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Page 2 of 7 Zhang et al. Hepatoma Res 2020;6:77 I http://dx.doi.org/10.20517/2394-5079.2020.74

invasion of HCC limit the long-term survival of HCC patients. The recurrence rate of HCC is as high
[20]
as 80% within 5 years after radical resection . However, due to a relatively insidious onset, most of the
patients are in the middle and late stages when they seek medical treatment, with only 10% at a stage
[21]
amenable to surgical intervention . Moreover, the postoperative recurrence rate is high. In recent years,
a variety of new technologies and therapies have emerged constantly, which have posed a challenge to
the surgical resection of HCC. In addition to liver transplantation, surgical resection of tumor has been
accepted as an effective local treatment for HCC. The innovation of HCC treatment technology and the
[22]
progress of surgical technology have improved the safety of HCC resection .

With advances in technology and techniques, minimally invasive surgery has now become the standard of
care in almost every field in general surgery, including hepatectomy surgery. Since the first laparoscopic
pericystectomy for hepatic echinococcosis carried out in France in 1991, there have been increasing reports
on the laparoscopic treatments for HCC. The da Vinci Surgical System (Intuitive Surgical Inc., United
States) is an advanced and minimally invasive surgery tool, which has been shown to have advantages in
[23]
complex hepatectomy. Liu et al. formulated international consensus statement on robotic hepatectomy
surgery. On the basis of ensuring the therapeutic effect and safety, the development of new surgical
treatment is conducive to the prognosis of patients and the development of the whole treatment system.

This review focuses on the latest advances in minimally invasive surgical treatment of HCC, including
laparoscopic hepatectomy (LH), robotic liver resection and other minimally invasive treatment
technologies.

LAPAROSCOPIC HEPATECTOMY
As far as the traditional treatment viewpoint is concerned, surgical resection is the first choice for the
[24]
treatment of liver cancer . With the update of treatment viewpoints and the innovation of technical
equipment, laparoscopic technology is widely used in various surgical treatment fields. LH as one of the
minimally invasive treatment methods for hepatocellular carcinoma, is increasingly used in clinical surgery
[25]
by more and more surgeons. In 1991, Reich et al. completed the first laparoscopic hepatectomy in the
world, and the laparoscopic technique was gradually applied to the surgical treatment of hepatobiliary
[26]
diseases. In 1994, Zhou et al. reported the first laparoscopic hepatectomy in China. Owing to the
differences and gaps in the mastery of technical difficulties and risk awareness, the rich liver blood flow,
laparoscopic hepatic portal occlusion that is more difficult than laparotomy, and lack of open operation feel
and rapid reactions, accurate hemostasis and control of bleeding are the key to the success of laparoscopic
hepatectomy, so the clinical development of laparoscopic hepatectomy is still in the development stage.
The classification of laparoscopic hepatectomy in domestic and foreign guidelines mainly includes
pure laparoscopic liver resection, hand-assisted laparoscopic liver resection and laparoscopic assisted
hepatectomy (hybrid procedures). The indications of laparoscopic hepatectomy vary globally. In 2013,
[27]
the domestic expert consensus proposed that the indications of laparoscopic hepatectomy include
symptomatic benign diseases, intra-and extra-hepatic bile duct calculi and liver malignant tumors.
However, there are still controversies about laparoscopic hepatectomy. According to a survey conducted in
Japan in 2013, more than half of the surveyed medical centers routinely perform laparoscopic hepatectomy,
but the indications are not consistent, and preoperative liver function reserve and intraoperative bleeding
control occupy the primary position. More than two-thirds of medical centers hold that laparoscopic
[28]
hepatectomy can be used for living donor liver transplantation . Limited by the surgical instrument and
technical mastery, small-scale hepatectomy or anatomical hepatectomy can be performed if the lesion
location of liver cancer is superficial and limited, and does not invade large blood vessels and bile ducts
[28]
according to the traditional surgical viewpoint . Due to the limitation of the laparoscopic visual field
and operation equipment activities, hand-assisted laparoscopic liver resection or laparotomy is the best
choice for some larger tumors requiring complex hepatectomy or large-scale hepatectomy. At present, the