What Is the Role of Minimally Invasive Liver Surgery in Treating Patients with Hepatocellular Carcinoma on Cirrhosis?

Abstract

Minimally invasive liver surgery (MILS) has been slowly introduced in the past two decades and today represents a major weapon in the fight against HCC, for several reasons. This narrative review conveys the major emerging concepts in the field. The rise in metabolic-associated steatotic liver disease (MASLD)-related HCC means that patients with significant cardiovascular risk will benefit more profoundly from MILS. The advent of efficacious therapy is leading to conversion from non-resectable to resectable cases, and therefore more patients will be able to undergo MILS. In fact, resection outcomes with MILS are superior compared to open surgery both in the short and long term. Furthermore, indications to surgery may be further expanded by its use in Child B7 patients and by the use of laparoscopic ablation, a curative technique, instead of trans-arterial approaches in cases not amenable to radiofrequency. Therefore, in a promising new approach, multi-parametric treatment hierarchy, MILS is hierarchically superior to open surgery and comes second only to liver transplantation.

Keywords: hepatocellular carcinoma; laparoscopic ablation; liver transplantation; minimally invasive liver resection; multi-parametric treatment hierarchy approach.

Figure 1

Review outline. Created in BioRender. HCC: hepatocellular carcinoma; MILS: minimally invasive liver surgery; LA: laparoscopic ablation; BCLC: barcelona clinic liver cancer; TACE: trans-arterial chemo-embolization.

Figure 2

Advantages of MILS over open surgery and TACE/RFA and preferred indications. HCC: hepatocellular carcinoma; LA: laparoscopic ablation; pRFA: percutaneous radiofrequency ablation; TACE: trans-arterial chemo-embolization.

Figure 3

The novel framework includes the concepts of multi-parametric and converse therapeutic hierarchy. This figure is derived from Ref. [68]. # Performance status expresses tumor-related symptoms and, therefore, tumor aggressiveness. * Extrahepatic metastases, invasion of the main trunk of the portal vein or inferior vena cava. The right-side arrow indicates the concept of “converse therapeutic hierarchy” (conversion or adjuvant approach). The arrow is dashed and faded since the evidence supporting this concept is still weak. Abbreviations: PS, performance status; AFP, alpha-fetoprotein; PIVKA-II, Protein Induced by Vitamin-K Absence-II; LDLT, living donor liver transplantation; DCD, donor after circulatory death; MELD, model for end-stage liver disease; CRPH, clinically relevant portal hypertension; TACE, trans-arterial chemo-embolization; PVT, portal vein thrombosis. Up arrow: increased/excessive/advanced; Down arrow: insufficient.