Lesson 1Adjunctive Techniques: Track Ablation, Artificial Ascites, and Adjunct Embolisation to Reduce Heat SinkThis section reviews adjunctive techniques that enhance safety and efficacy, including track ablation to prevent bleeding and seeding, artificial ascites or pleural effusion for organ displacement, and adjunct embolisation to mitigate heat sink. It details indications, methods, and documentation for these supportive measures.
Track ablation to prevent bleeding and seedingCreating artificial ascites: indications and methodArtificial pleural effusion for dome lesionsAdjunct transarterial embolisation for heat sinkCombining ablation with portal vein embolisationDocumentation and follow-up of adjunctive measuresLesson 2Tumour Assessment: Size, Segmental Location, Proximity to Vessels/Bile Ducts, and Surgical CandidacyThis section addresses tumour assessment before ablation, including measurement of size, segmental and subsegmental location, proximity to vessels and bile ducts, and evaluation of surgical candidacy and alternative curative options. It covers localisation, risks, and therapy selection criteria.
Measuring tumour size and multiplicitySegmental and Couinaud-based localisationProximity to major vessels and bile ductsAssessing heat sink risk from large vesselsEvaluating surgical and transplant candidacySelecting ablation versus other local therapiesLesson 3Ablation Modality Selection: Principles, Advantages, and Limitations of Radiofrequency, Microwave, Cryoablation, and Irreversible ElectroporationThis section compares ablation modalities, including radiofrequency, microwave, cryoablation, and irreversible electroporation, focusing on mechanisms of action, advantages, limitations, ideal indications, and device-specific safety considerations. It emphasises biophysics and modality choice by tumour characteristics.
Biophysics of thermal and nonthermal ablationRadiofrequency ablation: strengths and limitsMicrowave ablation: power and speed advantagesCryoablation: ice ball dynamics and risksIrreversible electroporation: niche indicationsChoosing modality by tumour size and locationLesson 4Needle Path Planning: Safe Trajectories, Avoidance of Pleura, Bowel, and Major Vessels, and Hydrodissection TechniquesThis section explains how to design safe needle trajectories for liver ablation, focusing on avoidance of pleura, bowel, and major vessels, and the use of hydrodissection and ancillary manoeuvres to protect adjacent critical structures. It includes imaging analysis, strategies, and positioning tips.
Analysing cross‑sectional imaging for safe accessPlanning trajectories to avoid pleura and lung basesStrategies to protect bowel and stomach loopsAvoiding and traversing near major hepatic vesselsHydrodissection: indications, agents, and techniqueUse of patient positioning to optimise needle pathLesson 5Patient Selection and Preprocedural Optimisation: Liver Function (Child-Pugh), Coagulation, and Anaesthesia ConsiderationsThis section covers patient selection and optimisation before ablation, including assessment of liver function with Child-Pugh and MELD, coagulation status, comorbidities, anaesthesia planning, and strategies to reduce peri-procedural risk. It details scoring, corrections, and consent processes.
Oncologic indications and contraindicationsChild-Pugh and MELD scoring for liver reserveCoagulation assessment and correction strategiesRenal function and contrast-related considerationsAnaesthesia choice: local, MAC, or generalPreprocedural fasting, medications, and consentLesson 6Imaging Guidance Options: Real-Time Ultrasound, CT-Guidance, CT-Fluoroscopy, MRI Guidance, and Image Fusion WorkflowsThis section examines imaging guidance options for liver ablation, including real-time ultrasound, CT, CT-fluoroscopy, MRI guidance, and image fusion workflows, with emphasis on modality selection, accuracy, and radiation considerations. It covers techniques, fusion, and dose optimisation.
Conventional and contrast-enhanced ultrasoundCT and CT-fluoroscopy guidance techniquesMRI-guided ablation: logistics and benefitsImage fusion of US with CT or MRI datasetsNavigation systems and needle tracking toolsRadiation dose optimisation during CT guidanceLesson 7Intra-Procedure Monitoring of Ablation Zone and Immediate Technical Success CriteriaThis section details intraprocedural monitoring of the ablation zone using ultrasound, CT, or MRI, criteria for adequate coverage and margins, assessment of immediate technical success, and strategies to adjust or repeat ablations in real time. It includes imaging, margins, and decision-making.
Real-time imaging of probe position and angleMonitoring ablation zone growth over timeAssessing minimal ablative margin requirementsUse of contrast-enhanced US or CT intra-procedureCriteria for immediate technical success or failureDecision-making for repeat or extended ablationLesson 8Imaging for Planning: Multiphase Liver CT, Contrast-Enhanced MRI, and PET When IndicatedThis section reviews imaging modalities used for ablation planning, emphasising multiphase liver CT, contrast-enhanced MRI, and PET when indicated, with attention to lesion conspicuity, staging, and mapping of vascular and biliary anatomy. It covers protocols, sequences, and assessment.
Multiphase CT protocols and timing optimisationMRI sequences for lesion detection and marginsUse of hepatobiliary contrast agents in MRIRole of PET and PET/CT in lesion characterisationImaging-based staging and resectability assessmentMapping vascular and biliary anatomy pre-ablationLesson 9Ablation Procedural Steps: Patient Positioning, Sterile Setup, Probe Insertion, Energy Delivery Parameters, Overlapping Ablations for MarginThis section describes stepwise execution of liver ablation, from patient positioning and sterile preparation to probe insertion, energy delivery parameters, overlapping ablations for adequate margins, and documentation of procedural details. It includes setup, insertion, and margin strategies.
Optimal patient positioning by segment locationSterile field setup and antibiotic prophylaxisSkin entry planning and local anaesthesiaProbe insertion, adjustment, and confirmationEnergy delivery settings and cycle durationOverlapping ablations to secure tumour marginsLesson 10Complications: Haemorrhage, Bile Leak, Thermal Injury to Adjacent Structures, Abscess — Recognition and ManagementThis section discusses complications of liver ablation, such as haemorrhage, bile leak, thermal injury to adjacent organs, abscess, and needle-track seeding, with emphasis on early recognition, imaging findings, and stepwise management strategies. It covers risks, diagnosis, and treatments.
Risk factors for major and minor complicationsRecognition and treatment of haemorrhageDiagnosis and management of bile leakThermal injury to bowel, diaphragm, and skinHepatic abscess: prevention and drainageNeedle-track seeding and long-term outcomesLesson 11Post-Ablation Imaging Protocols and Follow-Up Schedule to Confirm Complete AblationThis section outlines post-ablation imaging protocols, including timing and modality selection, standardised reporting of ablation zones, criteria for complete response versus residual disease, and structured follow-up schedules and intervals. It details objectives, criteria, and surveillance.
Immediate post-procedure imaging objectivesFirst follow-up scan timing and modality choiceImaging criteria for complete ablationDetection of residual or recurrent tumourStandardised reporting of ablation findingsLong-term surveillance intervals and duration
