Page 123 - Read Online

Page 2 of 9 Sioutas et al. Hepatoma Res 2021;7:26 https://dx.doi.org/10.20517/2394-5079.2020.111

the most commonly implemented curative option for patients diagnosed with HCC limited to the liver, with
preserved liver function, and without portal hypertension.

[5]
Laparoscopy can be used to diagnose, stage, and treat HCC . According to the Louisville Statement (2008),
the indications for laparoscopic liver resection (LLR) should be: solitary lesions ≤ 5 cm in diameter, in
segments 2-6; laparoscopic left lateral sectionectomy should be standard practice; and major liver resections
[5]
should be performed by experienced surgeons . In 2014, the Second International Consensus Conference
on Laparoscopic Liver Resection was held in Morioka, Japan, to establish further guidelines . The experts
[6]
concluded that LLR is not inferior in terms of overall survival, mortality, negative margins, and cost
compared to the open approach, while they also concluded that it is probably superior regarding length of
hospital stay and intraoperative transfusions .
[6]

[7]
However, only approximately 15% of patients present with resectable tumors . Since liver transplantation
(LT) was established as the optimal treatment for end‐stage liver disease, its indications have expanded to
include non-metastatic unresectable HCC (Milan criteria) . Actually, among well-selected patients
[8,9]
undergoing LT for HCC, the overall survival was found to be comparable to that of LT for non-malignant
etiology [10,11] . Following resection, HCC patients may exhibit a recurrence rate of 40%-90%, especially in the
case of underlying chronic liver disease, and in certain cases salvage LT can be a reasonable option [5,9,12] . As
[13]
LT may be more complicated in the case of adhesions after previous abdominal surgery , LLR may have an
additional advantage over its open counterpart in that scenario .
[14]
Considering the benefits of laparoscopic approaches and the curative potential of LT, we aim to review the
role of minimally invasive surgery in LT for HCC.

LAPAROSCOPIC LIVER RESECTION FOR HEPATOCELLULAR CARCINOMA
Technique and positioning for laparoscopic liver resection
[15]
The most common position for the patient is the supine one . The trocar for the laparoscope is inserted
through an umbilical incision, while four additional trocars are usually used: at the epigastrium, abdomen
bilaterally, and at the right hypochondrium [15,16] . Transthoracic or intercostal trocars are used when
[17]
[18]
operating on the superior part of the liver . Notably, single-incision LLR has also been described . The
Pringle maneuver is used to control intraoperative bleeding, and selective inflow occlusion is used to avoid
ischemia-reperfusion injury during anatomical major LLR . To reduce intraoperative bleeding, a low
[19]
central venous and airway pressure should be maintained . In addition, pneumoperitoneum should be
[15]
[15]
ideally kept to 8-10 mmHg to reduce the risk of gas embolism .
Apart from the standard method, hybrid or hand-assisted liver resection may also be used in challenging
cases . Additionally, technological advancement has led to the incorporation of the surgical robot in liver
[20]
surgery. Robotic liver resection (RLR) has the advantage of more technically precise surgery because of its
more flexible instrumentation and the 3D visualization of the operative field [21-23] .

Short-term outcomes
The international consensus statement conclusions have been further validated by several systematic
reviews and meta-analyses comparing LLR with open liver resection for patients with HCC. According to a
recent one by Wang et al. , major LLR has the benefits of fewer postoperative complications, less blood
[24]
[24]
loss, and shorter hospital length of stay with the potential drawback of longer operative time . Long-term
outcomes were comparable . Another meta-analysis showed that LLR can lead to decreased intraoperative
[24]
[25]
blood loss, need for transfusion, 30-day complication and mortality rate, and length of hospital stay .