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Page 4 of 6 Igarashi et al. Hepatoma Res 2022;8:21 https://dx.doi.org/10.20517/2394-5079.2022.02

Figure 2. Second operation: (A) preoperative 3D CT reconstruction; (B) isolation of Glissonean branches of Segment 4b (G4b); and (C)
macroscopic findings and pathological results. 3D CT, three-dimensional computed tomography.

Despite no vascular invasion, detailed histopathological examination in our institution suggested that the
recurrence patterns in this case were not multicentric occurrences based on liver cirrhosis but intrahepatic
metastasis because the pathological structures of the specimen following three repeat resections were similar
to each other in terms of differentiation. A genetic examination may be required to confirm the similarities
for a definitive diagnosis. Many previous studies reported that, compared to major open liver resection,
laparoscopic liver resection has short-term clinical advantages, including reduced blood loss, lower
postsurgical morbidity, and shorter hospital stay for HCC, and the long-term oncological outcomes were
comparable in both groups [10-12] . The oncological significance and advances in subsegmentectomy and cone
unit resection should be investigated in the future.

Laparoscopic repeat LAR for recurrent HCC could be a safe and feasible procedure, as suggested by
previous systematic reviews and meta-analysis [13-15] . We believe that the important points for making the
next operation easier with a few adhesions of the abdominal wall and hilum of the liver include no extra
mobilization, no ischemic area should be left by performing anatomical resection, to spray a spray-type
anti-adhesion barrier (Ad Spray type L®, TERUMO Corp, Tokyo, Japan) on the remaining liver and hilum
of the liver, and low intraoperative bleeding. In addition, the laparoscopic procedure might be good for the
dissection of adhesion due to its magnification.

In conclusion, we report the case of a patient with HCC who received full LAR three times. Laparoscopic
repeat LAR for recurrent HCC could be a safe and feasible procedure. We should investigate the oncological