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

Woo-Hyoung et al. analyzed 234 patients undergoing anatomical LLR for HCC: DFS was 67.5% and
[28]
55.3%, OS was 91.7% and 87.1% at 3 and 5 years respectively. In this work anatomical resection emerged
as a good prognostic factor for HCC recurrence, but had no impact on the OS. Another recent study by
Guro et al. considered retrospectively 177 patients who underwent major LLR or OLR, finding the early
[29]
(< 1 year) recurrence rate to be significantly higher in the open group, with similar OS and DFS rates.
Population in this study also showed a larger tumor size in the open group, which could explain the better
results in the laparoscopic one.

FEASIBILITY OF LLR
Although postero-superior segments (1, 4a, 7 and 8) are known to be the less accessible ones, recent
literature leans toward the concept that tumor location should no longer be a criteria for patient selection
in laparoscopic surgery [30,31] . Already in 2010, Yoon et al. published a retrospective study comparing
[32]
postero-superior (PS) and antero-lateral (AL) resections for HCC. The study concluded that PS patients had
longer operative time and length of hospital stay, but no significant difference in terms of post-operative
morbidity, recurrence or survival. A non-significant tendency towards a higher rate of conversion was
shown in PS patients.

In 2012, Ishizawa et al. analyzed 62 patients who had resections in all segments, confirming that PS
[33]
resections require longer operative time and are also affected by higher blood loss. The authors proved
accurate LLR to be feasible in all segments, but considered PS resections as “difficult segmentectomies”
which should be performed by surgeons with advanced open and laparoscopic experience.

Last, the laparoscopic approach reduces the formation of post-operative adhesions. This appeared, in the
case of repeat hepatectomy, to reduce operative time and difficulty of the adhesiolysis which could impact on
peri-operative morbidity in terms of bleeding and bowel or other organ injuries [13,34] . This suggests that LLRs
should be preferred, when feasible, considering the risk of recurrence and especially in potential candidates
for liver transplant .
[35]

LLR VS. ABLATION
Regarding single small HCCs, several authors have debated whether to perform laparoscopic resection or
local ablation. OLR was shown to be associated to higher rate of complications, greater blood loss and longer
hospital stay compared to radiofrequency ablation (RFA) [23,36,37] . These disadvantages are likely to be reduced
in laparoscopic resections. LLR seems to have better oncological results, in terms of lower recurrence rates,
when compared to RFA for the treatment of small (< 3 cm) HCCs [23,38-40] . OS in the two procedures do not
differ significantly [39,41] .

The main limitations of this study are that it was a single-center non-systematic review.

CONCLUSION
In conclusion, data have been accumulated in the recent literature in favor of safety and reliability of LLR for
HCC, especially in a cirrhotic setting. Currently, while LLR is the standard practice for patients requiring
minor hepatectomies, evidence regarding the feasibility of major LLRs is growing. Several studies also
show short-term benefits of LLR for major hepatectomies, with identical oncological results. A particular
advantage in the cirrhotic patient is a lower risk of postoperative decompensation and ascites. Still, these
operations are mainly performed in experienced centers. The next challenge will be the dispatch and training
of surgeons in accordance to these procedures, in order to achieve a meaningful improvement in patient care
and clinical outcomes.