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Yamaguchi et al. Hepatoma Res 2018;4:50 I http://dx.doi.org/10.20517/2394-5079.2018.68 Page 5 of 10

reductive surgery, depending on hepatic function, for patients with small HCC (5 cm or smaller) and major
resection of at least 2 segments for patients with large HCC.

The procedure for resection of the right hepatic vein at its root with preservation of the inferior right vein ,
[35]
the procedure for systematic resection of the HCC-bearing portal territory with dye infusion under ultrasound
guidance , and the procedure for systematic resection of the identified tumor-bearing territory with
[36]
transection of Glisson’s sheath [37,38] are reported as the surgical procedures preserving the liver parenchyma.
The procedure for resection of segment 3 and 4 with preservation of segment 2 is also included.
[39]

The surgical procedure for HCC in the caudate lobe generally removes the ventral liver parenchyma also,
which has raised the question of impaired hepatic functions. Surgical procedures such as dorsal resection of
the caudate lobe isolated and identified using the counterstaining technique [40,41] and isolated resection of the
caudate lobe after parenchymal transection along the middle hepatic vein currently have been designed.
[42]
Reports on laparoscopic hepatectomy for HCC are increasing lately. It is reported that laparoscopic hepatectomy
is superior to open hepatectomy due to the magnifying effect of the area being operated on and allows less
hemorrhage from the hepatic veins due to the hemorrhagic reduction effect of the pneumoperitoneum [43-45] .
It is also reported that laparoscopic hepatectomy has a lower incidence of complications such as ascites
than open hepatectomy [46-48] . Laparoscopic hepatectomy for HCC has been reported to have long-term
outcomes equivalent to those of open hepatectomy and superior to radiofrequency ablation in local control
for small HCC located at the liver surface. In Japan, laparoscopic hepatectomy is currently recommended
based on the judgments of the International Consensus Conference on Laparoscopic Liver Resection that
laparoscopic hepatectomy could be performed on patients with hepatic reserve sufficient to undergo open
hepatectomy and is advisable for partial resection or lateral segmental resection for solitary tumor with
a maximum diameter no more than 5 cm located in the anterior inferior segments (segments 2 to 6) .
[49]
In Europe and the US, some reports have described laparoscopic hepatectomy but have not made a clear
recommendation for it. In any case, it is considered that laparoscopic hepatectomy should be done by a
team with well-experienced surgeons and only at a well-equipped medical institution providing adequate
intensive care during the perioperative period due to insufficient accumulation of evidence about safety in
laparoscopic hepatectomy.

PROGNOSIS OF PATIENTS UNDERGOING HEPATECTOMY
The studies have reported that there was no significant difference in postoperative relapse rate between
patients with resection margin of at least 1 cm and patients with resection margin of less than 1 cm [50-52]
and comparison of the prognosis in patients with resection margin of at least 5 mm and less than 5 mm
also showed no significant difference in survival rate [53,54] . Based on these results, a minimum distance of
resection margin is allowed for hepatectomy for HCC in Japan. In contrast, Hu et al. reported that the
[55]
prognosis was favorable in patients with Milan criteria-compliant HCC with resection margin of at least
1 cm. Another study showed that patients with a resection margin of at least 2 cm had a more favorable
prognosis than patients with a margin of 1 cm . It is thought that the distance of the resection margin may
[56]
affect prognosis.

Well-known predictors of poor prognosis after hepatectomy also include tumor diameter of at least 5 cm, multiple
tumors, no capsular formation, positive vascular invasion, impaired liver function, TNM classification stage
3 or 4, and AFP level of at least 32 ng/mL [57,58] . Some research has indicated that tumor size is not a prognostic
predicator [59,60] .

Tumor markers such as PIVKA-II and AFP are reported as predictors of recurrence after hepatectomy for
HCC. HCC patients with a thrombus in the main portal vein or the first branch of the portal vein are considered