**8. Our technique**

We have been performing liver resection routinely for the past 30 years. The first attempt towards a bloodless and uneventful hepatectomy was the formation of a proper HPB Unit, formed by specialist surgeons, dedicated anesthetists, ICU beds and experienced radiologists (invasive). Gradual implementation and enhancement of the new techniques followed. In the beginning, finger fracture/crash clamp technique was performed in all cases of liver resection, with the addition of electrocautery and argon beamer as adjuncts. Following that, from the beginning of 2000s, we adopted and evolved the RF-assisted liver resections, with favorable outcomes during numerous hepatectomies. However, we moved to the two surgeons' technique with newer abdominal retractors (Thompson Liver / Oncology System) since 2006; our transection tools have been standardized to implementation of CUSA for dissection of liver parenchyma and Aquamantis for hemostasis (**Figures 1** and **2**).

For major hepatectomies the ipsilateral major hepatic veins were encircled within vessel loops. When an anatomic resection was planned, hilar dissection was performed (**Figure 3**).

The ipsilateral branch of hepatic artery, portal vein, and common bile duct were encircled within vessel loops, but not divided, until the parenchymal dissection reached that point. Hilar dissection was not performed for non-anatomical hepatectomy. During major hepatectomies, the ipsilateral hepatic artery, portal vein branches and bile duct branches were ligated intra-hepatically during parenchymal transection. In addition, for major hepatectomies, the major hepatic veins were either suture-ligated and divided or divided using endovascular staplers at the end of parenchymal transection (**Figures 4**–**8**).

Drains are routinely placed in all patients.

**Figure 1.** *Demarcation line using monopolar cautery.*

**Figure 2.** *Liver transection with CUSA and Aquamantis.*

**Figure 3.** *Hilar dissection.*

Anatomic and non-anatomic hepatectomies, wedge resections and liver ablations are routinely performed for the treatment of HCC from our team. Anatomic resections are selected in patients with unilobular disease and adequate liver function. Major hepatectomies include right and left hepatectomies, as well as extended right and extended left hepatectomies or trisectionectomies. Non-anatomic

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

resections and liver ablation can be performed for smaller lesions, multilobular disease, in patients with previous hepatic resection (recurrence) or in cases with severely impaired liver function. Parenchymal sparing is crucial for maintaining adequate liver remnant post hepatectomy for these patients. In addition, vascular reconstructions in cases with vascular infiltration is possible in specific cases, as ex-vivo hepatectomy with auto-transplantation in cases of locally advanced/ unresectable disease.

**Figure 4.** *Dissection of segmental branches.*

**Figure 5.** *Transection with vascular stapler.*

**Figure 6.** *Remaining liver parenchyma post right hepatectomy.*

**Figure 7.** *Use of hemostatic-fibrin glue and final inspection.*
