**1. Introduction**

Hepatocellular carcinoma (HCC) is the fifth most common malignancy and the third leading cause of cancer-related deaths worldwide [1]. Cirrhotic patients have the highest risk of developing HCC [2]. Numerous factors contribute to cirrhosis which precedes HCC development, including viral hepatitis, heavy drinking, and aflatoxin exposure. Hepatitis C epidemic in the Western world and Hepatitis B epidemic in China have attributed to the incidence of

© 2016 The Author(s). Licensee InTech. 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. © 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.

HCC [3]. However, HCC has a dismal prognosis, mainly due to the early recurrence; about 40% of patients that have undergone hepatectomy develop recurrence within the first year after surgery [2].

surgery. For cirrhotic patients with HCC, the minimization of the surgical incision and the subsequent preservation of the abdominal wall circulation and lymphatic flow explains the

Novel Techniques in the Surgical Management of Hepatocellular Carcinoma

http://dx.doi.org/10.5772/intechopen.79982

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The last decade, several meta-analyses of laparoscopic vs. open resection for HCC have been published [16–23]. These meta-analyses have analyzed and compared the results of many nonrandomized control trials and case-matched studies. Three categories of outcomes were

**a.** Operative outcomes, such as operative time, operative blood loss, and number of patients

**c.** Oncologic results, such as pathologic resection margins, incidence of port-site recurrence,

Jiang et al. [16] reported the superiority of laparoscopic liver resection (LLR) concerning the reduced intraoperative blood loss and blood transfusion, the expansion of the pathologic resection margins, the increase of R0 resection, and the shorter length of hospital stay. Laparoscopic resection has similar OS, DFS, and recurrence rate as open liver resection (OLR). Sotiropoulos et al. [17], in a recent meta-analysis of 44 studies, showed that laparoscopic resection is superior to open resection in terms of resection margin and R0 resection. It is possible that this difference in resection margin and R0 excision is due to the smaller size of tumors resected in the laparoscopic group. It was confirmed that the laparoscopic technique is strongly associated with less blood loss, fewer blood transfusions, less postoperative pain, faster recovery, and shorter hospital stay. Operative time and tumor recurrence were not statistically different between LLR and OLR as well as the long-term oncological results such as OS and DFS. These results confirm those of previous authors [15, 18, 21, 22]. Hand-assisted laparoscopic or laparoscopy-assisted resections (hybrid group) gain statistical advantage over the OLR group concerning the negative resection margin width and influence the results in favor of LLR. They, however, showed no difference as to the OS and 30-day mortality com-

The main concerns about LLR are the inadequate tumor resection margins and the potential risk of port-site recurrence. Tumor recurrence is the main cause of death in patients with HCC. The adequate tumor-free margin is a prognostic indicator of HCC [23]. Due to the lack of tactile sensation in laparoscopic surgery, the tumor location is sometimes difficult to determine. Intraoperative ultrasonography is a useful tool for precise identification of lesions and its borders [24, 25]. Another concerning factor is the risk of tumor peritoneal dissemination and port-site metastases [26, 27]. Interestingly, there has not been any evidence so far of tumor peritoneal dissemination or port-site metastases [20, 22]. The use of a plastic bag to remove

Concern has also been raised about the safety of laparoscopic techniques in cirrhotic patients. A plethora of patients with HCC also suffer from cirrhosis. Portal hypertension is a major risk

**b.** Postoperative outcomes, such as morbidity, mortality, and hospital stay.

disease-free survival (DFS), and overall survival (OS).

decrease in postoperative liver failure and ascites formation [15].

used to compare the two operative techniques:

that needed transfusion.

pared to the OLR group.

the specimen can help to prevent this complication.

Although liver transplantation is considered as the ideal treatment, hepatic resection remains the only curative method of therapy for HCC. Other methods of potentially curative therapy are radiofrequency ablation (RFA), microwave ablation (MWA), high power focused ultrasound ablation (HIFU), and transarterial chemoembolization (TACE) [4, 5].

Novel surgical techniques are being proposed to overcome the limitations of traditional anatomical open liver resection. Laparoscopic and robotic resection as well as nonanatomical resection and ALPPS procedure have emerged as new and effective ways of surgical therapy for HCC.

The aim of this chapter is to analyze the aforementioned novel surgical techniques in the management of HCC and present the results from the relevant studies.
