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Cho et al. Laparoscopic hepatectomy in cirrhosis

non-surgical setting, it is necessary to validate MELD advantages compared to non-anatomical liver resection
score in patients undergoing liver resection. for HCC in terms of patient survival and recurrence. [42,43]
HCC recurs after resection mostly in the liver because
The indocyanine green (ICG) test is one of the most HCC can spread along the portal branches by
commonly used liver reserved function test in Asia- microscopic vascular invasion, which contributes to
Pacific region. The cut-off value of ICG retention rate the poor prognosis of HCC. On this basis, anatomic
[44]
at 15 min for safe major liver resection is less than resection including the whole segment according to
14%. However, it is unclear whether this cut-off the portal tributaries could remove small microscopic
[33]
value is also applicable to patients with liver cirrhosis. metastasis and prolong patient survival and disease
free survival. Anatomical monosegment ectomy of
[45]
LLR IN PATIENTS WITH CTP CLASS B OR C segments 6 or 7 is extremely difficult even in open
surgery. For deep seated large tumor in segments
[46]
Liver cirrhosis is one of risk factors for developing 6 or 7, laparoscopic right posterior sectionectomy
postoperative morbidities after hepatectomy. will be chosen for more resection margin because
[34]
Severe blood loss or prolonged ascites after major segmentectomy or tumorectomy could be insufficient.
hepatectomy, especially by open surgery, can occur For deep seated tumor near to right hepatic vein,
by interruption of collateral circulation in the parietal laparoscopic extended right posterior sectionectomy
wall and surrounding ligamentsin patients with liver (resection of right posterior section together with right
cirrhosis. These complications may prolong the hepatic vein) can be alternative treatment instead of
[35]
postoperative hospital stay or cause hepatic failure right hemihepatectomy. [47]
in some patients. However, LLR may minimize the
reduction in collateral and lymphatic flow caused ONCOLOGIC OUTCOMES OF LLR IN
by laparotomy and mobilization, and may reduce PATIENTS WITH LIVER CIRRHOSIS AND ITS
compressive mesenchymal injury, as demonstrated CHALLENGES
in previous studies of patients undergoing LLR of
HCC. [36,37] The benefits of LLR in this setting include Several recent studies have compared the oncologic
earlier ambulation, less postoperative pain, earlier outcomes between LLR and open liver resection.
feeding, and a less postoperative complications. Other These studies showed that LLR was associated with
important advantages of LLR in patients with liver lower morbidity and mortality rates, but not 5-year
cirrhosis are the lower incidences of postoperative overall and disease-free survival rates. [48-50] In addition,
liver failure and ascites due to minimal invasiveness of the most up-to-date and comprehensive systematic
LLR, which helps to preserve collateral circulation. review and meta-analysis prepared at the second
[13]
Therefore, laparoscopic hepatectomy may be a good international consensus conference on LLR highlighted
option in patients with cirrhosis. [38] a reduction in the rates of postoperative ascites and
liver failure following LLR in cirrhotic liver. [51,52]
Most studies consider CTP class B or C cirrhosis
to contraindicate liver resection, and surgeons face Radiofrequency ablation is a compelling alternative to
a considerable challenge in treating patients with liver resection in patients with liver cirrhosis, especially
uncompensated cirrhosis. There have been a few in terms of the overall morbidities. In patients with
reports describing the oncological outcomes of patients peripherally located lesions, percutaneous ablation
with CTP class B or C cirrhosis. A recent retrospective may carry a high risk of tumor seeding while LLR
[39]
study of 16 patients with CTP class B or C cirrhosis who can be safely performed and may permit pathological
underwent LLR showed that LLR did not compromise assessment of tumor biology and of the surrounding
the oncological outcomes of patients with HCC and liver parenchyma. One propensity score matching
[53]
clinically significant cirrhosis. Recently, precoagulation analysis showed that liver resection offered a consistent
[40]
technique before parenchymal transection, intermittent survival benefit and did not increase the incidence of
Pringle maneuver during resection, and hybrid technique major complications compared with radiofrequency
using hand port were proposed to decrease the technical ablation in patients with hepatitis B virus-related HCC
difficulty of LLR in cirrhotic liver. [41] and portal hypertension. [54]

ANATOMICAL VERSUS NON-ANATOMICAL CONCLUSION
RESECTION
LLR has a vital role to play in the first-line treatment of
There are still many controversies, but many surgeons HCC in selected patients with compensated cirrhosis
believe that anatomical liver resection has some and portal hypertension.
Hepatoma Research ¦ Volume 2 ¦ September 30, 2016 261