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Kilburn et al.                                                                                                                                                                                 Laparoscopic resection of HCC

           INTRODUCTION                                       in the abdominal wall, hilum and retroperitoneum, and
                                                              a stiffened liver that resists laparoscopic handling.
           Hepatocellular  carcinoma  (HCC)  is  the  fifth  most   However, laparoscopic resection of HCC in both non-
           common cause of cancer and the third most common   cirrhotic and cirrhotic patients can provide good clinical
           cause of cancer-related death worldwide. Furthermore,   outcomes, act as bridge-to-transplant and deliver
           it is the leading cause of death for patients with   acceptable survival rates. [19]
           cirrhosis. [1,2]  In North America and Europe, the incidence
           of HCC has been rising, likely due to changing risk   The worldwide experience in laparoscopic liver resection
           factors for  cirrhosis, including  hepatitis  C  infection  in   for HCC is increasing, although major resections are
           baby-boomers, alcohol use, obesity, and non-alcoholic   still limited to few centers. The current study describes
           fatty liver disease. [3,4]  At presentation, only 10-15% of   our experience in Brisbane,  Australia, with focus on
           patients are candidates for surgical resection. Other   perioperative outcomes.
           treatment options include liver transplantation, ablation,
           transcatheter artrial chemoembolisation, and systemic   METHODS
           chemotherapy. Liver resection, more commonly
           reported as an open procedure, is a well-established,   Data acquired from a prospectively collected
           potentially curative treatment for patients with HCC,   laparoscopic liver surgery database from multiple
           and is the procedure of choice in many patients with   centers  in  Brisbane,  Australia,  were  examined  and
           preserved liver function. [5,6]                    retrospectively reviewed. Ethics approval was obtained
                                                              prior to the commencement of the study. Consecutive
           Minimally invasive management of HCC is increasing   patients  who  underwent  laparoscopic  resection
           in  frequency,  including  patients  with  underlying   of HCC between January, 1999 and September,
           cirrhosis. [2,7-11]  There  may  be  a  number  of  benefits  of   2015 were selected.  All patients underwent high
           laparoscopy over laparotomy for HCC, which have been   quality preoperative imaging with contrast-enhanced
           widely  reported.  Potential  benefits  include  decreased   computer tomography and magnetic resonance
           blood loss and need for blood transfusion, decreased   imaging. Selection for laparoscopic resection took into
           complications (i.e. less postoperative ascites, wound   consideration tumor size and location, the degree of
           infection),  decreased  length  of  stay,  and  reduced   underlying liver disease and portal hypertension, and
           technical  difficulty  with  subsequent  surgery,  including   the patient’s fitness and ability to tolerate a prolonged
           transplantation. [2,9,10,12,13]  Oncological principles can   pneumoperitoneum. Patients with Child-Pugh B and
           be maintained with laparoscopy and outcomes are    C cirrhosis were generally excluded. All patients were
           comparable, if not better, with laparoscopy compared   discussed and management was agreed upon at a
           to open HCC resection. [13-17]  The  benefits  may  derive   multi-disciplinary team meeting.
           from  the  pathophysiological  changes  that  occur  with
           laparoscopy compared to laparotomy, which may      Collected intraoperative data included details of the
           be accentuated in the presence of cirrhosis.  These   surgical procedure (minor vs. major; anatomic vs. non-
           include less disruption of the abdominal wall, reduced   anatomic), operation duration, blood loss and conversion
           immune response, and the tamponade effect of       to laparotomy.  A wide range of clinicopathological
           pneumoperitoneum.                                  factors were collected regarding underlying liver disease
                                                              (METAVIR score), etiology, number and size of tumors,
           Laparoscopic resection of HCC is technically       lymphatic or vascular invasion, tumor differentiation,
           challenging.  It  requires  both  laparoscopic  skills  and   presence of satellite nodules, and pathological margins.
           advanced liver surgical skills.  The limited viewing   A microscopic margin of ≥ 1 mm was defined as R0.
           angles, fulcrum effect of laparoscopic ports, instrument
           clash, reduced tactile feedback, and reduced operating   Surgical technique had been described previously. [20,21]
           dexterity pose significant challenges in complex surgery.   In brief, pneumoperitoneum was established via an open
           Liver exploration and mobilization, hemorrhage control   access technique and maintained at 12-15 mmHg. Four
           during parenchymal transection, the use of laparoscopic   to 6 working ports were used. The Pringle maneuver
           ultrasound,  ensuring  adequate  oncological  margins,   was used selectively. In selected patients with dome
           and  suturing  can  be  more  difficult  with  laparoscopy,   lesions, additional intercostal and transthoracic trocars
           especially in the presence of cirrhosis.  The operative   were used. For major hepatectomies, inflow vascular
                                            [18]
           time  is  generally  longer  than  open  surgery.  Skilled   structures were controlled with clips or vascular staplers
           assistance is essential, and for long cases surgeon   and the hepatic veins were controlled extrahepatically.
           and assistant fatigue is common. The cirrhotic poses   Parenchymal  transection was  performed  using
           additional complexity with potentially altered vasculature   LigaSure  (Covidien,  Mansfield,  MA,  USA),  harmonic
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