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Page 2 of 6 Igarashi et al. Hepatoma Res 2022;8:21 https://dx.doi.org/10.20517/2394-5079.2022.02

[8]
“subsegment resection,” “cone unit resection”, and repeat LAR for HCC, remain unproven .

We report the case of a patient with HCC who received full LAR three times, focusing on the technical
aspects of the Glissonean approach. We all discuss the limitations of AR for HCC.

CASE PRESENTATION
Preoperative information
A 67-year-old man with alcoholic liver cirrhosis and no hepatitis B or C virus infection was referred to our
hospital. Abdominal computed tomography (CT) showed a 3 cm liver mass in Segments 3 and 4a with the
typical features of HCC with early arterial enhancement and portal vein washout, which was classified as
LR-5 of the Liver Imaging Reporting and Data System (LI-RADS). Preoperative evaluation of the liver
function revealed Child-Pugh class A and the 15 min retention rate of Indocyanine green (ICG15) was 11%.
The serum levels of tumor markers for alpha-fetoprotein (AFP) and protein induced by vitamin K absence
or antagonist-II (PIVKAII) were 67.7 ng/mL and 74 mAU/mL, respectively. Preoperative surgical
simulation using three-dimensional (3D) CT rendered on a specific workstation (ZIOSTATION 2, Ziosoft
Inc., Tokyo, Japan) suggested the feasibility of limited anatomical subsegmentectomy instead of left
hepatectomy (resection volume was 115 mL, which was 9.7% of the total liver volume) on Makuuchi’s
criteria.

Surgical techniques
The Glissonean approach from the liver hilum was applied to selectively isolate and finally close these
pedicles for the segment or subsegment involved by the tumor. ICG dye fluorescence (0.5 mg/body) was
used to obtain demarcation lines both superficially and in the deep parenchyma, achieving a true
anatomical resection.

Course of treatment
We performed pure LAR of Segments 3 and 4a. The operative time was 264 min, the estimated blood loss
was 5 mL, and there was no need for blood transfusion. The patient was discharged on Postoperative Day 6
without any postoperative complications. Pathological findings of the tumor proved stage II moderately
differentiated HCC with negative resection margins and no vascular invasion [Figure 1].

Nine months after the previous surgery, abdominal CT revealed recurrence, with two liver masses (1.5 and 1
cm), which were classified as LR-5 of LI-RADS located in Segment 4b. Liver function was Child-Pugh A and
ICG15 was slightly elevated (23%). Serum levels of AFP and PIVKA-II were 67.8 ng/mL and 17 mAU/mL,
respectively. We performed a second LAR of Segment 4b. The operative time was 195 min and the
estimated blood loss was 28 mL. The patient was discharged on Postoperative Day 8 with no postoperative
complications. Pathological findings showed stage II moderately differentiated HCC with negative resection
margins and no vascular invasion [Figure 2].

Three months later, abdominal CT revealed recurrence, which was a 1.3 cm liver mass classified as LR-5 of
LI-RADS located in Segment 2. ICG15 was not elevated (16%). Serum levels of AFP and PIVKA-II were
58.9 ng/mL and 20 mAU/mL, respectively. We performed a third LAR of Segment 2. The operative time
and the estimated blood loss were 183 min and 60 mL, respectively. The patient discharged on Postoperative
Day 7 with no postoperative complications. Pathological examination of the resection specimen proved
stage II moderately differentiated HCC with negative resection margins and no vascular invasion
[Figure 3]. The patient showed no recurrence during the follow-up, nine months after the third surgery.