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Chapter 13
Laparoscopic Liver Surgery for the Management of Hepatocellular Carcinoma: The American Perspective
Kadiyala V. Ravindra and Joseph F. Buell
Keywords Laparoscopic liver surgery · Laparoscopic liver resection · HCC · Hepatic resection · Patient selection
Despite better understanding and advances in oncology, the best available thera-peutic option for the management of hepatocellular carcinoma (HCC) is surgical – either liver transplantation or resection. Liver transplantation appears most attractive since it treats the primary tumor and the field defect associated with the underly-ing liver disease. However, this option is feasible only when there are an adequate number of organs available and when the disease and patient meet certain stringent criteria. Most centers abide by the Milan criteria [1] to determine candidacy for liver transplantation. These are a single tumor 55 cm, two or three tumors all <3 cm, absence of major vascular invasion, and no extrahepatic disease. Unfortunately, only a minority of hepatoma patients fit these morphological parameters. Many other cir-rhotic patients do not fulfill the requirements for transplantation due to comorbidity or psychosocial reasons. A few centers have attempted to expand transplantation to patients with greater tumor burden. These criteria were developed by the UCSF group and consist of solitary tumor ≤6.5 cm, or three or fewer nodules with the largest lesion ≤4.5 cm, and total tumor diameter ≤8 cm, without gross vascular invasion [2].
Hepatic resection should be considered for patients deemed unsuitable for transplantation. However, proper selection of patients is required to avoid postop-erative liver failure. On rare occasions, laparoscopic resection has been utilized to select patients for liver transplantation – particularly when there is a ques-tion of major vascular invasion arising in the presence of small tumors. When patients are unable to undergo resection, they are then considered for ablative strate-gies including radiofrequency ablation [3], cryoablation [4], percutaneous alcohol injection [5], microwave ablation [6], laser ablation [7], chemoembolization [8], chemotherapeutic beads, and infusion of yttrium microspheres [9].
K.V. Ravindra ( )
Department of Surgery, Duke University Medical Center, Durham, NC, USA
K.M. McMasters, J.-N. Vauthey (eds.), Hepatocellular Carcinoma, 207 DOI 10.1007/978-1-60327-522-4_13, C Springer Science+Business Media, LLC 2011
208 K.V. Ravindra and J.F. Buell
Hepatic resection poses several important challenges. In the setting of normal parenchyma, resection maybe limited only by the presence of extrahepatic spread, bi-lobar disease, or major vascular extension. These criteria serve only as relative contraindications and should be considered on a case-by-case basis. Major liver resection in a patient with normal parenchyma is tolerated down to a functional liver remnant of only two or three segments. However, in the setting of a diseased liver, resection is an entirely different proposition. A fibrotic or cirrhotic liver has poor and unpredictable ability to regenerate with resultant liver failure. This is a deterrent to major liver resection in hepatoma occurring against the background of cirrhosis.
Various methods have been used to guide the extent of possible resection in this situation. These include the Child’s status, ICG excretion test [10], and evidence of portal hypertension (platelet count, wedged hepatic venous pressure gradient) [11] (Table 13.1). Despite these tools, planning and executing liver resection in cirrho-sis continues to be a serious undertaking. Recent advances in the care of cirrhotic patients have enabled mortality rates as low as 3% [12].
Table 13.1 Selection criteria for liver resection for hepatocellular carcinoma in chronic liver disease
For a major resection (≥ three segments) Child-Pugh class A
Indocyanine green retention at 15 min <15% No esophageal varices
Platelets >100,000/mm3 Transaminases ≤ two times normal
Hypertrophy of liver after portal vein embolization Functional residual liver volume > 50%
For a limited resection (
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