**6.2 Salvage liver transplantation after liver resection**

The use of resection as a bridge to transplantation has been advocated as a way of solving the organ donor shortage, whereby transplantation is offered only to patients who develop an intrahepatic recurrence. In the United States, a national Consensus Conference on Liver Allocation for HCC, recommended that : 1- a recurrence more than 2 years after resection for HCC of any stage should be considered de novo, and to considered priority score for HCC if the lesion meets Milan criteria; and 2- a recurrence that presents less than 2 years after resection for a T2 lesion should be elegible for HCC priority score if the lesion meets Milan criteria (Pomfret, 2009). The largest series of salvage transplantation come from French centers with conflicting results: Adam et al (Adam, 2003) report a 5 year survival for salvage transplantation of 29% versus 58% for primary liver transplantation for HCC. In their series, the recurrence rate for liver resection was 77% but only 17% of patients were elegible for salvage transplantation.By utilizing a strategy that offers salvage transplantation for decompensated liver function and positive margins after resection, Belghiti et al ( Belghiti, 2003) have shown a comparable 5 year survival for both salvage and primary liver transplantation of 59% and 61%, respectively. The use of resection as a bridge to transplantation may offer important histopathological information that can help identify and subselect patients best suited for transplantation but its application is limited by the fact that only a relatively small number of patients with hepatocellular cancer are candidates for liver resection.

#### **6.3 Laparoscopic resection for HCC**

In cirrhotics with preserved liver function and the absence of significant portal hypertension, the laparoscopic approach carries several benefits. Due to the smaller incisions, the collateral abdominal wall circulation is better preserved and an increase in the portal pressure is avoided. Intra-abdominal adhesions are decreased and successful salvage transplantation after laparoscopic resections have been reported (Laurent, 2009). The accepted criteria for laparoscopic approach include: single lesions in peripheral segments of the liver and less than 6 cm in size (Buell, 2008).Outcomes after laparoscopic resection for HCC range from 68 to 74 % 3-year survival (Chen, 2008).In Europe, the 1 and 3 year diseasefree survival after laparoscopic resection is 77.5% and 47.1%, respectively (Dagher, 2010); Pittsburgh reported an 88% and 82% disease-free survival at 1 and 3 years, respectively (Nguyen,2011). The option of laparoscopic or open liver resection for HCC should be considered in the context of a multidisciplinary approach to the individual patient's tumor, liver reserve and potential transplant candidacy.
