For decades, surgical resection has been regarded as the gold standard for curative-intent treatment of liver tumors, particularly colorectal liver metastases. The operating room (OR) has been the epicenter of progress, with advances in open and laparoscopic techniques steadily reducing morbidity while maintaining oncological rigor. Yet, in parallel, interventional radiology (IR) has undergone its own transformation. Improvements in imaging, navigation, and energy-based technologies have allowed image-guided ablation to move from a palliative to a curative treatment.
This lecture explores how we are now entering a third phase: a hybrid era, where the meaningful progress is no longer defined by competition between modalities, but by structured collaboration between surgeons and interventional radiologists.
Minimally invasive liver surgery has demonstrated that reducing access does not compromise oncologic outcomes. Randomized trials and large prospective cohorts have shown that laparoscopic liver resection can lower complication rates, shorten hospital stay, and improve recovery without sacrificing long-term survival. These developments challenged traditional surgical dogma and laid the groundwork for further disruption. If oncologic principles can be preserved with smaller incisions, can they also be preserved without resection at all?
In parallel, thermal ablation has matured substantially. Microwave and radiofrequency ablation now offer predictable ablation zones, and validation software helps us ensure complete tumor ablation. This leads to improved local control, and better safety. Therefore, ablation is no longer reserved exclusively for frail or inoperable patients.
Progress in the field of ablation has long been hampered by selection bias. Patients undergoing ablation have historically differed systematically from those undergoing surgery, making fair comparisons difficult. Treatment decisions have been driven by institutional culture and specialty boundaries rather than robust evidence.
Recent years have seen a shift. The fabulous Collision-team proved that prospective randomized trials comparing resection and ablation are feasible, and our own New-Comet trial completed inclusion last October. These studies are designed not to prove that one modality should replace the other, but to define where each fits best within a modern, patient-centered treatment algorithm.
This is where the hybrid paradigm becomes essential. Rather than asking whether surgery or ablation is superior, the more relevant question is: which patients benefit from which approach, and when should they be combined? Hybrid strategies – such as laparoscopic-assisted ablation, intraoperative ultrasound-guided treatments, or staged combinations of resection and ablation – allow teams to tailor therapy to disease distribution while preserving liver function and future treatment options.
Such approaches demand genuine collaboration. Surgeons must be fluent in the principles and limitations of ablation, while interventional radiologists must be integrated into oncologic strategy rather than consulted as a last resort. Multidisciplinary tumor boards should evolve from sequential referrals to true joint planning arenas, where technical feasibility, oncologic intent, and patient preferences are weighed together.
This talk will trace the evolution from OR-dominated care, through the rise of IR-led interventions, to the current need for hybrid models that transcend traditional boundaries. Drawing on data from randomized trials, prospective registries, and institutional experience, it will highlight how collaboration—not technological supremacy—is becoming the key determinant of progress in liver-directed therapy.
Finally, the lecture will address future directions. Advances in imaging, three-dimensional planning, and intra-procedural validation promise to further blur the lines between surgery and intervention. Training paradigms may need to adapt, fostering cross-disciplinary competence and shared ownership of outcomes.
In an era where minimally invasive therapy is no longer a niche but an expectation, the transition from resection to ablation to collaboration represents not a loss of surgical identity, but its natural evolution.
