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Morise. Hepatoma Res 2020;6:79 I http://dx.doi.org/10.20517/2394-5079.2020.76 Page 3 of 6

patient selection. The fact that LRLR was currently adopted to patients of poor general and liver condition
but with favorable factors related to tumors and surgical procedures was also shown. Notable differences
between centers in the number and percentage of LRLRs were revealed. The number of LRLRs in each
center ranged from 0 to 67 (median 10) and the rate among all cases was from 0% to 100% (median 57.1%).
Furthermore, no correlation was found between the number and percentage (P = 0.349). It is thought to
be because indications differ depending on each center’s experience with different patient populations in
terms of the prevalence of HCC, although all are high-volume centers of LR. LRLR for HCC is currently
adopted only for patients with favorable characteristics depending on each center’s experiences. It means
that this procedure is still in its developing stage. All patients after matching, in comparison to those before
matching, had better general and liver conditions, as well as tumors and surgery-related conditions. The
patients after matching were favorable patients who would have been eligible for either LRLR or open
repeat LR depending on the experience of each center.

The survival curve of LRLR patients after matching was clearly separated and better than that of open
patients, although without significant difference (median 12.55 years vs. 8.94 years; P = 0.086). On the other
hand, disease-free survival after matching and overall survival before matching in laparoscopic and open
repeat LRs were similar. Although LRLR patients before matching were selected with poorer liver function,
matched LRLR patients had better liver function and might have been able to undergo repeated treatments
due to less adhesion and liver function deterioration caused by laparoscopic approach. Although resection
margin should be one of the important factors for long-term results of LR theoretically, the optimal
[29]
resection margin for HCC remains controversial . In our study, 6.25% of the data for resection margin
could not be retrieved, and unfortunately this factor was not in the propensity-score matching analysis.
However, among the patients with sufficient data, the rates of R1 resection in the original groups of open
and laparoscopic repeat LR were 16.1% and 6.3%. The rate in open group is comparable to and that in LRLR
is lower than previous reports [29,30] . It is speculated that the status of resection margin in LRLR is not, at
least, inferior to that in open, although this difference in our study may partially be caused by the fact that
LRLR is currently adopted to patients of favorable factors related to tumors and surgical procedures.

For the short-term results, the study showed that LRLR was accompanied by less blood loss and a longer
operation time. Decreased morbidity is considered as one of the advantages of LLR for HCC patients [22-25] .
However, our matched patients have favorable liver function, and, thus, the impact of LLR might be
lower. The differences in hospital stay between centers/areas, possibly due to insurance systems and
hospitalization practices, were large and, thus, no difference should have been observed in hospital stay.

Currently, there is no randomized-control trial for open and laparoscopic repeat resection and only four
propensity-score matching studies [Table 1] [31-33] . Besides our study, the studies include patients with other
diseases than HCC with few data for long-term results. However, adding of only a few existing meta-
analyses [34,35] , they all mentioned that LRLR for selected patients is feasible with, at least, comparable results
to open procedure.

OUR OWN EXPERIENCES
Until 2019, we experienced 34 LRLR and 12 cases of three or more (up to five) times repeat LR [Table 2].
There are no cases with combined resection of another organ or LLR for two or more segments in repeat
cases. In the comparison excluding first LLR cases with same features as well, there are no significant
differences in operation time, blood loss, hospital stay, conversion, and morbidity rates among first, repeat,
and three or more times repeat LLRs. This is different from the situation of open repeat LR. Open repeat LR
takes generally more operation time and blood loss. This may be caused from that laparoscopic direct access
to working space, after minimal adhesiolysis, can be enabled especially in small surface LRLR [Figure 1] [22-24] .
We think it could be an advantage of LRLR over open repeat LR [24-27] . However, conversion rate and