**2. Selection of patients for right trisectionectomy of huge liver tumor**

Up to now, the treatment of huge liver cancers is still very difficult due to poor outcomes and higher mortality and morbidity [9–11]. A number of reports have indicated that right trisec‐ tionectomy is effective for extensive hepatic malignancy, based on patients who have had longterm survival after this operation [9,12,13].

The situations of tumor were detected mainly by image examinations, including B-type ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and angiography. To assess liver function of the patients before operation, we adopted the classic Child–Pugh classification, the ICGR test, and some concrete parameters, as described in standards [9].

The feasibility of right trisectionectomy for a given patient must be carefully evaluated according to the following criteria [9]: (1) tumor(s), including less than 2 satellite nodules, must be limited to the right lobe and left medial portion of the liver (there is no evidence of cancer invasion in left lateral segment); (2) tumor mass with clear borders or a pseudocapsule, and there is no tumor thrombus in the trunk of the portal vein and hepatic vein; (3) there is no evidence of distant metastasis; (4) compensatory enlargement of the left lateral section should

related HCC cases are from developing countries [1]. Recently, increasing trends in HCC incidence have been reported from several western countries, including France, Australia, and the United States, mainly because of the rising incidence of HCV [2]. At least one million new cases of HCC occur annually, and mortality from this disease remains high despite treatment. It was reported that 10–20% of newly diagnosed HCCs are >10 cm in diameter, which is commonly defined as huge HCC. Patients with huge HCC who survive more than 5 years were rarely reported in the literature. Recently, it is reported that a 5-year survival rate is less than 3–5% if without treatment. The mean overall survival rates via treatments at 1 year, 3 years, and 5 years are 66.1%, 39.7%, and 32.5%, respectively, 93.5%, 70.1%, and 59.1% for early-stage patients [1, 3–5]. Several novel strategies have been developed for the therapy of HCC in recent years, and the outcomes have taken marked progress. However, recurrence and metastasis rates remain high. Up to now, surgery, including hepatectomy and liver transplantation,

The developing history of hepatic surgery is strongly involved in the history of bleeding control during hepatic resections. In the early 1900s, a small but significant step forward was made in liver surgery by J. Hogarth Pringle [6], who in 1908 described a method for digital compression of the hilar vessels to control hepatic bleeding from traumatic injuries. Since the middle of the last century, right trisectionectomy (previous trisegmentectomy) has been used for huge hepatic neoplasms covering right and left medial section (Figure 1). In 1975, Starzl [7] described and clearly defined in detail a safe technique of right trisectionectomy (Figure 2). Then he reported his experience on 30 cases of the operation in 1980, including malignant and benign hepatic lesion [8]. Rui [9] reported his experience of 33 cases of primary liver cancer

**2. Selection of patients for right trisectionectomy of huge liver tumor**

Up to now, the treatment of huge liver cancers is still very difficult due to poor outcomes and higher mortality and morbidity [9–11]. A number of reports have indicated that right trisec‐ tionectomy is effective for extensive hepatic malignancy, based on patients who have had long-

The situations of tumor were detected mainly by image examinations, including B-type ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and angiography. To assess liver function of the patients before operation, we adopted the classic Child–Pugh classification, the ICGR test, and some concrete parameters, as described in

The feasibility of right trisectionectomy for a given patient must be carefully evaluated according to the following criteria [9]: (1) tumor(s), including less than 2 satellite nodules, must be limited to the right lobe and left medial portion of the liver (there is no evidence of cancer invasion in left lateral segment); (2) tumor mass with clear borders or a pseudocapsule, and there is no tumor thrombus in the trunk of the portal vein and hepatic vein; (3) there is no evidence of distant metastasis; (4) compensatory enlargement of the left lateral section should

remains to be the main curative strategy for hepatocellular carcinoma.

patients undergoing right trisectionectomy.

284 Recent Advances in Liver Diseases and Surgery

term survival after this operation [9,12,13].

standards [9].

**Figure 1.** Photograph shows major hepatectomy. The regions in black color present the resected parts of the liver in various major hepatectomy.

3

Figure 2. Photograph from Prof. TE Starzl shows right trisectionectomy. **Figure 2.** Photograph from Prof. TE Starzl shows right trisectionectomy.

be obvious; (5) the Child–Pugh classification of liver function must be grade "A" and the indocyanine green retention rate at 15 min (ICGR 15) should be lower than 15% before surgery; and (6) serum bilirubin is less than 34 mmol/L, serum albumin higher than 30 g/L, and serum prothrombin time larger than 60% before surgery.

A total of 459 primary liver cancer patients were hepatomized in our group. Among them, 33 cases of right trisectionectomies were performed. The patients included 24 males (72.7%) and 9 females (27.3%) with ages ranging from 15 to 69 years. Of the 33 cases, 28 (84.8%) were hepatitis B surface antigen (HBsAg) positive and 5 (15.2%) were negative. There were 8/33 cases (24.2%) with slight cirrhosis and 25/33 cases (75.8%) without cirrhosis; 22/33 cases (66.7%) were grade A in Child–Pugh classification, and 11/33 cases (33.3%) were grade B when the patients were hospitalized, but became grade A before surgical procedures through positive hepatic protective therapy; 27/33 cases (81.8%) with elevated serum α-fetoprotein (the highest value of AFP was 20,000 ng/ml) and 6/33 cases (18.2%) with normal α-fetoprotein. Sizes of tumor ranged from 8 to 20 cm. The stage of tumors was all IVa (T4N0M0). Pathological examination showed that 27 cases (81.8%) were hepatocellular carcinoma, 2 cases (6.1%) were cholangiocarcinoma, and 4 cases (12.1%) were mixed hepatocellular cholangiocarcinoma. Tumor thrombi were found in 17 cases (51.5%) in the right branch of the portal vein. Macro‐ scopic satellite nodules were found in 15 cases (45.5%) and did not presented in left lateral section of the liver. All right trisectionectomies were performed under continuous single interruption of porta hepatis. The 1-, 3-, and 5-year survival rates after right trisectionectomy were 71.9%, 40.6%, and 34.4%, respectively [9]. The longest cancer-free survival of right trisectionectomy in our group is 26 years. This patient is still alive in Beijing. Recently, it is reported from The National Health and Family Planning Commission of The People's Republic of China that a mean of 5-year survival rate for HCC is 10.1% in China. It is obvious that right trisectionectomy would benefit the patients with resectable huge HCC.
