Laparoscopic liver resection for hepatocellular carcinoma is gaining acceptance

Abstract

© Digestive Medicine Research. All rights reserved. Dig Med Res 2021;4:22 | https://dx.doi.org/10.21037/dmr-21-44 Laparoscopic liver resection (LLR) has evolved dramatically in the last years with an increasing number of centers adopting this surgical approach worldwide (1). Though technically demanding, LLR is becoming extensively used following the evolution of the recommendations from different consensus conferences, from Louisville in 2008 (2) and Morioka in 2014 (3) to Southampton in 2017 (4). When compared with open resection, LLR has repeatedly shown a reduction in complication rates, blood loss, need for transfusion and hospital stay (1). Surgical treatment of hepatocellular carcinoma (HCC) has specific features due to the fact that most HCC arise in cirrhotic livers mainly in Western countries (5). Liver resection in cirrhosis increases the risk of developing significant complications, such as hepatic failure, ascites and encephalopathy, that may affect survival (6). LLR for the treatment of HCC has shown a reduction in overall morbidity, including the development of ascites, liver failure and respiratory complications, with improved overall survival, but not disease-free survival (7,8). After some initial reluctance, there is currently no doubt that LLR is feasible and result in excellent surgical outcomes when performed by experienced surgeons. According to a recent Asian Pacific consensus conference, minor LLR is a preferred practice for HCC at experienced centers, while major LLR for HCC should be performed in centers of excellence (9). In addition, oncological results after minor LLR for HCC are at least comparable to the open approach, while evidence in favor of major LLR is not as strong, particularly in cirrhotic patients (10). Anatomical resection in patients with HCC has been related to an improvement in survival. A recent metaanalysis showed a significant improvement in one-, threeand five-year disease-free survival after anatomical open liver resection when compared to non-anatomical resection (11). In this study, complication rates and early mortality were comparable despite an increase in blood loss after anatomical surgery. The potential benefit in survival of the anatomical approach has also been observed in HCC with microvascular invasion (12). Nevertheless, not all studies have shown homogeneous results. Marubashi et al. failed to demonstrate any benefit in survival in a propensity scorematching study comparing 329 open anatomical resections for HCC versus 329 non-anatomical resections (13). Anatomical LLRs for HCC are also gaining widespread acceptance in experienced centers (14). The potential benefit of the anatomical laparoscopic approach has been observed even in large HCC. In this sense, a recent study showed a significant benefit in three-year disease-free survival with significantly less intrahepatic recurrence after anatomical laparoscopic resection, though with increased time of surgery and blood loss (15). Apart from the potential superiority of anatomical resection, there are still some other important matters to be defined in the use of minimally invasive approach in HCC: the role of indocyanine green fluorescence, the potential Editorial