title: Multimedia manuscript. Dual-scope guided (simultaneous thoraco-laparoscopic) transthoracic transdiaphragmatic intraoperative radiofrequency ablation for hepatocellular carcinoma located beneath the diaphragm.
abstract: BACKGROUND
  Among treatment modalities for unresectable hepatocellular carcinoma (HCC), radiofrequency ablation (RFA) is getting popular due to low morbidity and its effectiveness. However, when the tumor is located just under the diaphragm, a percutaneous approach for RFA is often impossible because of the difficulty in visualizing the tumor with conventional ultrasonographic examination.
  
  
  METHODS
  Simultaneous thoraco-laparoscopic transthoracic transdiaphragmatic intraoperative RFA was performed on a 55 year-old male with HCC just beneath the diaphragm as well as laparoscopic RFA for dysplastic nodule near the gallbladder. Most of all, the patient wanted to undergo liver transplantation for the HCC and underlying liver cirrhosis. Therefore we chose to provide this procedure as a bridge to the liver transplantation. A total of four trocars (12 mm, 10 mm, 5 mm trocars for laparoscopy, and one 5 mm trocar for thoracoscopy), a 10 mm flexible laparoscope, a 5 mm thoracoscpe, and a laparoscopic ultrasound were used for this surgical procedure. After finishing laparoscopic RFA for dysplastic nodule near the gallbladder, the patient was placed into the left lateral decubitus for dual-scope guided transthoracic transdiaphragmatic intraoperative RFA. Complete separation of the diaphragm from the hepatic dome and good visualization of the subdiaphragmatic vessels provided a safe procedure without any injury to the diaphragm and other vessels.
  
  
  RESULTS
  The operative time was 240 minutes and the blood loss was zero. The postoperative course was uneventful. The diet was started on the operative day. A chest tube and an abdominal drain was removed on first day after surgery. The patient discharged on the second day after surgery. The patient has been followed up for three months after the dual-scope guided intraoperative RFA without any evidence of tumor recurrence. He is now actively being evaluated for liver transplantation.
  
  
  CONCLUSIONS
  Dual-scope guided (simultaneous thoraco-laparoscopic) transthoracic transdiaphragmatic intraoperative RFA is an easy, safe, and effective minimal invasive modality for treatment of the selective patient with HCC, with liver cirrhosis, which is located immediately under the diaphragm. Further experiences and a long term follow up is mandatory.
authors.affiliation: Department of Surgery, Yonsei University College of Medicine, 134 Shinchon-dong, Seoudaemun-gu, Seoul, 120-752, Korea. cmkang@yumc.yonsei.ac.kr
authors.forename: Chang Moo
authors.initials: CM
authors.lastname: Kang
authors.forename: Heung Kyue
authors.initials: HK
authors.lastname: Ko
authors.forename: Si Young
authors.initials: SY
authors.lastname: Song
authors.forename: Kyung Sik
authors.initials: KS
authors.lastname: Kim
authors.forename: Jin Sub
authors.initials: JS
authors.lastname: Choi
authors.forename: Woo Jung
authors.initials: WJ
authors.lastname: Lee
authors.forename: Byung Ro
authors.initials: BR
authors.lastname: Kim
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D003964:Diaphragm; D006801:Humans; D007430:Intraoperative Care / Q000379:methods*; D010535:Laparoscopy; D008113:Liver Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019212:Multimedia; D013906:Thoracoscopy