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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
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