Revisiting the Surgical Approach for Recurrent Hepatocellular Carcinoma: Insights from a Single Institute's Experience in Overcoming Challenges

Abstract Introduction: Hepatocellular carcinoma (HCC) prevails in Taiwan, primarily attributed to the high incidence of hepatitis B and hepatitis C infections with high recurrent rates of 50-70% within five years after initial treatment. When confronted with recurrent HCC, treatment options include salvage liver transplantation, trans-arterial chemo-embolization (TACE), re-hepatectomy, and radio-frequency ablation (RFA). Notably, repeat hepatectomy exhibits superior oncological outcomes compared to alternative approaches. While laparoscopic liver resection (LLR) has demonstrated safety and feasibility in primary HCC resection, the persistence of intra-hepatic recurrence necessitates effective interventions. However, repeat liver resection posed challenges, including adhesions from previous surgeries, limited access to recurrent tumors, altered liver structure post-regeneration, difficulties in obtaining hilar control, and compromised liver reserve. Patients and methods: We retrospectively review our collective experience spanning January 2009 to December 2021, encompassing 57 patients with recurrent HCC. Among them, 37 patients underwent laparoscopic approaches, while 20 patients opted for traditional procedures. Results: Notably, both groups exhibited similar operative times and perioperative outcomes, with significantly reduced hospital stays observed in the laparoscopic cohort (median: 5 vs 7, p<0.001). The introduction of laparoscopic techniques also sparked a strategy shifting in our surgical approach to recurrent HCC. Conclusion: Our manuscript aims to delineate a stepwise approach for navigating the challenges inherent in repeat operations, elucidating techniques for peritoneal cavity entry, meticulous adhesiolysis, effective Pringle maneuver application, tumor identification, and pertinent insights into perioperative outcomes. Under the stepwise approach, laparoscopic repeat liver resection can be performed safely and effectively with low incidence of conversion. This treatment choice should be offered to the patient in a mature surgical team of minimal invasive liver resection.