**3.2.1 Patient selection**

Much of the patient selection process for resection of HCC centers around assessment of the underlying liver parenchyma. The Child-Pugh classification system provides a rough framework from which to base the selection process. In generally, Child A patients are able to tolerate limited forms of resection, while Child B and C patients are typically referred for more palliative procedures such as systemic therapy or transarterial chemoembolization. In the West, assessment is directed at determining the presence of significant portal hypertension. Generally, patients with hepatic-venous pressure gradient of less than 10, esophageal varices of no greater than grade 1, and platelet counts of over 100,000 are considered acceptable risk. In addition, bilirubin levels must be normal.

A common technique in Eastern centers is the assessment of indocyanine green clearance rate (ICG). This technique involves the injection of an organic dye which is then measured in the peripheral blood after a 15 minute interval. Clearance of the dye is used as a surrogate for hepatic metabolic function. ICG retention of no more than 10-20% is considered to be acceptable. Using this technique in 1056 consecutive patients with normal bilirubin and no ascites, Imamura has been able to achieve hepatic resection with zero operative mortality (Imamura, H et al 2003).

Advances in imaging technology have lead to the increasing use of systemic liver volumetry as a preoperative risk assessment tool. A future liver remnant to standard liver volume ratio of greater than 20% is considered safe in patients with healthy liver parenchyma, while ratios of 30-40% are considered necessary for patients with compensated cirrhosis. An insufficient future liver remnant may be addressed with the use of adjunctive techniques such as portal vein embolization, which will be discussed in greater detail in the section on resection in cirrhotics.

Tumor related factors that preclude surgical resection include extrahepatic disease and invasion of the main portal vein, vena cava, and common hepatic artery. Multinodular disease that can't be resected with an adequate future liver remnant is also a relative contraindication to resection, although there is a role for resection of the dominant lesion with radiofrequency ablation of the remaining disease in highly selected cases. Although size alone is not a criteria for resectability, there is a practical limit to the size of lesion that can be safely approached laparoscopically. The recent international position statement for laparoscopic liver surgery recommends limitation of the laparoscopic approach to tumors <5cm in diameter for all but the most experienced of centers (Buell, JF et al 2009a).

### **3.2.2 Technical considerations and oncologic adequacy**

Unlike the case of hepatic colorectal metastases, there does appear to be a benefit to wider surgical margins in patients with HCC. For patients with solitary HCC lacking vascular invasion, a margin of at least 2cm has proven beneficial in a randomized controlled trial setting. Furthermore, the tendency of HCC to spread via the portal venous system favors the use of planned anatomic resection in patients with adequate hepatic reserve. The inability to perform anatomic resection should not be considered a contraindication, however, as more

Laparoscopic Liver Resection 73

(Buell, JF et al 2009b). Prior to embarking upon beginning a program in laparoscopic liver surgery, it is necessary to acquire experience with both advanced laparoscopy and open hepatic surgery. These requirements have made the widespread adoption of laparoscopic liver surgery appropriately slow. As advanced laparoscopy becomes an increasingly important part of general surgery training programs, these prerequisites will become less of

After establishing the necessary expertise in laparoscopy and open hepatic surgery, the ideal starting point is small, benign lesions in the periphery of the liver. Extensive use of hand assistance is also critical in reducing the learning curve. Koffron has described the hybrid technique, in which mobilization of the liver is performed laparoscopically, and parenchymal transection is then performed in an open fashion through the hand port incision (Koffron, AJ et al 2007). He has termed this approach "laparoscopic liver surgery for everyone," and we agree that this approach represents an ideal starting point for a

Once comfortable with performing more limited resections, the next step in development is the performance of major, anatomic resections. In this setting, the left lateral segmentectomy is the ideal starting point. Although much attention is given to the parenchymal transection phase, it should be noted that the greatest risk for vascular injury and subsequent conversion to an open procedure is actually during the mobilization phase. The most commonly injured vessel in this setting is the phrenic vein, which must be carefully identified and avoided. Conversion, as we have emphasized previously, should not be viewed as a failure or complication. Instead, the decision to convert to an open or hand assisted procedure rather than continue with a potentially unsafe situation laparoscopically

Experience with resection of lesions located in the peripheral segments of the liver provides a foundation of skills, including mobilization, transection, hemostasis, and laparoscopic ultrasound. Once this fundamental skill set has been developed thoroughly, the surgeon is then able to proceed to more difficult lesions. At this point, malignant and/or large lesions located in the right and posterior segments of the liver can then be approached in the culmination of programmatic development. We have found that facility with minor resections can be achieved in 30 to 50 cases. More difficult resections such as formal lobectomy and right posterior resection require an additional 60 to 80 cases to master. Thus, the road to development of a laparoscopic liver resection program is long and often arduous, but is highly rewarding to both the surgeon and the patient when properly

Nearly 15 years after first being described, laparoscopic liver resection has been gradually gaining acceptance in a number of centers worldwide. As the necessary skills in advanced laparoscopy and hepatic surgery become more widespread, we anticipate that the further adoption of laparoscopic liver resection will increase more rapidly. The maturation of long term series have proven the oncologic adequacy of the laparoscopic approach in a variety of settings. With the development of a greater number of surgeons who are proficient in laparoscopic liver surgery, many more patients will benefit from decreased blood loss, less postoperative pain, and shorter lengths of stay. From being a novel procedure practiced in only a handful of centers worldwide, laparoscopic liver resection is now established as a

a hurdle, with the expected more rapid acceptance of laparoscopic liver surgery.

laparoscopic liver program.

is a mark of good surgical judgment.

travelled.

**6. Conclusion** 

limited resection as been shown to be beneficial in the setting of cirrhosis (Rahbari, NN et al 2011).

Despite the limitations imposed by the greater difficulties in technical resection and patient selection, laparoscopic resection has proven to be a safe and effective alternative to open surgery in appropriately selected patients. Lai has demonstrated 5 year survival of 50%, with disease free survival of 36%, while Dagher has shown 5 year overall and disease free survival of 64.9% and 32.2%, respectively (Dagher, I et al 2010; Lai, EC et al 2009). Others have shown laparoscopic resection to be associated with lower morbidity and postoperative ascites compared to open resection (Belli, G et al 2009b). Although hepatocellular carcinoma in the setting of cirrhosis represents the most difficult of diseases to approach via laparoscopy, these results show that the technique is safe and effective when performed in centers that have acquired the appropriate experience.
