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Morise et al. Repeat LLR for recurrent HCC in cirrhotic liver

A B HCC/CLD patients often undergo minor resection of the
hard, fibrotic liver, which has a poor functional reserve
and is surrounded by blood or lymphatic collateral
vessels, which should be preserved. The number of
reported repeat LLR cases for HCC/LLR patients is very
small, and these are summarized in Table 2.

There are three previous reports of repeat LLR focused
C for HCC/CLD patients. Belli et al., Hu et al., and
[15]
[13]
Kanazawa et al. reported 12, 6, and 20 cases,
[22]
respectively. They all concluded that repeat LLR
for recurrent HCC in cirrhotic patients is a safe and
feasible procedure. Belli et al. reported that the
[13]
surgical time for repeat LLR was shorter and the
adhesiolysis was easier for patients previously
Figure 4: Intra-operative findings after resection (A), pathological
findings (B), and examination of the resected specimen (C). (A): treated using LLR compared to open LR (OLR),
The area was resected laparoscopically, with the Glissonian branch and also detailed the advantages of the minimally
of subsegment 4c being exposed on the bottom of the transection invasive approach for managing the chronic oncologic
plane. The sites labelled 4a and 4b indicate the stumps of the [22]
Glissonian pedicles of subsegments 4a and 4b. The site labelled 4c sequelae of cirrhosis. Kanazawa et al. compared
indicates the Glissonian branch supplying subsegment 4c, exposed repeat LLR to repeat OLR in n = 20 groups of patients
on the bottom of the transection plane. (B): Pathologically, the three and concluded that postoperative morbidity and the
tumors were well-differentiated hepatocellular carcinomas with
fibrous capsules but without vessel invasion, surrounded by stage duration of postoperative hospitalization have been
F4 tissue (liver cirrhosis) decreased by the introduction of LLR for patients with
recurrent HCC.
DISCUSSION
We previously reported that LLR is useful for
The development of post-operative adhesion is known patients with severe liver dysfunction, as it minimizes
to increase the surgical time in subsequent surgeries, disturbance of the collateral blood/lymphatic flow
as a result of the need for adhesiolysis, the risk of caused by laparotomy and liver mobilization, and
intraoperative complications and the possibility of the mesenchymal injury caused by compression
[24]
[31,32]
conversion from laparoscopic procedure to laparotomy. of the liver. Thus, LLR limits the occurrence of
[25]
Although a history of abdominal surgery had been complications, such as massive ascites, which can lead
[3]
considered a contraindication for laparoscopic surgery to postoperative liver failure. We also reported that the
in the early days of the procedure, improvements in smaller working space required for LLR necessitated
technique and instrumentation have more recently less adhesiolysis, with a direct approach to the region
[20]
permitted many laparoscopic procedures to be affected by the tumor being possible in repeat LLR.
safely applied to such patients. [24,26-29] However, LLR This also meant that patients undergoing repeat LLR
remains a technically demanding procedure and had similar perioperative results to patients without
the indications for and efficacy of repeat LLRs are a history of surgery, especially in the case of minor
still under discussion. Successful liver resection resections for HCC/CLD patients. The majority of the
requires adequate adhesiolysis and mobilization of patients described in previous reports of repeat LLR
the involved liver area. Adhesions can be obstacles to for HCC/CLD underwent minor resection as a repeat
the visualization and dissection of the hepatoduodenal LLR. Therefore the influences of alterations to hilar
ligament and hilar area, which are often crucial steps and intrahepatic anatomy from the first hepatectomy
in LLR. Liver capsule bleeds easily during adhesiolysis should have been relatively small. Since alterations
and mobilization, creating a suboptimal surgical field, in hilar and intrahepatic vascular supply would
in addition to the increase in blood loss. [30] greatly impact on the second hepatectomy, further
consideration of a role for major or anatomical repeat
The outcomes of repeated LLRs have been reported LLR is needed. However, results to date suggest that
in several small case series. [13-16] However, these a clear advantage of LLR for minor repeat resections
studies often included both HCC/CLD and metastatic of impaired liver is that it only requires minimal
patients, [17-21] while the clinical settings for repeated LLR adhesiolysis.
are quite different in HCC/CLD and metastatic patients.
Patients with metastasis sometimes undergo major liver In the case reported here, the patient underwent
resection involving the handling of Glissonian pedicles four LLRs over six years without severe deterioration
in soft, congested and/or fatty parenchyma. Conversely, of liver functional reserve, represented by the
256 Hepatoma Research ¦ Volume 2 ¦ September 19, 2016