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Kato et al. Hepatoma Res 2021;7:10 I http://dx.doi.org/10.20517/2394-5079.2020.129 Page 3 of 15

Table 1. Background patient and tumor characteristics
All Cases (n = 57) AR (n = 23) NAR (n = 34) P-value
Age, years 71 (20-82) 72 (20-82) 71 (54-82) 0.56
Sex, M/F 42/15 19/4 23/11 0.20
Liver function
TB, mg/dL 0.9 (0.3-1.7) 0.8 (0.8-1.3) 0.9 (0.3-1.7) 0.54
Alb, g/dL 4.0 (3.1-5.2) 4.0 (3.6-5.2) 3.9 (3.1-5.0) 0.77
AST, IU/L 29 (14-139) 25 (15-69) 35 (14-139) 0.16
ALT, IU/L 25 (9-158) 27 (10-82) 25 (9-158) 0.82
PT, % 92 (28-134) 92 (28-127) 93 (60-134) 0.92
4
PC, × 10 /mm 3 13.3 (5.2-23.5) 14.4 (6.9-23.5) 12.1 (5.2-23.1) 0.03 #
ICGR15, % 14.4 (2.6-82.4) 13.1 (3.6-22.6) 19.1 (2.6-82.4) 0.02 #
Liver cirrhosis (n) 54% (31) 35% (8) 68% (23) 0.01 #
Tumor characteristics
Tumor size, cm 2.1 (0.6-12.5) 2.5 (0.7-12.5) 1.8 (0.6-10.0) 0.002 #
Tumor number 1 (1-6) 1 (1-6) 1 (1-5) 0.53
Difficult segments (n) 53% (31) 65% (15) 47% (16) 0.17
AFP (ng/mL) 7.3 (2.0-5811.0) 4.8 (2.0-5811.0) 8.2 (2.0-2041.0) 0.33
DCP (mAU/mL) 26 (10-95560) 35 (11-30899) 23 (10-95560) 0.11
Recurrent tumors (n) 37% (21) 30% (7) 25% (14) 0.41
UICC Stage
IA, IB 32 10 22
II 19 9 10 0.03 #
IIIA, IIIB 4 4 0
IVA, IVB 2 0 2

AR: anatomic resection; NAR: non-anatomic resection; HCC: hepatocellular carcinoma; TB: serum total bilirubin level; Alb: serum
albumin level; AST: serum asparatate aminotransferase level; ALT: serum alanine aminotransferase level; PT: prothrombin time; PC:
serum platelet count; ICGR 15: indocyanine green retention rate at 15 min; Difficult segments: segments I, VII or VIII; AFP: alpha-feto
protein; DCP: des-gamma-carboxy prothrombin; UICC Stage: Tumor stages based on the Union for International Cancer Control TNM
#
classification; P < 0.05

biliary structures needing to be reconstructed. We selected open surgery for centrally located tumors of 10 cm
or larger with suspected invasion of the major hepatic veins. Between LLR and RLR, we do not have
selection criteria. However, cases needing the extirpation of portal vein tumor thrombi were assigned to
open or robotic approach only. Moreover, in cases where PVTT was not limited to the ipsilateral first-order
portal vein branch, we selected open surgery.

During this study period, in contrast to LLR, RLR was not covered by national insurance and was
performed at patients’ own expense in our institute. This economic standpoint, along with the availability
of the machine in the hospital, affected the selection of the resection approach in this study.

Selection of hepatectomy procedures or hepatectomy itself with regard to hepatic functional reserve and
remnant liver volume was performed in the same way in open, laparoscopic and robotic approaches. In
cases where severe adhesion was anticipated because of repeat liver resections, we chose the approaches
depending on the number and types of previous liver resections, location and size of the tumor, and
preoperative image findings.

Patient characteristics
The characteristics of the 57 HCC cases treated with RLR are shown in Table 1. Briefly, the median
patient age at the time of surgery was 71 years, and the majority of patients were male (n = 42; 74%). The
hepatic functional reserve of all cases was Child-Pugh class A. The median serum levels of preoperative
total bilirubin (TB), albumin (Alb), aspartate aminotransferase (AST), alanine aminotransferase (ALT),
prothrombin time (PT), and platelet count (PC) were 0.9 mg/dL, 4.0 g/dL, 24 IU/L, 25 IU/L, 92%, and
3
13.3 × 10 /mm , respectively. The median indocyanine green (ICG) retention rate at 15 min (ICGR15) was
4
14.4%. Liver cirrhosis was diagnosed in 31 patients by postoperative pathologic examination (54%).