Anterior approach for major right hepatic resection for large hepatocellular carcinoma

Abstract

Objective: To report the surgical and long-term outcomes of major right hepatic resection for large hepatocellular carcinoma (HCC) using the anterior approach compared with the conventional approach.

Summary background data: Great difficulty can be encountered during major right hepatic resection for large HCC using the conventional approach. Forceful retraction during mobilization of the tumor might result in serious complications, including dissemination of cancer cells, iatrogenic tumor rupture, and excessive bleeding, leading to unfavorable surgical and long-term outcomes.

Methods: In patients who had large HCC at the right lobe of liver and underwent major hepatic resection, the technique of anterior approach was used. After hilar control of the inflow blood vessels and without prior mobilization of the right lobe of liver and the tumor, parenchymal transection was performed using an ultrasonic dissector from the anterior surface of the liver until the anterior surface of the inferior vena cava was exposed. All venous tributaries, including the right hepatic vein, were controlled before the right lobe of liver was mobilized. Surgical and long-term outcomes were analyzed retrospectively and compared with patients who underwent surgery using the conventional approach.

Results: From 1989 to 1997, the anterior approach was used for major right hepatic resection in 54 patients with HCC of 5 cm or more in diameter. When compared with the 106 patients with similar clinical parameters who underwent hepatic resection using the conventional approach during the same period, the patients in the anterior approach group had significantly less intraoperative blood loss and blood transfusion, a lower hospital death rate, a lower incidence of pulmonary metastases, and a better median disease-free survival and median overall cumulative survival.

Conclusion: The anterior approach is the preferred technique for major right hepatic resection for large HCC because it resulted in improved surgical and survival outcomes compared with the conventional approach.

Figures

Figure 1. (A) Computed tomography scan showing the direction and line of parenchymal transection in the anterior approach for a large right-lobe hepatocellular carcinoma. (B) Intraoperative diagram of the anterior approach for major right hepatic resection for large hepatocellular carcinoma. Complete hepatic parenchymal transection is performed down to the caudate lobe, and the middle hepatic vein is transected. (C) Intraoperative diagram showing complete transection of hepatic parenchyma and mobilization of the caudate lobe from the inferior vena cava, which is completely exposed. (D) Intraoperative diagram showing completion of hepatic resection and delivery of the specimen. (C, caudate lobe; IVC, inferior vena cava; (LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein)

Figure 2. Disease-free survival of patients who underwent major right hepatic resection using the anterior approach (54 patients) and the conventional approach (106 patients).

Figure 3. Cumulative overall survival of patients who underwent major right hepatic resection using the anterior approach (54 patients) and the conventional approach (106 patients).