**9. Results**

Between January 1st 2010 and January 1st 2021, more than n = 300 consecutive hepatectomies were performed in three referral hepatobiliary centers in Greece, from affiliated surgeons. Patients included in this study was treated for hepatocellular carcinoma and were treated with curative intent (hepatectomy). Adult patients that underwent elective operations were enrolled. All emergency operations or operations for other liver malignancies were excluded.

*Surgical Therapy of Hepatocellular Carcinoma: State of the Art Liver Resection DOI: http://dx.doi.org/10.5772/intechopen.100231*

N = 170 patients underwent liver resection for HCC during the study period. Mean age was 75 years (Range: 20–85). There were 115 males and 55 female patients. Etiology of liver disease was liver cirrhosis in most cases, due to alcoholic liver disease (ALD) (23.5%), hepatitis B (HBV) infection (42.35%), hepatitis C (HBC) infection (17.64%) and hepatic steatosis (16.4%). Most of the patients (n = 99, 55%) were BCLC-A patients, while n = 71 (45%) patients were BCLC-B or BCLC-C staged. N = 89 patients (52.35%) passed away during the follow-up. Post-operative complications according to Clavien-Dindo classification, were grade I in 54.66%, grade II in 24% and III-IV in 17.33% of the cases, respectively. Thirty and 90-day mortality rates were 1.13%. Mean length of hospital stay was 17.5 days. Mean OS was 46.66 months, while mean PFS was 31.56 months. OS figures for 1, 3 and 5 years was 87.14%, 64% and 42% respectively.

This data indicates that liver resection for HCC with utilization of the combined technique of saline-linked radiofrequency ablation and ultrasonic aspiration, is safe and feasible, leading towards bloodless liver resection without the use of vascular occlusion, ensuring that surgical treatment for HCC becomes comparatively safer (**Figure 8**).

**Figure 8.** *Right hepatectomy for HCC in a cirrhotic patient.*

#### **9.1 Minimally invasive liver resection**

Minimally invasive liver resection is on the rise. However, the majority of performed operations are minor or limited resections in highly selected patients, from experienced hepato-biliary surgeons. The first laparoscopic liver resection was reported in 1991 [40], was referred to excision of peripheral hepatic lesions. Anatomic resections such as left lateral hepatectomy were followed thereafter [41]. The first series of laparoscopic hepatectomies were published in 1998 by Hüscher et al. [42] using totally laparoscopic and hand-assisted (hybrid) approach for right-sided liver resections.

Although it has several theoretical advantages, only a small percentage of liver resections are performed by minimally invasive surgery. A French national database study, published in 2014, presented that only 15% of liver resections were performed through minimally invasive approach [43].

Minor laparoscopic resections in anterolateral segments, as well as left lateral sectionectomy are considered the gold-standard approach in the hands of experts nowadays [44]. On the other hand, excision of bilateral lesions or lesions in posterosuperior segments or in central locations of the liver (segments 1, 4a, 7, and 8), and mostly major hepatectomies are still considered rather challenging. Another key factor is the learning curve for minimally invasive liver resection, that can reach up to 75 operations [45].

Robot-assisted surgery has been gradually adopted as an alternative to laparoscopy, mainly in complex and major liver resections [46]. Despite all the potential advantages, most of the available evidence present no superiority of robotic assisted comparing to laparoscopic liver resections [47].

### **10. Conclusion**

Hepatocellular Carcinoma (HCC) is the most frequent primary liver tumor. Well-established risk factors include chronic hepatitis B and C, non-alcoholic liver cirrhosis and liver steatosis amongst others, leading to impaired liver function in most cases. Surveillance programs and multi-disciplinary team approach aim to early diagnosis and effective therapy. Liver resection is the mainstay of treatment for HCC. All efforts are made towards bloodless hepatectomies, with adoption of newer techniques and evolvement of existing approaches. Laparoscopic or robotic liver resection can offer all the advantages of minimally invasive surgery in the hands of experts and for specific group of patients. Our technique of liver resection for HCC consists of saline-linked radiofrequency ablation and ultrasonic aspiration, is safe and feasible, leading towards bloodless liver resection without the use of vascular occlusion, ensuring that surgical treatment for HCC becomes comparatively safer in specialized hepatobiliary cancer centers.

*Surgical Therapy of Hepatocellular Carcinoma: State of the Art Liver Resection DOI: http://dx.doi.org/10.5772/intechopen.100231*
