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Cho et al. Laparoscopic hepatectomy in cirrhosis

Asian countries, especially, have a disproportionately in patients with very poor hepatic reserve, non-
high prevalence of HCC, mainly because chronic anatomical minor liver resection such as tumorectomy
hepatitis B and C viruses are endemic in these is usually performed. However, it is sometimes very
countries, and are associated with high risks of liver difficult and unexpected huge bleeding from hepatic
[4]
cirrhosis and HCC. [5] vein could occur because the operative field is poor,
intra-abdominal free space is narrow for manipulation
Liver transplantation (LT) appears to be the most of many instruments, and the transection line can be
attractive treatment option because it treats both curved or angled. LLR for HCC in the posterosuperior
[24]
the cancer and the underlying disease. However, LT segments in selected patients was reported to be as
is limited by its high cost and the burden of lifelong safe and feasible, and offered comparable oncologic
immunosuppression. [6,7] Furthermore, the scarcity outcomes to open liver resection. Moreover, LLR has
of donors does not permit LT in all patients with other benefits, including reduced blood loss, fewer
early HCC. With recent technical advances and complications, and shorter postoperative hospital stay
[2]
improvements in postoperative patient management, than open liver resection. [25]
liver resection for HCC is now considered to be a
safer procedure than it was in the past. [8-11] Therefore, SELECTION OF SUITABLE PATIENTS
liver resection is currently regarded as the first-line
treatment in many centers for HCC, especially in When considering liver resection in patients with cirrhosis,
patients with compensated cirrhosis. [12] both surgical stress and the oncologic outcomes
should be considered. Similar to open surgery,
[13]
Since the first report of laparoscopic liver wedge uncompensated cirrhosis is generally considered to be
resection, steadily increasing numbers of small case- a contraindication for liver resection and hence LLR.
[26]
series have demonstrated the feasibility, adequacy, Uncontrolled portal hypertension, including esophageal
and safety of laparoscopic liver resection (LLR). [13-16] varices and low platelet count, is usually considered
Now, LLR is commonly performed in patients with as a contraindication for LLR. Because patients with
[27]
HCC and chronic liver disease. HCC usually have associated chronic liver disease
or cirrhosis, these patients may be predisposed to
The aim of this review was to assess the current hepatic failure after surgery. Therefore, it is important to
indications, advantages, and limitations of LLR for HCC preoperatively predict the patient’s liver remnant volume
in patients with cirrhosis. We also discuss the feasibility of and liver function after surgery before selecting the
LLR and its oncologic outcomes relative to open surgery. type and extent of liver resection. The hepatic reserve
functional capacity is estimated before liver resection to
INDICATIONS facilitate patient selection and predict the safety margin
of parenchymal resection in individual patients.
The indications for LLR have changed substantially
since its introduction. In the early stages of LLR, it was The Child-Turcotte-Pugh (CTP) score is a simple
limited to benign diseases. With increasing knowledge and the most widely used system for scoringhepatic
and experience of this procedure, its indications have function before liver resection. It is based on 5 easily
expanded to malignant diseases, including HCC measurable variables and, for more than 4 decades,
and colorectal liver metastasis. However, unlike has been considered the gold standard for selecting
[17]
laparoscopic cholecystectomy, laparoscopy has been candidates for liver resection. However, even CTP
[28]
limitedly used for liver resection due to the risk of air class A patients may develop liver failure after LLR. [29]
embolism and the difficulty of parenchymal dissection
and bleeding control. Therefore, LLR has been The model for end-stage liver disease (MELD) score
[18]
frequently performed for tumors superficially located was made to predict the survival of patients with
in the anterolateral segments. [19] severe portal hypertension and variceal bleeding who
underwent transjugular intrahepatic portosystemic
For HCC located in segment 7, right posterior shunt procedure, and then has been further
[30]
sectionectomy is choice of type of resection because developed for the selection of patients who are waiting
it can preserve more functional volume of the liver for LT. Several studies showed that the application
[31]
than right hepatectomy. However, right posterior of MELD score to predict mortality in patients who
sectionectomy is technically more difficult and underwent liver resection, not LT worked well, and
considered as major hepatectomy because it requires it may outperform the CTP classification in terms of
parenchymal dissection along the intersectional predicting operative risk before liver resection.
[32]
plane. [20-23] For HCC located in segments 7 or 8 However, because MELD score was developed in
260 Hepatoma Research ¦ Volume 2 ¦ September 30, 2016