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Otsuka et al.                                                                                                                                   Indications and technique for LLR in HCC with liver cirrhosis

           hepatoduodenal  ligament,  which develop  as a result   Robot-assisted technique  in LLR  has  been  attempted,
           of portal hypertension,  should  be minimized  in the   although the population of patients with liver cirrhosis
           cirrhotic liver.                                   is  quite  limited.   A  recent  report  suggested  that  the
                                                                            [38]
                                                              augmented dexterity and greater range of motion provided
           Parenchymal transection in cirrhotic liver is more   by endowristed instruments are helpful, especially in LLR
           hemorrhagic  than  in  non-cirrhotic liver, because  of   of posterosuperior segments of the liver. [39]
           loss  of  elasticity  due  to  fibrosis  and  regeneration  of
           liver tissue, the weakness of the altered intrahepatic   Specimen retrieval
           vasculature,  difficulty  in  identifying  intraparenchymal   After liver resection is completed, the removed specimen
           structures, coagulative disorders caused by liver   should be placed in a plastic bag, to avoid seeding and
           dysfunction, portal hypertension, and hypersplenism.   implantation of tumor cells in the operative field. Small
           Therefore, reduction of blood loss is a key to successful   specimens can be retrieved from a trocar wound made
           LLR.  Although controversial in laparoscopic surgery,   at the umbilical site. Larger specimens are retrieved from
           temporary or intermittent application of Pringle’s   an extended umbilical incision, suprapubic incision, or an
           maneuver,  use  of  a  vessel  tape  tourniquet  or  vessel   incision made at an incision site for a previous surgery.
           clamp,  can  help  reduce  blood  loss  during  liver
           parenchymal transection. While performing Pringle’s   OPERATIVE OUTCOMES OF LLR FOR HCC
           maneuver,  surgeons  should  be  careful  not  to  injure   WITH LIVER CIRRHOSIS
           collaterals around the hepatoduodenal ligament.
                                                              Short-term outcomes
           Pre-coagulation technique, in which the resection line   Liver resection for HCC  can be performed  in some
           is diathermically coagulated using a microwave tissue   patients with advanced liver disease. Post-hepatectomy
           coagulator or monopolar electrocautery before liver   morbidity is reported to be high, and long-term prognosis
           parenchymal transection, can help reduce blood loss in   is poor in patients with portal hypertension. [40-42]  Such
           cirrhotic liver. In anatomical hepatectomy, hepatic inflow   patients might be better served by liver transplantation
           vessels are  isolated  with tape traction and occluded   or ablation. [43]  However, some recent studies reported
           before liver parenchymal transection, to identify optimal   encouraging liver resection outcomes, even in patients
           segmental territory before liver transection. In liver   with portal hypertension. [21,44,45]  Therefore,  hepatic
           parenchymal transection, laparoscopic coagulating   resection may be regarded as the primary treatment
           shears are used to divide the superficial layer of the liver.   option for patients with mild portal hypertension, if liver
           Deeper transection should be performed by meticulously   transplantation is not possible.
           exposing intraparenchymal structures with an ultrasonic
           surgical aspirator or clamp-crushing technique. Vessels   Systematic  reviews  and  meta-analyses  of
           with a diameter of 3-7 mm are divided with vessel-sealing   nonrandomized comparative or case-control studies of
           devices or clips. Then, vessels with a diameter of 2 mm   HCC suggest that LLR results in less blood loss and
           or less are diathermically sealed using bipolar sealing   shorter postoperative hospital stays [46-49]  as compared
           devices and then divided. Hemostasis of the resection   with open hepatectomy. [50-54]  With respect to technical
           plane  is  achieved  with  monopolar  or  bipolar  cautery.   considerations, the reported conversion rate to open
           A  laparoscopic  stapler  is  used  to  divide  major  hepatic   surgery for LLR is 0-19.4%. [49,53,54]  Hemorrhage during
           vessels and for simple transection of liver parenchyma   hepatic parenchymal transection is the most frequent
           with a thickness of 1-1.5 cm. [36]                 reason for conversion. [49,53,54]   To control hemorrhage
                                                              during  liver parenchymal  transection, it is essential
           LLR is usually performed by pure laparoscopic procedure;   to  select the  appropriate surgical devices, including
           however,  there  are  options  for  a  minimally  invasive   diathermy precoagulation of the resection plane before
           approach.  Hand-assisted  and  laparoscopy-assisted   liver transection. [55]
           procedures are also occasionally used in technically
           challenging cases. A hand-assisted procedure is suitable   A  clear  benefit  of  minimally  invasive  surgery  is  that  it
           for resection of tumors located in the posterosuperior   minimizes abdominal wall trauma. LLR preserves collateral
           regions of the liver, to verify tumor margins in the limited   formation in the abdominal wall and thus results in lower
           operative  field  and  control  bleeding.  The  laparoscopy-  incidences  of  ascites  accumulation  and  postoperative
           assisted procedure divides the liver attachment by   liver failure, as compared with open surgery. [18,51,54]  Less-
           laparoscopy and transects the liver parenchyma through   incisional  procedures,  such  as  single-port  endoscopic
           a small upper abdominal incision under direct vision. It   surgery, are likely to be less destructive when performed
           can be used for major hepatectomy or LLR when dense   for carefully selected patients. [56]
           adhesion is present in the abdomen.  These approaches
                                         [37]
           may serve as a bridge to pure laparoscopic procedure.   Additionally, repeat hepatectomy for recurrent HCC
            244                                                                                                     Hepatoma Research ¦ Volume 2 ¦ September 19, 2016
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