Published online Apr 27, 2026. doi: 10.4240/wjgs.v18.i4.113354
Revised: January 22, 2026
Accepted: February 25, 2026
Published online: April 27, 2026
Processing time: 241 Days and 11.9 Hours
In laparoscopic microwave ablation (MWA) of large hepatic hemangiomas with a maximum diameter between 5.0 cm and 10.0 cm, some scholars suggest that omitting occlusion of the first hepatic portal can simplify surgical procedures and shorten the operation time. Conversely, other scholars propose that occluding the first hepatic portal may reduce the “thermal sink effect”, enhance ablation ef
To compare the efficacy of laparoscopic MWA for large hepatic hemangiomas with vs without occlusion of the first hepatic portal, and to identify independent factors influencing the decision to perform occlusion.
A retrospective analysis was conducted on 220 patients with large hepatic he
Tumor maximum diameter, number of hemangiomas, and distance from major hepatic vessels were identified as independent factors influencing the decision to perform portal occlusion. After PSM, the occlusion group showed significantly better outcomes than the non-occlusion group in terms of intraoperative ablation time, number of ablations, puncture site bleeding volume, conversion rate to open surgery, total bilirubin and indirect bilirubin levels on postoperative days 1 and 3, alanine aminotransferase level on postoperative day 3, and the incidence of hemolytic jaundice, hemoglobinuria, and acute kidney injury (all P < 0.05). The occlusion group also exhibited more favorable outcomes in operative time, alanine aminotransferase on postoperative day 1, aspartate ami
Tumor maximum diameter, distance from major vessels, and number of tumors are independent factors in
Core Tip: Laparoscopic microwave ablation is safe and effective for small hemangiomas as it does not block the first hepatic portal. Giant hemangiomas (diameter ≥ 10.0 cm) are more commonly treated with hepatic resection rather than microwave ablation. If the first hepatic portal is not blocked, surgery is simpler and quicker for large hemangiomas (5.0 cm ≤ diameter < 10.0 cm). Conversely, blocking the first hepatic portal reduces the “heat sink effect” - a phenomenon where blood flow dissipates heat during ablation, thereby improving ablation efficiency and lowering the incidence of adverse reactions. However, there is no consensus or research on whether to block the first hepatic portal in this case.
- Citation: Meng TF, Wang S, Chen C, Deng SK. Analysis of the efficacy of first hepatic portal blockade in laparoscopic microwave ablation treatment of hepatic vascular tumors. World J Gastrointest Surg 2026; 18(4): 113354
- URL: https://www.wjgnet.com/1948-9366/full/v18/i4/113354.htm
- DOI: https://dx.doi.org/10.4240/wjgs.v18.i4.113354
Hepatic hemangioma, the most common benign liver tumor, has an incidence of 5% to 7% and is most frequently found in middle-aged women[1,2]. Although its exact origin is not completely understood, congenital vascular malformations are considered the primary cause[3,4]. Hepatic hemangiomas are classified into three types according to diameter: Small (< 5.0 cm), large (5.0-10.0 cm), and giant (≥ 10.0 cm)[5,6]. As a benign tumor, it usually causes no symptoms and rarely becomes malignant[7]. Therefore, conservative management or active monitoring is often recommended[8,9]. According to the 2019 Multidisciplinary Expert Consensus on the Diagnosis and Treatment of Hepatic Hemangioma[10-12], treatment should be considered when a hemangioma is large and presents with certain risk factors, such as symptoms or severe complications, or if it shows continuous growth. Available treatments include surgical resection, hepatic artery embolization, local ablation (e.g., microwave or radiofrequency), and liver transplantation[12]. Prior studies have confirmed that both surgery and laparoscopic microwave ablation (MWA) are effective for hepatic hemangioma[13,14]. Compared to traditional surgery and other ablation methods, laparoscopic MWA offers advantages such as shorter operation time, faster recovery, and fewer complications, making it a widely used option[15]. However, laparoscopic MWA can still lead to complications, including hemolytic jaundice, hemoglobinuria, acute kidney injury, transient liver impairment, bleeding at the puncture site, pulmonary infection, and thermal damage[16]. While laparoscopic MWA is safe and effective for small hemangiomas without blocking the first hepatic portal vein, giant hemangiomas (≥ 10.0 cm) are generally treated with surgical resection rather than MWA[17], or large hemangiomas (5.0-10.0 cm), not blocking the first hepatic portal vein can simplify and speed up the procedure[17,18]. On the other hand, performing the blockage can reduce the “heat sink effect”, a phenomenon in which blood flow carries away heat during ablation, thereby improving the efficiency of ablation and decreasing the risk of adverse events[18]. Still, there has been no clear consensus or dedicated research on whether the first hepatic portal vein should be blocked in such cases. To address this question, we compared the outcomes of laparoscopic MWA with and without first hepatic portal vein blockage in patients with large hepatic hemangiomas. Our aim was to evaluate the effect of this technique and help determine the best treatment strategy for these patients.
We retrospectively analyzed 220 patients with large hepatic hemangiomas (5.0 cm ≤ diameter < 10.0 cm) who underwent laparoscopic MWA in the Department of Hepatobiliary Surgery at Yunnan Provincial First People’s Hospital from October 2021 to October 2025. According to whether hepatic portal occlusion was performed during surgery, patients were assigned to either the blockade group (n = 87) or the non-blockade group (n = 133). All participants provided written informed consent, and the study protocol was approved by the hospital’s ethics committee.
Inclusion criteria: (1) Preoperative computed tomography (CT) or magnetic resonance imaging confirming a diagnosis of hepatic hemangioma; (2) Single tumor with a maximum diameter between 5.0 cm and less than 10.0 cm; (3) Presence of tumor-related symptoms such as abdominal pain or bloating; (4) Annual tumor growth rate exceeding 2.0 cm/year; and (5) Undergoing the first hepatic portal blockade procedure.
Exclusion criteria: (1) Presence of malignant tumors or severe cardiopulmonary or hematological diseases; (2) Child-Pugh class C liver function; (3) Coexisting biliary diseases; and (4) Incomplete clinical data.
After general anesthesia, the patient was placed supine, with adjustments made according to the location of the hemangioma. Following pneumoperitoneum establishment and other routine steps, a laparoscope was inserted via a supraumbilical puncture to examine the liver and the hemangioma. Guided by preoperative CT/magnetic resonance imaging findings, a laparoscopic ultrasound probe was introduced at the intersection of the left or right midclavicular line and the umbilical level to identify the exact location and size of the hemangioma. For tumors situated in special locations, surrounding liver ligaments and tissues were dissected to adequately expose the tumor.
Under laparoscopic ultrasound guidance, a microwave electrode needle was inserted into the planned ablation zone of the hemangioma. The Pringle maneuver was applied to achieve hepatic portal occlusion before initiating ablation. Using a power of 50 W, each ablation lasted 1.5-3.0 minutes. The ablation area was adjusted according to the lesion size. Ablation was continued until hyperechoic changes were observed within the lesion on ultrasound and charring became visible on the liver surface. Multiple overlapping ablations were performed as needed to ensure complete coverage of the lesion.
Intraoperative monitoring included ablation duration and number of ablations. We also recorded the volume of bleeding from the puncture site, instances of conversion to open surgery due to uncontrolled bleeding, and total operative duration. On postoperative days 1 and 3, liver injury markers were assessed, including alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), and indirect bilirubin (IBIL). The presence of fever or hemolytic jaundice was also documented. Hemolytic jaundice was defined as TBIL > 34.2 μmol/L with a predominant increase in IBIL, unchanged direct bilirubin, and possible jaundice of the skin, mucous membranes, or sclera. Acute kidney injury was defined as an increase in serum creatinine by ≥ 0.3 mg/dL (≥ 26.5 μmol/L) or ≥ 1.5 times baseline within 48 hours, occurring within 7 days postoperatively, or sustained urine output < 0.5 mL/(kg/h) for 6 hours. Other adverse events monitored included hemoglobinuria, new pulmonary infections, pleural effusion, and bile leakage.
The distance from the hemangioma edge to major hepatic blood vessels was recorded. Postoperative hospital stay duration was also documented. One month after surgery, contrast-enhanced CT was performed to evaluate the complete ablation rate and assess tumor shrinkage or residual lesions. Ablation was considered complete if no nodular or irregular enhancement was observed at the periphery of the ablation zone; otherwise, it was classified as incomplete.
To minimize sample selection bias, propensity score matching (PSM) was performed using binary logistic regression. Variables included age, gender, maximum tumor diameter, number of tumors, tumor location, distance from the tumor to adjacent major vessels, and preoperative liver function indicators. A 1:1 matching between the two groups was conducted using a caliper value of 0.02.
Data were analyzed using SPSS 27.0. The nearest neighbor PSM method was applied for 1:1 matching. Normally distributed continuous variables in baseline data were expressed as mean ± SD, while non-normally distributed variables were summarized as medians with interquartile ranges. Categorical variables were presented as n (%) and analyzed using the χ2 test or Fisher’s exact test, as appropriate. Continuous data were tested for normality; the t-test was used for normally distributed variables, and the Mann-Whitney U test for non-normal distributions. Variables showing statistically significant differences before PSM were included in a multivariate logistic regression analysis. P < 0.05 was considered statistically significant.
Before PSM, the blocked group exhibited a larger maximum tumor diameter, a shorter distance to adjacent blood vessels, and a greater number of tumors compared to the unblocked group (P < 0.05). After PSM, 87 patients remained in the blocked group and 79 in the unblocked group. No significant differences in baseline characteristics were observed between the two groups after matching (P > 0.05). Detailed data are presented in Table 1. Variables showing statistically significant differences before PSM were incorporated into a multivariate logistic regression analysis, with hepatic portal blockage as the outcome variable. The results indicated that maximum tumor diameter, number of tumors, and distance from the tumor to major hepatic vessels were independent factors influencing the decision to perform hepatic portal occlusion during surgery (P < 0.05), as summarized in Table 2.
| Before the PSM | After the PSM | |||||||
| Variable | Blocking (n = 87) | Non-blocking (n = 133) | Test statistic | P value | Variable | Blocking (n = 87) | Non-blocking (n = 79) | Test statistic |
| Age (years), mean ± SD | 45.92 ± 9.97 | 46.54 ± 10.06 | t = -0.450 | 0.653 | 45.92 ± 9.97 | 44.77 ± 9.40 | t = -0.761 | 0.448 |
| Gender | χ2 = 1.188 | 0.276 | χ2 = 0.558 | 0.455 | ||||
| Male | 24 (27.59) | 46 (34.59) | 26 (32.91) | 24 (27.59) | ||||
| Female | 63 (72.41) | 87 (65.41) | 53 (67.09) | 63 (72.41) | ||||
| Maximum tumor diameter (cm) | 6.300 (5.4, 7.3) | 6.500 (6.0, 8.0) | -2.742 | 0.006a | 7.000 (5.0, 7.8) | 6.500 (6.0, 8.0) | Z = -1.868 | 0.062 |
| Number of tumors | 5.804 | 0.016a | Z = 0.02 | 0.888 | ||||
| 1 | 42 (48.28) | 86 (64.66) | 42 (48.28) | 39 (49.37) | ||||
| ≥ 2 | 45 (51.72) | 47 (35.34) | 45 (51.72) | 40 (50.63) | ||||
| Location | 0.203 | 0.652 | Z = 0.611 | 0.434 | ||||
| Left liver | 28 (32.18) | 39 (29.32) | 28 (32.18) | 30 (37.97) | ||||
| Right liver | 59 (67.82) | 94 (70.68) | 59 (67.82) | 49 (62.03) | ||||
| Adjacent blood vessels (cm) | 2.700 (2.1, 3.1) | 2.800 (2.3, 3.5) | -2.627 | 0.009a | 2.700 (2.1, 3.1) | 2.600 (2.1, 3.1) | Z = -0.097 | 0.923 |
| ALT (U/L) | 16.000 (12.0, 26.0) | 18.000 (12.0, 27.0) | -0.784 | 0.433 | 16.000 (12.0, 26.0) | 17.000 (11.0, 29.0) | Z = -0.529 | 0.597 |
| AST (U/L) | 18.000 (15.0, 24.0) | 19.000 (16.0, 22.5) | -0.907 | 0.364 | 18.000 (15.0, 24.0) | 19.000 (15.0, 24.0) | Z = -1.039 | 0.299 |
| TBIL (μmol/L) | 10.300 (7.9, 13.1) | 11.600 (8.0, 14.9) | -1.431 | 0.152 | 10.300 (7.9, 13.1) | 11.700 (7.9, 14.9) | Z = -1.358 | 0.174 |
| IBIL (μmol/L) | 7.700 (5.5, 10.1) | 8.400 (5.7, 10.6) | -0.79 | 0.43 | 7.700 (5.5, 10.1) | 7.900 (5.5, 10.4) | Z = -0.22 | 0.826 |
Compared with the unblocked group, the blocked group demonstrated shorter ablation time, fewer ablation sessions, lower puncture site bleeding volume, and reduced operative duration. Statistically significant differences were observed in ablation time, number of ablations, and puncture site bleeding (P < 0.05). None of the patients in the blocked group required conversion to open surgery, whereas 11 patients in the unblocked group were converted due to uncontrolled bleeding during ablation, a difference that was also statistically significant (P < 0.05). These results are shown in Table 3.
| Blocking (n = 87) | Non-blocking (n = 79) | Test statistic | P value | |
| Duration of ablation (minute) | 7.000 (6.0, 9.0) | 11.000 (9.0, 15.0) | Z = -5.689 | 0.000a |
| Number of ablation sessions | 3.000 (3.0, 4.0) | 4.000 (3.0, 5.0) | Z = -3.649 | 0.000a |
| Bleeding at puncture site (mL) | 30.000 (20.0, 50.0) | 50.000 (20.0, 100.0) | Z = -3.087 | 0.002a |
| Duration of surgery (minute) | 120.000 (100.0, 150.0) | 120.000 (90.0, 155.0) | Z = -0.762 | 0.446 |
| Conversion to open surgery, n (%) | χ2 = 12.974 | 0.000a | ||
| Yes | 0 (0.00) | 11 (13.92) | ||
| No | 87 (100.00) | 68 (86.08) |
On postoperative days 1 and 3, TBIL, IBIL, and ALT levels on day 3 were significantly lower in the blocked group than in the unblocked group (P < 0.05). Although ALT and AST levels on postoperative day 1 were also lower in the blocked group, these differences did not reach statistical significance (P > 0.05). Detailed values are provided in Tables 4 and 5.
The incidence of adverse reactions was lower in the blocked group than in the unblocked group. Specifically, the blocked group had 3 cases of hemoglobinuria, 6 cases of hemolytic jaundice, and no cases of acute kidney injury, whereas the unblocked group had 12 cases, 15 cases, and 8 cases, respectively. These differences were statistically significant (P < 0.05). The blocked group also showed fewer instances of fever, new pulmonary infections, and pleural effusion, though these differences were not statistically significant (P > 0.05). Ablation efficacy was higher in the blocked group, although the difference was not statistically significant (P > 0.05). The postoperative hospital stay was shorter in the blocked group compared to the unblocked group, but again, this difference was not statistically significant (P > 0.05). These data are summarized in Table 6. No cases of bile leakage occurred in either group. All postoperative adverse reactions were effectively managed with supportive care, including hepatoprotective therapy, fluid infusion, diuresis, and urine alka
| Adverse reaction | Blocking (n = 87) | Non-blocking (n = 79) | Test statistic | P value |
| Fever | χ2 = 2.763 | 0.096 | ||
| Yes | 7 (8.05) | 13 (16.46) | ||
| No | 80 (91.95) | 66 (83.54) | ||
| Hemoglobinuria | χ2 = 6.944 | 0.008a | ||
| Yes | 3 (3.45) | 12 (15.19) | ||
| No | 84 (96.55) | 67 (84.81) | ||
| Hemolytic jaundice | χ2 = 5.477 | 0.019a | ||
| Yes | 6 (6.90) | 15 (18.99) | ||
| No | 81 (93.10) | 64 (81.01) | ||
| Acute kidney injury | χ2 = 9.256 | 0.002a | ||
| Yes | 0 (0.00) | 8 (10.13) | ||
| No | 87 (100.00) | 71 (89.87) | ||
| Pulmonary infection | χ2 = 1.404 | 0.236 | ||
| Yes | 8 (9.20) | 12 (15.19) | ||
| No | 79 (90.80) | 67 (84.81) | ||
| Pleural effusion | χ2 = 1.018 | 0.313 | ||
| Yes | 6 (6.90) | 9 (11.39) | ||
| No | 81 (93.10) | 70 (88.61) | ||
| Complete ablation | χ2 = 0.017 | 0.896 | ||
| Yes | 69 (79.31) | 62 (78.48) | ||
| No | 18 (20.69) | 17 (21.52) | ||
| Postoperative hospital stay (days) | 6.000 (5.0,7.0) | 6.000 (4.0,7.0) | Z = -1.235 | 0.217 |
Hepatic hemangioma, as the most common benign liver tumor, requires strict treatment guidelines due to its distinctive clinical biological behavior, with the goal of achieving optimal therapeutic outcomes while minimizing trauma[19,20]. With the increasing adoption of minimally invasive techniques, laparoscopic MWA has gradually become an effective treatment option for hepatic hemangiomas. MWA operates by generating a high-frequency electromagnetic field through microwave electrodes, which causes rapid oscillation of polar molecules in the tissue, thereby generating heat[21]. Under ultrasound guidance, an implantable microwave antenna is positioned within the tumor tissue to produce localized high temperatures that induce tumor cell death. When the temperature exceeds 60 °C, tumor cells undergo irreversible necrosis; temperatures above 120 °C leads to complete necrosis of the tumor and adjacent tissue, achieving an effect comparable to surgical resection[22].
During laparoscopic MWA for large hepatic hemangiomas, the hepatic artery and portal vein collectively contribute to hepatic inflow, accounting for approximately 25% of the systemic circulation volume[23,24]. If the first hepatic portal is not occluded, the substantial size and rich vascularity of the hemangioma can lead to rapid heat dissipation, thereby reducing the efficacy of ablation[25,26]. If the first hepatic portal is not occluded, the substantial size and rich vascularity of the hemangioma can lead to rapid heat dissipation, thereby reducing the efficacy of ablation.
In this study, pre-PSM intergroup comparisons revealed statistically significant differences in maximum tumor diameter and distance to adjacent major blood vessels between the blocked and unblocked groups (P < 0.05). Multivariate logistic regression analysis identified maximum tumor diameter and proximity to major vessels as key determinants in the decision to perform first hepatic portal blockade during laparoscopic MWA for large hepatic hemangiomas. When a hemangioma is large and situated close to major vessels, abundant regional blood flow can lead to heat loss, compro
The study demonstrated that under first hepatic portal blockade, the blocked group exhibited shorter ablation duration, fewer ablation sessions, and reduced bleeding at the puncture site. Operative time and conversion rates to open surgery were also lower compared to the unblocked group. During laparoscopic MWA for large hepatic hemangiomas, temporary blood flow interruption under hepatic portal blockade reduces perfusion in the ablation area, effectively mitigating heat loss due to blood flow, diminishing the “heat sink effect”, and expanding the ablation zone per unit time. This reduces the number and duration of ablations required and improves overall ablation efficiency[11]. Furthermore, temporary blood flow interruption during first hepatic portal blockade reduces perfusion within the ablation area. This controlled reduction in blood flow minimizes the risk of injury to surrounding vessels during the procedure and significantly decreases bleeding at the puncture site. As a result, it helps prevent uncontrolled hemorrhage from the puncture tract and reduces the need for conversion to open surgery. Should uncontrolled bleeding occur during the operation, prompt occlusion of hepatic inflow allows effective hemostasis and helps avoid serious complications.
During laparoscopic MWA with first hepatic portal blockade, mean arterial pressure, cardiac output, and central venous pressure decrease significantly, reflecting systemic hemodynamic imbalance. This may also lead to hemodynamic disturbances, necessitating greater volumes of colloid infusion to maintain microcirculatory stability and increasing the demand for fluid resuscitation. Such disturbances may be associated with hepatic ischemia-reperfusion injury, further impairing tissue oxygenation and organ function. The altered pressure gradient and microcirculatory disturbances during portal occlusion could elevate the risk of postoperative liver injury and complications. However, this study found that the blocked group exhibited lower postoperative levels of ALT, AST, TBIL, and IBIL, as well as a lower incidence of hemolytic jaundice, hemoglobinuria, and acute kidney injury compared to the unblocked group. This suggests that by reducing the “heat sink effect”, hepatic portal blockade allows more focused delivery of ablation energy to the target lesion, thereby minimizing collateral thermal injury to normal hepatocytes and erythrocytes caused by blood flow-mediated heat dispersion. As a result, the extent of liver injury and erythrocyte destruction is reduced. With less hemoglobin released into the circulation, renal metabolic capacity remains compensatory, thereby preventing hemoglo
Additionally, the complete ablation rate under hepatic portal blockade was slightly higher than that in the unblocked group, suggesting that the technique can ensure effective and complete ablation while reducing injury to normal liver tissue and erythrocytes, thereby lowering the incidence of postoperative adverse reactions[20]. The hospital stay of patients in the blocked group was shorter than that in the unblocked group, although the difference was not statistically significant.
This study utilized PSM to balance baseline characteristics, reducing data bias and the influence of confounding variables between groups and enhancing the reliability of the conclusions. The results suggest that preoperative evaluation of hemangioma maximum diameter, distance to adjacent vessels, and number of tumors can guide the decision on whether to perform first hepatic portal blockade. Furthermore, in laparoscopic MWA for large hepatic hemangiomas, the use of first hepatic portal blockade can ensure complete ablation, improve ablation efficiency, and reduce the occurrence of postoperative adverse reactions.
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