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Page 2 of 6 Morise. Hepatoma Res 2020;6:79 I http://dx.doi.org/10.20517/2394-5079.2020.76

A B

Figure 1. Open (A) and laparoscopic (B) repeat liver resections. The directions of view and manipulation in each approach are indicated
with red arrows. A: in the open approach, the subphrenic rib cage is opened with a large subcostal incision and the liver is mobilized
(lifted) from the retroperitoneum; B: in laparoscopic approach, the instruments intrude into the cage from the caudal direction, and the
surgery is performed with minimal damage on the associated structures. Orange arrows indicate the dissection of adhesion. A: total
adhesiolysis is performed in open procedure; B: direct approach to the tumor in laparoscopic procedure can facilitate small surface
repeat liver resection with minimal adhesiolysis. IVC: inferior vena cav

[3]
After the beginning of laparoscopic LR (LLR) in the early 1990s , the accumulated experiences plus
[3-6]
technical/technological advancements have expanded the indication of LLR . However, the bulky and
weighty liver protected inside the subphrenic “rib cage”, and the invisible tumors/vessels inside it, should
be handled in LR. There are obstacles to overcome in LLR: restricted manipulation, poor tactile sensation,
and disorientation occurring under the limited laparoscopic view . Increases in operation time and
[7,8]
bowel injury were known in surgery with adhesion [9,10] , and increased morbidity and conversion in
laparoscopic re-do surgeries have been reported [10,11] . Many laparoscopic re-do surgeries [10-14] have become
usual procedures; however, the application of laparoscopic repeat LR (LRLR) is controversial. Adhesion
can disturb the liver mobilization and the dissections of vessels and Glissonian pedicles. Scars/adhesions
causing the deformity of the liver and its internal structures disrupt the identifications of tumors and
vessels. They increase the risks of complications and conversions during LRLR.

On the other hand, LLR is reported to have benefits, such as reductions of postoperative ascites and liver
[15]
failure , for patients with liver cirrhosis (LC) [16-18] . During open LR, the subphrenic “rib cage” in which
the liver is protected is opened with subcostal incision, and the liver is mobilized for picking up. In LLR,
directly intruding instruments to the cage perform the manipulation [Figure 1, “Caudal approach” [19-21] ]
with minimum damages to surrounding structures and collateral vessels in LC patients. Similarly, direct
access with minimal adhesiolysis to the working space can be enabled, especially in small surface LRLR
[Figure 1] [22-24] . It could be an advantage of LRLR over open repeat LR [24-27] .

This review describes the current status of LRLR for HCC from the result of our multi-institutional study
and our own experiences.

THE PROPENSITY SCORE MATCHING STUDY FOR HCC PATIENTS
We conducted the first international propensity score matching study comparing LRLR to open repeat LR
[28]
for HCC patients with 1,582 registered cases from 42 centers. LRLR was feasible for selected patients
and not inferior to open procedure in both short- and long-term results of the study. The conversion rate
of LLR patients in this study on an intention to treat basis was low (3.8%), which might be caused by the