**2.2 Re-hepatectomy**

Repeat hepatic resection has been widely recognised as one of the most effective treatments for intra-hepatic recurrent HCC compared to other therapeutic modalities (Chen et al., 2004; Itamoto et al., 2007; Minagawa et al., 2003; Sugimachi et al., 2001; Tralhao et al., 2007; Wu et al., 2009; Zhou et al., 2010). It should be the treatment of choice in suitable patients with preserved liver function and functional status. The safety and long-term results of repeated resection has been well-established, with operative mortality rates ranging from 0% to 8.5% and the reported cumulative 5-year survival rate after a second hepatectomy was comparable to the survival after initial hepatectomy for primary HCC (Aeii et al., 1998; Farges et al., 1998; Hu et al., 1996; Itamota et al., 2000; Kakazu et al., 1993; Matsuda Y et al., 1993; Minagawa et al., 2003; Nagano et al., 2009; Nagasue et al., 1996; Poon et al., 1999; Shimada et al., 1996, 1998; Suenaga M et al., 1994; Sugimachi et al., 2001; Zhou et al., 2010).

In a recent systemic review where studies reporting in at least 10 patients are included, Zhou et al analysed 29 studies of repeat hepatectomy for recurrent HCC with a curative intent (Zhou et al., 2010). A total of 1149 patients underwent repeat hepatectomy for recurrent HCC and the rate of repeat hepatectomy ranged from 8.7% to 44%. The median or mean operating time ranged from 136 to 365 minutes and the median or mean estimated blood loss ranged from 211 to 1980 ml. Majority of patients received minor resection at the time of repeat resection. The reported ranges of the 1-, 3- and 5-year survival were 69% to 100%, 21% to 87% and 25% to 87% respectively.

These results may support the use of repeat resection for recurrent HCC. Moreover, it is noteworthy that the rate of extra-hepatic spread after hepatic resection is low. The reported incidence of extra-hepatic metastases after primary liver resection was 5% to 20% while that after second resection was almost the same (Belghiti et al., 1991; Bismuth et al., 1995; Kosuge et al., 1993; Makuuchi et al., 1998). Nevertheless, repeat resection is technically demanding and difficult due to possible adhesions between the raw liver surface and the surrounding organs, distortion and anatomical disorientation caused by the rotation of liver remnant as a result of regeneration and limited liver reserve after previous resection (Figure. 1).

So far, no consensus has been reached for the standard selection criteria for re-hepatectomy. In general, patients with good performance status and adequate liver functional reserve could be selected for re-hepatectomy if oncological clearance can be achieved (Zhou et al., 2010). The main consideration remains the probability of patients developing posthepatectomy liver failure.

An important finding reported by the Japanese groups is that the overall survival after second hepatectomy was significantly poorer in patients who recurred within 1 year after first hepatectomy than those who recurred more than 1 year after initial operation (Minagawa et al., 2003; Nagano et al., 2009). The authors postulated that many of these cases of early recurrence might be a result of intrahepatic metastasis from primary HCC and hence, associated with a poorer outcome. As a result, Minagawa et al, after reviewed 67 patients received repeated hepatectomy for recurrent HCC, concluded that a disease-

recommending liver transplantation as the standard treatment for recurrent HCC deems

Repeat hepatic resection has been widely recognised as one of the most effective treatments for intra-hepatic recurrent HCC compared to other therapeutic modalities (Chen et al., 2004; Itamoto et al., 2007; Minagawa et al., 2003; Sugimachi et al., 2001; Tralhao et al., 2007; Wu et al., 2009; Zhou et al., 2010). It should be the treatment of choice in suitable patients with preserved liver function and functional status. The safety and long-term results of repeated resection has been well-established, with operative mortality rates ranging from 0% to 8.5% and the reported cumulative 5-year survival rate after a second hepatectomy was comparable to the survival after initial hepatectomy for primary HCC (Aeii et al., 1998; Farges et al., 1998; Hu et al., 1996; Itamota et al., 2000; Kakazu et al., 1993; Matsuda Y et al., 1993; Minagawa et al., 2003; Nagano et al., 2009; Nagasue et al., 1996; Poon et al., 1999; Shimada et al., 1996, 1998; Suenaga M et al., 1994; Sugimachi et al.,

In a recent systemic review where studies reporting in at least 10 patients are included, Zhou et al analysed 29 studies of repeat hepatectomy for recurrent HCC with a curative intent (Zhou et al., 2010). A total of 1149 patients underwent repeat hepatectomy for recurrent HCC and the rate of repeat hepatectomy ranged from 8.7% to 44%. The median or mean operating time ranged from 136 to 365 minutes and the median or mean estimated blood loss ranged from 211 to 1980 ml. Majority of patients received minor resection at the time of repeat resection. The reported ranges of the 1-, 3- and 5-year survival were 69% to

These results may support the use of repeat resection for recurrent HCC. Moreover, it is noteworthy that the rate of extra-hepatic spread after hepatic resection is low. The reported incidence of extra-hepatic metastases after primary liver resection was 5% to 20% while that after second resection was almost the same (Belghiti et al., 1991; Bismuth et al., 1995; Kosuge et al., 1993; Makuuchi et al., 1998). Nevertheless, repeat resection is technically demanding and difficult due to possible adhesions between the raw liver surface and the surrounding organs, distortion and anatomical disorientation caused by the rotation of liver remnant as a

So far, no consensus has been reached for the standard selection criteria for re-hepatectomy. In general, patients with good performance status and adequate liver functional reserve could be selected for re-hepatectomy if oncological clearance can be achieved (Zhou et al., 2010). The main consideration remains the probability of patients developing post-

An important finding reported by the Japanese groups is that the overall survival after second hepatectomy was significantly poorer in patients who recurred within 1 year after first hepatectomy than those who recurred more than 1 year after initial operation (Minagawa et al., 2003; Nagano et al., 2009). The authors postulated that many of these cases of early recurrence might be a result of intrahepatic metastasis from primary HCC and hence, associated with a poorer outcome. As a result, Minagawa et al, after reviewed 67 patients received repeated hepatectomy for recurrent HCC, concluded that a disease-

result of regeneration and limited liver reserve after previous resection (Figure. 1).

logistically impractical.

**2.2 Re-hepatectomy** 

2001; Zhou et al., 2010).

hepatectomy liver failure.

100%, 21% to 87% and 25% to 87% respectively.

free interval of more than 1 year after primary hepatectomy, single HCC at primary resection, and negative portal vein invasion at repeated resection were favourable prognostic factors after repeated resection with excellent 3- and 5-year survival rates of 100% and 86% respectively. They, therefore, recommended these patients should be indicated for repeat resection even if they have undergone major hepatic resection as the primary hepatectomy as long as the liver function can be preserved (Minagawa et al., 2003).

Fig. 1. Intra-operative picture of a patient who underwent right posterior sectionectomy for a recurrent HCC at segment VIII. Multiple adhesions over liver surface were also showed.

The good results from repeat hepatectomy should be interpreted with caution as patients selected for repeat hepatectomy were usually patients with better prognosis, e.g. better liver reserve and smaller tumours.

Recently, laparoscopic hepatectomy is well accepted as a safe and feasible treatment for primary HCC in selected patients with similar result to the open approach (Lee et al., 2007; Vignano et al., 2009). It is recommended for peripheral lesion requiring limited hepatectomy or left lateral sectionectomy (Lee et al., 2011; Vignano et al., 2009). Feasibility of repeat laparoscopic liver resection in recurrent HCC had been reported (Belli et al., 2009; Cheung et al., 2010; Hu et al., 2011; Liang et al., 2009). However, all these reports only focused on the technical aspects and the short-term outcomes. The importance of careful patient selection should be emphasized when considering laparoscopic re-resection and it should only be done by surgeons who are highly experienced in both laparoscopic and open hepatic surgeries.
