**1. Introduction**

Hepatocellular carcinoma (HCC) is the second most lethal malignancy worldwide [1]. Despite the advent of effective antiviral drugs to eradicate hepatitis C infection, the prevalence of HCC is projected to increase secondary to increasing rates of fatty liver disease from diabetes and the obesity epidemic [2]. Unfortunately, there has been little to no change in the survivability of HCC over the last three decades [3] in spite of the increasing array of therapeutic options, leaving much room for improvement. The armamentarium for managing HCC is wide and includes surgical resection, orthotopic liver transplantation (OLT), ablative techniques using ethanol (percutaneous ethanol injection, PEI), microwave (MWA) or radiofrequency (RFA), catheter-directed transarterial chemoembolization (TACE) or radioembolization (TARE),

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

external beam radiation therapy in the form of stereotactic body radiation therapy (SBRT) or proton beam therapy (PBT), systemic targeted small molecule tyrosine kinase inhibitors, check-point inhibitor immunotherapy and investigational agents. These modalities are often used together in a multidisciplinary approach.

85–90% of patients with HCC have concomitant liver dysfunction. It is critical to account for the degree of liver dysfunction in addition to the patient's overall functional and nutritional status. Patients with liver disease are often malnourished with diminished performance status and comorbid conditions. To help stratify clinical liver dysfunction, patients are classified by the Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) system. These two systems classify patients based on physical exam and laboratory data, with increasing scores associated with higher overall surgical risk. In general, patients with CTP score up to B7, MELD score <9 without significant portal hypertension can be considered for PH. Patients with more severe liver dysfunction and HCC can be considered for OLT if they meet specific criteria [8, 9].

Surgical Resection in HCC

61

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

Assessment of the hepatic function and future liver remnant (FLR) is important for patient selection prior to surgical resection [10]. The volume of the FLR and the regenerative capacity are key predictors of postoperative morbidity. Several laboratory tests have been used to evaluate hepatic reserve in cirrhotic patients including assessment of clearance of indocyanine green, sorbitol and 99mTc-galactosyl serum albumin scintigraphy [11]. Preoperative volumetric analysis can be performed with 3D computerized tomography volumetry [12]. To minimize the chance of post-hepatectomy liver failure, data suggest a liver remnant to be at minimum >20% of preoperative liver volume in a normal functioning liver, >30% for patients who have undergone >3 months systemic chemotherapy and >40% in those with advanced

Several techniques for preoperative optimization of the FLR exist including portal vein embolization (PVE) and the associated liver partition with portal vein ligation for staged hepatectomy (ALPPS) [15]. Initially developed in 1986, PVE results in atrophy of the embolized segments and compensatory hypertrophy of the perfused segments [16], within approximately 4–6 weeks, with at least >10% growth of the FLR predicting adequate regeneration post-PH. PVE has been shown to reduce the rate of postoperative complications in select patients with chronic liver disease [17], and can also be used safely in patients undergoing concurrent chemotherapy for colorectal metastases. One study demonstrated improved prog-

ALPPS was developed in 2007 to induce liver hypertrophy in patients planned for extended liver resections with marginal FLR. A two-step operation, the initial data demonstrated it to be quite effective with rapid hypertrophy [15], however, it has not gained wide acceptance secondary to significant morbidity and mortality and the need for larger scale studies [19–21]. However, there are more recent reports of "mini-ALPPS" where the procedure is performed

The surgical anatomy of the liver is based on Claude Couinaud's classification system and further refined in the Brisbane 2000 Terminology of Liver Anatomy and Resections (**Figure 1**)

minimally invasively and with limited peripheral division of the parenchyma.

nosis after PH in patients with impaired hepatic function [18].

liver disease [13, 14].

**3. Surgical considerations**

**3.1. Surgical anatomy**

Surgical resection, or partial hepatectomy (PH), is a potentially curative surgical treatment option for up to 15–20% of patients with HCC. The primary objective of PH is to remove the HCC with an adequate margin, while preserving as much functional liver parenchyma to avoid post-resection hepatic failure. With improvements in preoperative assessment, patient selection, surgical and anesthetic techniques, intraoperative ultrasound, PH for HCC is now routine and safe. Operative mortality has been reduced to less than 5% with a 5-year overall survival of 60–75%.
