Minimally Invasive Liver Surgery in the Setting of the Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common form of liver cancer, ranking fourth among cancer-related causes of death. It occurs in >90% of cases in the setting of cirrhosis, and the coexistence of two diseases (HCC and cirrhosis) implies that liver transplantation offers the best long-term outcomes when adequate patient selection is provided.^1–5 However, liver resection (LR) is carried out as a valid option to bridge the stay on the waiting list for transplantation of patients with end-stage liver disease, and has helped dramatically mitigate the scarcity of donor pool for the past decades. ⁶ In this setting, the possibility of performing minimally invasive liver surgery (MILS) on chronic liver patients contributed to the development of laparoscopic LR (LLR) for HCC. Restricting surgery to small or no incision results not only in better cosmetic effects, but above all in a much less complex postoperative period, with less pain, and a greater chance of faster recovery for the patients. MILS benefits patients with portal hypertension, who are more prone to bleeding and ascitic decompensation. Since few decades MILS has changed the surgical thinking shifting toward diminishing invasiveness even in area such as liver surgery where traditionally invasiveness pervades the most majority of surgical strategy. LLR performed each year are increasing and so the number of scientific publication and of the scientific societies related to this field of medicine, at this regard I like to mention, once more, the Italian experience of the Italian Group of Minimally Invasive Liver Surgery “I GO MILS,” which develops and reports all the activity related to LLR in the country.

Treatment of HCC must be multidisciplinary and patient oriented, and take into account the patient's clinical stage, liver function reserve, and performance status.

This special issue of the Journal of Laparoendoscopic and Advanced Surgical Techniques aims to explore some novelties related to MILS in the scenario of the HCC.

Starting from the Multidisciplinary Network Model for the management of Primary Liver Tumors proposed by Celsa et al., ⁷ we then have chance to find data about a systematic review and meta-analysis on the advantages of the laparoscopic liver surgery in patients with cirrhosis and portal hypertension written by Coletta et al. ⁸

Following the articles authored by Pagano et al. ⁹ and by Tropea et al. ¹⁰ focus, respectively, on the achievements gathered with the Enhanced Recovery After Surgery (ERAS) protocol in the LLR and with the laparoscopic microwave thermal ablation approach to treat unresectable HCC.

A further excellent systematic review and meta-analysis on the role of anatomic LLR is provided by Solaini et al. ¹¹

Eventually a great article from the Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) Italian Registry ¹² reports on the advantages offered by the minimally invasive approach in the setting of the first step of the ALPPS procedure.