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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
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