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Giacca et al. Hepatoma Res 2018;4:47 I http://dx.doi.org/10.20517/2394-5079.2018.79 Page 3 of 7

on cirrhosis, demonstrated better results in the laparoscopic group for length of hospital stay, level of post-
operative pain and ascites. Rate of incisional hernia was also lower in this group. These authors used the
comprehensive complication index (CCI) to prove a significantly less severe overall morbidity. They showed
no significant difference in terms of intra-operative blood loss. None of the patients in both groups required
transfusions. In the Yoon’s cohort of patients, operative time was significantly shorter in the open group.
The main limits of this study are that it is not an RCT and that the great majority of patients (more than
90%) had HBV-related cirrhosis. We are of the opinion that patients with HCC on chronic hepatitis B may
offer a less challenging setting for resection and less post-operative complications when compared to other
etiologies of cirrhosis .
[19]

Another recent propensity-score study by Xu et al. compared the laparoscopic and open approaches
[20]
for major hepatectomies to treat HCC on cirrhosis. This study, which included 103 patients, confirmed a
lower occurrence of post-operative ascites and showed no difference in all other medical and surgical post-
operative complications. A lower post-operative occurrence of ascites had already been observed by other
authors and described in meta-analyses [15,16,21] . Also in the Xu’s series, the open group had significantly lower
operative and Pringle times, while the laparoscopic group showed a significantly shorter length of stay and
a higher overall cost of hospitalization.

A study that aimed at comparing laparoscopic and OLR for HCC following sequential trans-arterial
chemoembolization (TACE)-portal vein embolization (PVE) was published by Goumard et al. The results
[22]
from this study showed no difference in oncological radicality in terms of R0 resections and tumor margins.
LLRs were proven to offer shorter length of stay and fewer grade B post-operative liver failures.

Results from the first Asia Pacific consensus meeting of LLR for HCC were published in 2018 . The meeting
[23]
of experts produced 22 recommendations, concluding that minor LLRs should be performed in experienced
centers and major LLRs in centers of excellence. In these selected centers LLR with portal vein reconstruction
is also possible if vascular involvement only targets the left lateral branches. The meeting’s conclusions also
mention some of the new frontiers of LLRs, such as the use of indocyanine green fluorescence and robotic
resection, which could become high-quality tools to optimize surgery in the near future.

CONVERSION RATES
Another main-point of interest in evaluating the feasibility of LLRs for HCC is conversion rate. Goumard et al. had
[22]
a higher conversion rate compared to the other studies, reaching 25% but never in an emergency setting.
These authors defined conversion criteria as: significant bleeding, failure to accurately recognize the biliary
anatomy and poor exposure leading to failure or slow progression during parenchymal transection. Work
from other authors showed conversion rates ranging from 5% to 13% [14,17,24] . The largest available case series
in all LLRs for HCC is a retrospective analysis by Dagher et al. , which presented a conversion rate of 10%.
[25]
A recent retrospective analysis of 2861 cases of LLRs by Halls et al. showed a conversion rate of 7.8%, in
[26]
which bleeding was the most common cause. Almost 19% of conversions were due to adhesions. In this
series, 11.5% of patients had cirrhosis and a conversion rate of 11.1%, which turned out to be statistically
significant when compared to the conversion rate of 7.3% in non-cirrhotic patients.

ONCOLOGICAL OUTCOMES
In all studies, there was no evidence of inferiority of LLR in terms of oncological results and survival
rates, both OS and DFS [13,14,17,18,20,27] . Moreover, the work by Han et al. compared the laparoscopic and
[17]
open groups in terms of pathological liver status, tumor size and satellites, microvascular and capsular
invasion, tumor grade and stage. No significant difference was found. Recently, a retrospective study by