From minimal to maximal surgery in the treatment of hepatocarcinoma: A review.

Hepatocellular carcinoma represents one of the most challenging frontiers in liver surgery. Surgeons have to face a broad spectrum of aspects, from the underlying liver disease to the new surgical techniques. Safe liver resection can be performed in patients with portal hypertension and well-compensated liver function with a 5-year survival rate of 50%, offering good long-terms results in selected patients. With the advances in laparoscopic surgery, major liver resections can be performed with minimal harm, avoiding the wound and leak complications related to the laparotomies. Studies have shown that oncological margins are the same as in open surgery. In patients submitted to liver resection (either laparoscopic or open) who experience recurrence, re-resection or salvage liver transplantation has been showing to be an alternative approach in well selected cases. The decision making approach to the cirrhotic patient is becoming more complex and should involve hepatologists, liver surgeons, radiologists and oncologists. Better understanding of the different risk factors for recurrence and survival should be aimed in these multidisciplinary discussions. We here in discuss the hot topics related to surgical risk factors regarding the surgical treatment of hepatocellular carcinoma: anatomical resection, margin status, macrovascular tumor invasion, the place of laparoscopy, salvage liver transplantation and liver transplantation.