**6. Conclusion**

Although ALPPS had lower 1-year DFS rate, no significant difference in the 90-day mortality rate was discovered comparing the two techniques [66]. ALPPS was associated with a higher completion rate, a lower probability of tumor progression during the stage interval, and a lower insufficient regeneration rate; these findings are similar to those of previous studies

Many variations of the ALPPS technique have been recently mentioned in the literature with the aim of improving safety and extending indications of hepatectomy. Modifications, such as avoiding liver mobilization and hepatoduodenal skeletonization, seem to prevent tumor spreading, adhesions, overall invasiveness, and parenchymal ischemia [69–73]. In addition, anterior approaches, portal vein embolization (PVE) as an alternative to ligation, partial liver splitting, tourniquet application or ablation procedures replacing parenchymal transection, and laparoscopic approaches represent fundamental modifications to the original ALPPS procedure that aim to improve safety [15]. The result of these modifications is the reduction of morbidity and mortality in this innovative surgical procedure. Furthermore, prospective controlled studies are needed to confirm which of these modifications should be considered as a reliable and safe alternative strategy to

The incidence of HCC continues to increase due to the dissemination of hepatitis B and C virus infection. Hepatic resection is the gold standard treatment for HCC [74]. Nevertheless, postoperative recurrence of HCC, 3 and 5 years after hepatectomy is 50–60% and 70–90%,

It is known that HCC invades mainly the intrahepatic vascular system and spreads along the

Since Makuuchi et al. introduced the concept of anatomical resection (AR), the advantages of anatomic resection for HCC have been suggested in many studies [79]. On the other hand, limited nonanatomic resection (NR) with a minimal safety margin may be preferred for patients with impaired liver function [80]. Tanaka et al. showed that microscopic vascular invasion was more important than tumor size as a predictive factor for local recur-

Anatomical liver resection is a plausible option for patients with HCC, as HCC tends to cause intrahepatic metastasis through vascular invasion, and its advantages in improved OS or DFS

In a systematic review of Cucchetti et al., AR seemed to yield improved 5-year OS and DFS compared to NR [83]. Zhou et al. [84] and Bigonzi et al. [85] presented significantly improved

portal and hepatic vein branches, producing intrahepatic metastases [77, 78].

**5. Anatomical vs. nonanatomical resection for HCC**

for HCC patients have widely been reported [82].

[56, 67, 68].

84 Liver Cancer

classical ALPPS.

respectively [75, 76].

rence [81].

5-year OS with AR.

Hepatocellular carcinoma is a malignancy with an increasing incidence and a dismal prognosis. Patients are often referred to specialists in an advanced stage of the disease. Surgery is the primary treatment and novel surgical techniques are developed offering better perioperative and oncological results (**Table 1**). Nevertheless, prospective, randomized controlled studies have to be designed for the confirmation of such possible advantages of those new surgical techniques.


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**Table 1.** Advantages and limitations of novel surgical techniques for hepatocellular carcinoma management.
