumors were included. The technical success rate was 100%, with an average ablation duration of 22.32 ± 12.53 min (10.25 ± 1.29 min per lesion). Average blood loss was 85.71 ± 40.50 ml, and the average hospital stay was 4.43 ± 1.50 days. No major postoperative complications were observed, and patients with minor complications recovered after conservative treatment. During follow-up, one lesion developed local recurrence, resulting in a local control rate of 95.08%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e LTA assisted by LLSTs is a safe and feasible technique for challenging liver tumor cases, though further exploration is warranted to address remaining limitations.\u003c/p\u003e","manuscriptTitle":"Application of laparoscopic liver surgery techniques in laparoscopic thermal ablation of liver tumors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-31 10:27:44","doi":"10.21203/rs.3.rs-6978945/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-08T20:58:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-06T17:25:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"250985104023604695757099369073354544502","date":"2025-09-06T17:17:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-23T20:10:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-16T08:58:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"170620907915994354472121582912802383529","date":"2025-08-11T04:40:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145965374101655511287639424702340210851","date":"2025-08-08T08:19:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-28T16:20:42+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-01T19:57:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-27T06:18:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-27T06:16:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2025-06-26T02:47:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0f44181c-36ee-4819-80db-c8c2d76947e5","owner":[],"postedDate":"July 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:15:07+00:00","versionOfRecord":{"articleIdentity":"rs-6978945","link":"https://doi.org/10.1186/s12876-025-04502-w","journal":{"identity":"bmc-gastroenterology","isVorOnly":false,"title":"BMC Gastroenterology"},"publishedOn":"2025-12-08 15:59:06","publishedOnDateReadable":"December 8th, 2025"},"versionCreatedAt":"2025-07-31 10:27:44","video":"","vorDoi":"10.1186/s12876-025-04502-w","vorDoiUrl":"https://doi.org/10.1186/s12876-025-04502-w","workflowStages":[]},"version":"v1","identity":"rs-6978945","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6978945","identity":"rs-6978945","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}