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Page 2 of 8 David et al. Hepatoma Res 2018;4:2 I http://dx.doi.org/10.20517/2394-5079.2017.51

Keywords: Hepatocellular carcinoma, minimally invasive surgical procedures, laparoscopy

INTRODUCTION
Although incidence and mortality rates for cancer overall are declining, based on the 2017 National
Comprehensive Cancer Network (NCCN) guidelines for hepatobiliary cancers, the incidence and mortality
[1]
rates for liver cancer are increasing . In particular, hepatocellular carcinoma (HCC) is the most common
primary solid tumor in the world, and is ranked as the third leading cause of cancer-related death
[2]
worldwide . Several staging systems have been developed in order to guide the management decisions in
patients with HCC; among those, the Barcelona Clinic Liver Cancer (BCLC) Classification system has been
[3]
approved and widely accepted in clinical practice . According to the BCLC algorithm, curative treatment
[including surgical resection, radiofrequency ablation (RFA) and transplantation] is recommended only for
very early or early-stage (stage 0-A) HCC, whereas palliative treatment is recommended for intermediate
[3]
and advanced stage HCC (stage B-C) . In this regard, BCLC indication for curative resection is markedly
limited. However, recent studies have shown that surgical resection can provide good outcomes for both
short and long-term, despite the presence of portal hypertension, multi-nodular disease, large nodules
[4]
(> 3 cm), and those with macrovascular infiltration . Particularly in the last decade, laparoscopic liver
resection (LLR) may particularly be beneficial since it is less invasive, with significantly less post-operative
[5]
complications, but with comparable oncologic outcomes to the open approach .

The aim of this study is to show the benefit of surgical resection, and to compare the peri-operative and long-
term outcomes, particularly in terms of recurrence and overall survival (OS), between LLR and open liver
resection (OLR) for HCC classified as intermediate stage (B) under BCLC.

METHODS
Study design and patient selection
A retrospective review of the Electronic Medical Record database was done to identify all patients who
underwent primary liver resection for HCC. From January 2004 to December 2013, a total of 1287
hepatectomies was performed at Seoul National University Bundang Hospital. Of these hepatectomies, 389
patients underwent liver resection for HCC. Among these patients, 49 patients staged as intermediate stage
(BCLC B) were identified and selected. The study population included 2 comparable groups: OLR group
composed of 21 patients, and the LLR group comprised of 28 patients.

Preoperative evaluation
A complete evaluation and surgical treatment for patients with HCC were discussed during multi-
disciplinary meetings. Liver function was evaluated using complete biochemical profiles and liver function
tests, including indocyanine green (ICG) tests. Results were expressed as percentage of ICG retained 15 min
15
(ICG ) after injection. Resectability was decided by a multidisciplinary team approach.
15
Liver volume measurement
Triple-phase computed tomography (CT) was routinely used for preoperative imaging evaluation. The axial
images were then loaded to a computer workstation where the semimanual Rapidia software (Infinitt Co.,
Ltd., Seoul, Korea) was installed. Cross-sectional areas of the liver on each transverse-slice image were
obtained by manual tracing of the liver contour using a cursor, with free-curves drawn by experienced
surgeons. Liver parenchymal volume was then generated automatically by summation of all the manually
[6]
calculated areas of successive transverse-slice images . The minimal amount of sufficient future liver
[7]
remnant of > 30% was mandatory before surgery .
Surgical technique
All liver resections were performed by a specialist hepatobiliary surgeon proficient in laparoscopic and
open liver surgery. In general, the approach to both OLR and LLR was similar. Major anatomical resection