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Kilburn et al.                                                                                                                                                                                 Laparoscopic resection of HCC

            Table 3: Postoperative and histopathological data
            Postoperative and               All patients            Non-cirrhotic             Cirrhotic
            histopathological data
            Length of hospital stay, days,    5 (1-72)                5 (3-13)                5 (1-72)
            median (range)
            Mortality, 90-day, n (%)           1 (1.9)                 0 (0)                    1 (3)
            Overall morbidity, n (%)           7 (13)                  2 (11)                  5 (15)
             Infection                         3 (6)                   1 (6)                    2 (6)
             Ascites                           3 (6)                   0 (0)                    3 (9)
             Bile leak                         1 (2)                   1 (6)                    0 (0)
            Tumor margin, mm, median             9                       5                      15
            Margin status, n (%)
             R0                               48 (92)                 17 (94)                  31 (91)
             R1                                4 (8)                   1 (6)                    3 (9)
            Tumor size, mm, median (range)   33 (5-220)              40 (20-150)             28 (5-220)
            Number of tumors, median (range)   1 (1-5)                 1 (1-2)                 1 (1-5)
            Multifocality, n (%)              17 (33)                  2 (11)                  15 (44)
            Tumor differentiation, n (%)
             Well differentiated              13 (25)                  6 (33)                  9 (26)
             Moderately differentiated        36 (70)                 11 (61)                  23 (67)
             Poorly differentiated             3 (5)                   1 (6)                    2 (6)
            Vascular invasion, n (%)          17 (33)                  8 (44)                  9 (26)
            Lymphatic invasion, n (%)          4 (9)                   1 (6)                    3 (9)
           Subsequent  cases  involving  dome  lesions  were   different  between  patients  with  and  without  cirrhosis.
           preferentially performed with a combined transthoracic   Apart  from  the  single  post-operative  mortality,  all
           and transabdominal approach.                       complications were Clavien-Dindo grade 1 or 2.

           Median operative time was 120 min and median blood   Multifocal HCC was far more prevalent in cirrhotics
           loss was 300 mL. Patients with cirrhosis experienced   compared with non-cirrhotics (44% vs. 11%, P = 0.008).
           more bleeding than those without (median 350 mL in   Multifocality  was  generally  diagnosed  incidentally  on
           cirrhotics vs. 150 mL in non-cirrhotics, P = 0.049). The   pathology  of  the  resected  specimen  as  patients  with
           median length of stay was 5 days and was not different   multifocal disease were excluded from resection.
           between the cirrhotic and non-cirrhotic groups.    Microvascular invasion was present in 17 patients
                                                              (33%). Equivalent R0 resection  rates  were achieved
           Postoperative and pathological data are summarized in   for cirrhotics and non-cirrhotics (94% vs. 91%). Despite
           Table 3. There was 1 mortality, which occurred early in   the higher rate of subsegmental resections, the median
           the series. The patient had Child-Pugh B cirrhosis and   margin in cirrhotics was 15 mm compared with 5 mm in
           underwent a left lateral sectionectomy. Blood loss was   the non-cirrhotics (P = 0.067).
           1,600 mL and this patient died due to decompensated
           liver  failure.  Overall  7  patients  (13%)  developed  a   Median  follow-up  was 41 months.  Median  overall
           postoperative complication.  Morbidity  rates were not   survival was 89 months. Overall survival for the entire
                                                              cohort at 1, 3, and 5 years was 88%, 81%, and 61%,
                10                                            respectively  [Figure 2].  The corresponding survival
                       Non-cirrhotic                          for  non-cirrhosis  patients  was  93%,  77%,  and  67%,
                       Cirrhotic
                 8     Total                                  and  for  patients  with  cirrhosis  was  86%,  83%,  and
              Number of patients  6 4                         patients, 43% for non-cirrhosis, and 71% for patients
                                                              50%. Disease-free survival at 5 years was 57% for all
                                                              with cirrhosis.

                                                              DISCUSSION


                0 2                                           Laparoscopic  liver  resection  is  a  technically
                  1999  2001  2003  2005  2007  2009  2011  2013  2015  demanding operation.  The presence of cirrhosis
                                                              increases the operative difficulty, and is considered a
                                    Year
                                                              relative contraindication to laparoscopic resection in
           Figure 1: Annual frequency of laparoscopic resection of HCC.   some centers.  To our knowledge, there are no data
           HCC: hepatocellular carcinoma                      suggesting poorer outcomes for patients who undergo
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