**4. Operative technique**

Resections are either "anatomic" or "non-anatomic". Anatomic resection defines a resection that obeys Brisbane divisions and is preferred for malignant disease because it has been found to lower rate of positive margins, decrease regional recurrences and improve surgical outcome. Non-anatomic resection refers to parenchymal transection that does not respect segmental planes and is typically used for debulking procedures, benign tumors or when trying to preserve remnant parenchyma. Achieving a microscopic margin negative (R0) resection is paramount to reducing local recurrence. 1 cm surgical margins have historically been considered standard, but narrower margins have been safely demonstrated [23].

There are six standard, anatomic hepatic resections as defined by the Brisbane classification (**Figure 2**). Right hemi-hepatectomy consists of surgical resection of segments V-VIII and left hepatectomy includes segments II-IV and occasionally segment I. In an extended right hepatectomy or a right trisectionectomy/trisectorectomy, segments IV-VIII, and in an extended left hepatectomy or a left trisectionectomy, segments II-IV, V and VIII are resected. A left lateral sectorectomy involves resection of segments II-III and a right posterior sectionectomy includes segments VI-VII. Segmentectomies denote resection of any individual segment.

The common principle of anatomic hepatectomies involves parenchymal transection after both vascular inflow and outflow have been controlled. Given that each hepatic segment has

with sutures, clips, argon beam coagulator and application of various hemostatic agents. Biliary leaks are controlled with clipping and suture ligation. Prior to abdominal closure, drains are placed if there is an infected operative field or if a biliary reconstruction is performed [25].

Surgical Resection in HCC

65

http://dx.doi.org/10.5772/intechopen.81345

Although established as a safe and beneficial approach for numerous intra-abdominal operations, laparoscopic techniques were slow to be adopted for liver surgery for several reasons [26]. Concerns over technical feasibility of vascular dissection and control, organ mobilization, parenchymal dissection and management of intraoperative complications were prohibitive. Furthermore, it was unknown if port-site seeding, inadequate margins and poor oncologic

The benefits of laparoscopic liver surgery are numerous. In addition to the generalized benefits of laparoscopic surgery including a more rapid functional recovery, smaller incisions which reduce the incidence of surgical site infections and postoperative pulmonary complications, there are additional advantages specific to laparoscopic liver surgery. Steep Trendelenburg positioning reduces intrahepatic venous pressure and the pneumoperitoneum exerts tamponade effect on vasculature leading to reduced intraoperative blood loss. Laparoscopy creates a caudal-cranial surgical view which affords improved visualization of major vascular structures compared to the ventral-dorsal angle of visualization of an open hepatectomy. For cirrhotic patients, small laparoscopic incisions avoid disruption of abdominal wall collaterals and the constraint on fluid shifts in a laparoscopic partial hepatectomy can decrease the incidence of liver-related complications. Minimally invasive hepatectomy also results in less

There have been numerous studies to date demonstrating the safety and efficacy of laparoscopic liver surgery. In 2009, a worldwide experience of 127 series including 2804 cases of laparoscopic partial hepatectomy demonstrated comparable 5-year overall survival and disease free survival compared to open hepatectomy [27]. Half of these cases were done for malignant disease with greater than 80% of resections boasting negative surgical margins. In 2015, a randomized control trial was published demonstrating safety and feasibility of laparoscopic liver resection with reduction in length of stay and intraoperative blood loss compared to open hepatectomy [28]. Numerous systematic analyses have substantiated these data, demonstrating that the laparoscopic partial hepatectomy is associated with decreased intraoperative blood loss, shorter length of hospital stay, and decreased number of positive resection margins. Overall, there were consistently fewer complications found in the laparoscopic group in these reviews [29]. A case–control propensity matched studies also found no difference in 1-, 3-, and 5-year overall survival and disease-free survival [30]. The National Surgical Quality Improvement Program database was evaluated to compare short-term outcomes among patients undergoing minimally invasive partial hepatectomy. Over 3000 patients were include in the study

outcomes would be more common in the minimally invasive approach.

adhesion formation which facilitates additional surgery in the future.

**5. Minimally invasive hepatectomy**

**5.1. Laparoscopic-assisted partial hepatectomy**

**Figure 2.** Schematic illustrations of the standard hepatic resections as labeled. Source: Cho, Fong. Hepatic Resection. In: Ashley SW, editor. Scientific American Surgery. Hamilton: Decker. 7th ed; 2014. pp. 1094–1114.

their unique vascular inflow and outflow, each segment can be safely excised without damage to surrounding hepatic segments. Intraoperative ultrasonography is used routinely for identification of the vascular structures, evaluation of tumor location, extent and relationship to the surrounding vasculature.

After initial laparoscopic inspection excludes unresectable disease (in selected cases), the incision is made. In an open conventional approach, appropriate incision and exposure is critical to safe hepatectomy. There are several incisions used including the bilateral subcostal (Chevron), right/left subcostal, J-type or the inverted Y (Mercedes) incision.

Once the liver is mobilized by dividing ligamentous attachments, careful inspection, palpation and ultrasound examination are performed to evaluate for any missed tumors. Arterial aberrancies are identified and portal triad inflow is controlled with sutures and clips or staple ligation. The corresponding hepatic vein is isolated and ligated. Parenchymal transection is performed along the line of devascularization. Different techniques for parenchymal transection exist, varying from clamp-crushing, waterjet, monopolar/bipolar cautery, radiofrequency ablative devices, bipolar vessel sealing devices, ultrasonic dissection devices to staplers. The clamp-crush technique is rapid and has been associated with lower rates of blood loss compared to other methods [24]. Once the resected segment is removed, hemostasis is obtained with sutures, clips, argon beam coagulator and application of various hemostatic agents. Biliary leaks are controlled with clipping and suture ligation. Prior to abdominal closure, drains are placed if there is an infected operative field or if a biliary reconstruction is performed [25].
