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

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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. Hepatocellular carcinoma minimally invasive hepatectomy repeat hepat Figures Figure 1 Figure 2 Figure 3 Introduction Hepatocellular carcinoma (HCC) ranks as the 3rd leading cause of cancer-related mortality globally, with a noticeable increase in mortality over recent decades [ 1 ] Taiwan, characterized by a high prevalence of Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, experiences an elevated incidence of HCC, standing as the 2nd leading cause of cancer-related deaths in the country [ 2 , 3 ]. Employing a multidisciplinary approach aligned with the Barcelona Clinic Liver Cancer (BCLC) classification is widely acknowledged and seeks to enhance the treatment outcomes for HCC [ 4 ]. While liver resection can yield 60 to 80 percent 5-year overall survival rates in early-stage HCC, recurrence rates surge in patients’ post-primary treatment, reaching up to 80% according to various reports [ 5 ]. Among the treatment options for recurrent HCC, repeat resection emerges as a promising avenue for improved survival [ 6 ]. The safety and feasibility of laparoscopic liver resection (LLR) in treating hepatocellular carcinoma have been established in international consensus meetings [ 7 ]. However, laparoscopic repeat liver resection (LRLR) is perceived as a more challenging procedure due to adhesions from prior operations, altered normal structural orientation, and the need for highly selective patients and experienced surgeons [ 8 ]. These complexities often hinder a surgeon's decision to opt for a repeat laparoscopic approach. Notably, recent advancements in technologies such as indocyanine green (ICG) scopes, robotic surgery, intra-operative image guidance, and enhanced bleeding control, as discussed in the latest international laparoscopic liver surgery (ILLS) consensus, signify the evolving landscape of laparoscopic liver resection [ 9 ]. Moreover, the most comprehensive multicentric propensity score-matched observational study has reaffirmed the feasibility and safety of LRLR [ 10 ]. The decision to adopt a laparoscopic approach for recurrent intrahepatic malignancies is significantly influenced by surgeons' experience and familiarity with the procedure. Furthermore, most literature on LRLR originates from high-volume centers [ 10 ]. Previously considered a relative contraindication, especially for novice laparoscopic liver surgeons, laparoscopic repeat liver resection challenges traditional concepts. In this retrospective study, we aim to explore the optimal timing for the surgical team to undertake the initial repeat laparoscopic liver resection and compare the short-term perioperative outcomes between LRLR and open hepatectomy in a pioneer team to perform laparoscopic hepatectomy. This study marks the pioneering endeavor to investigate the optimal timing of the surgical team's transition from traditional surgery to a minimally invasive approach for patients with recurrent HCC. Methods Patient Selection: A retrospective study spanning from January 2009 to December 2021 was conducted at Chang Gung Memorial Hospital, Keelung. Approval for this study was obtained from the Institutional Review Board of Chang Gung Memorial Hospital (IRB No. 02300984B0). The study enrolled patients who underwent surgical management for recurrent HCC and the selection of patients is illustrated in Fig. 1 and Fig. 2 . Open repeat liver resection was carried out by seasoned liver surgeons at the time of diagnosis. In contrast, laparoscopic repeat liver resection was performed by a dedicated team comprising two fixed surgeons, recognized pioneers in laparoscopic liver resection within our institution. Diagnosis of recurrence was established through preoperative dynamic abdominal computed tomography or magnetic resonance imaging. Assessment of preoperative liver function was conducted using basic liver function tests, Child-Pugh Score, and Indocyanine green (ICG) test. A multidisciplinary team consisting of medical doctors specializing in radiofrequency ablation (RFA), hepatobiliary surgery, radiology, radiation oncology, and medical oncology was involved in the pre-treatment evaluation of all patients. The choice of operative procedure was determined based on preserved liver function, tumor characteristics (location and size), and the patient's previous surgical history. Surgical Procedure: Patients were positioned on a rotating table in the supine position with suspended legs, transitioning to a reversed Trendelenburg position during laparoscopic liver resection. For tumors located in the left lobe or anterior segment, upper arm extensions were utilized, while patients with tumors in the right posterior segment were positioned in the left hemi-lateral decubitus position. A Hasson method was employed to insert a camera port at the supra-umbilical position, and extended adhesiolysis was performed around the incision to create adequate operational space, addressing any noted adhesions. Subsequent trocars were inserted step by step following the initial port, utilizing electrical cutting, monopolar coagulation, or energy devices for further adhesiolysis and trocar insertion. Trocar placement was optimized based on tumor location to facilitate liver rotation and adhesion dissection from previous surgeries. Intraoperative navigation using the ICG scope (Stryker, Kalamazoo, MI, USA) and intraoperative ultrasonography guided parenchymal transection, ensuring adequate margins, especially for lesions not readily visible. Successful procedures were conducted via pure laparoscopic liver resection. Hepatic parenchymal resection involved the crush-clamp method using Harmonic Hi10000 (Ethicon Endo-Surgery, Cincinnati, OH, USA), Cavitron ultrasonic surgical aspirator (CUSA), and a bipolar clamp coagulation system (Karl Storz Endoscope, Tuttlingen, Germany). Routine utilization of the Pringle maneuver by Huang's loop [ 11 ] was applied, with partial vascular control using Debakey Bulldog clamp (GerMed USA, New York, USA )in cases of severe adhesions around the hepatoduodenal ligament. Seprafilm membrane (Baxter, Deerfield, Illinois, USA) application aimed to prevent postoperative adhesions around the resection margin, inferior vena cava (IVC), hepatoduodenal ligament, and under the midline mini-laparotomy wound in all patients. Closed system drains employing the Jackson-Pratt draining system were inserted around the liver parenchymal cut surface at surgery's conclusion, later removed after postoperative days once diet intake commenced, and no bile leakage was detected. Prophylactic antibiotics were administered preoperatively, repeated every 4 hours during surgery, and continued for one postoperative day. All patients received multidisciplinary peri-operative pain management. Perioperative Outcome: Recorded parameters included intraoperative blood loss, need for blood transfusion, and surgical duration, subsequently compared. Complications were graded according to the Clavien-Dindo classification[ 12 ], and postoperative hospital stay duration was documented. Evaluation of tumor resection margins defined clear margins as at least 1 mm away from the tumor. Surgical morbidity encompassed readmission within 30 days, while surgical mortality constituted mortality within 3 months. Statistical Analysis: All statistical analyses were conducted utilizing SPSS software (version 23; IBM Corp., Armonk, NY, USA). Non-normally distributed continuous variables were recorded as medians with interquartile range (IQR), and differences were assessed using the Mann-Whitney U test, while categorical variables were presented as numbers and frequencies (%) and compared using the Chi-squared test or Fisher's exact test. A significance level of P < 0.05 (two-tailed) was considered statistically significant. Result A total of 57 patients were included in the study, comprising 37 in the laparoscopic group and 20 in the open hepatectomy group. Patient characteristics for both LRLR and open repeat liver resection (ORLR) are summarized in Table 1 . The majority of patients were male, accounting for 32 male patients (86.5%) in the laparoscopic group and 13 male patients (65%) in the open hepatectomy group. Body mass index (BMI) was comparable between both groups. Most patients with recurrent HCC exhibited either HBV or HCV infection, with one patient in each group presenting combined HBV and HCV infection. Notably, the proportion of patients with HCV was significantly higher in the open group. All patients were classified as Child Pugh class A at the time of hepatectomy, displaying adequate Eastern Cooperative Oncology Group (ECOG)and American society of anesthesiologist (ASA) statuses. Within the LRLR group, the majority underwent laparoscopic hepatectomy as their initial operation, yet 11 patients (29.7%) previously underwent open hepatectomy. All patients were categorized as BCLC stage 0 or A during the era of repeat hepatectomy, regardless of laparoscopic or open approach. Table 1 Demographic data Laparoscopic N = 37 Open N = 20 p Age, years 63[61–70] 67.5[58–73] 0.508 Sex, male (%) 32(86.5%) 13(65%) 0.088 BMI 25.35[23.06–27.1] 23.83[22.18–24.83] 0.21 Hepatitis HBV 18(48.6%) 6(30%) 0.174 HCV 11(29.7%) 12(60%) 0.026 Non B and non C 9(24.3%) 3(15%) 0.51 Liver function Child-Pugh Score* NA A 100% 100% B 0 0 C 0 0 Previous operation <0.001 Laparoscopic hepatectomy 26(70.3%) 0 Open hepatectomy 11(29.7%) 20(100%) ECOG 0[0–1] 0[0–0] 0.304 ASA 3[ 3 – 3 ] 3[ 3 – 3 ] 0.294 Tumor size BCLC stage 0 8(21.4%) 4(20%) A 29(78.6%) 16(80%) *Child-Pugh Score missing: 3.5%; BMI: body mass index HBV: hepatitis B virus, HCV: hepatitis C virus, ECOG: Eastern Cooperative Oncology Group, ASA: American society of anesthesiologist, BCLC stage: Barcelona Clinic Liver Cancer stage Table 2 illustrates that most patients underwent minor hepatectomy and lateral segmentectomy during repeat hepatectomy, with both groups utilizing intermittent Pringle’s maneuver intraoperatively. Notably, all patients in the laparoscopic group underwent a second operation. The ratio of major hepatectomy was slightly higher in the laparoscopic group compared to the open group, at 16.2% versus 10%. Table 2 Surgical characteristic Laparoscopic N = 37 Open N = 20 p Extension of resection 0.127 Lateral segmentectomy 2(5.4%) 5(25%) Minor hepatectomy 29(78.4%) 13(65%) Major hepatectomy (≥ 2 segments) 6(16.2%) 2(10%) Pringle maneuver 37(100%) 20(100%) Perioperative outcomes outlined in Table 3 indicate comparable operative times and blood loss between both groups, without statistical significance. Although the requirement for red blood cell (RBC) transfusion was similar, the laparoscopic group demonstrated a significantly higher incidence of plasma transfusion (median: 2 vs 0, p = 0.014). No conversions were observed in the laparoscopic group, and complication rates, 90-day readmission, mortality rates, and resectability were analogous between both groups. Notably, the laparoscopic group exhibited significantly shorter postoperative hospital stays (median: 5 vs 7, p < 0.001). Table 3 Perioperative outcome Laparoscopic N = 37 Open N = 20 p Operative time, min 230[184–319] 205.5[176–294] 0.553 Estimated blood loss, mL 200[50–400] 200[125–450] 0.468 Perioperative blood transfusion, U PRBC 0[0–0] 0[0–0] 0.681 FFP 2[0–2] 0[0–1] 0.014 Platelet 0[0–0] 0[0–0] 0.656 Conversion 0 NA NA Complications 1 CDC < IIIa 35(94.6%) 19(95%) CDC ≥ IIIa 2(5.4%) 1(5%) Hospital length of stays, days 5[ 5 – 7 ] 7[6.5–10] <0.001 Surgical margin < 1mm, n(%) 6(16.2%) 3(15%) 1 30 days Readmission 2(5.4%) 0 0.536 Mortality (90 days) 1(2.7%) 1(5%) 1 PRBC: packed red blood cell ,FFP: fresh frozen plasma, CDC: Clavien-Dindo Classification Furthermore, the distribution of procedures based on the year of operation is summarized in Fig. 3 . This graphical representation indicates a gradual increase in the number and proportion of laparoscopic repeat liver resections for recurrent HCC, accompanied by a decline in the number of open repeat liver resections. The first case of laparoscopic repeat liver resection was recorded in 2018, followed by a substantial increase in subsequent years. Discussion Hepatocellular carcinoma (HCC) stands as the 5th leading cause of cancer-related deaths globally and the second in Taiwan [ 1 , 2 ]. The heightened prevalence of hepatitis B and C infections significantly contributes to HCC's incidence, reaching 47.05 per 100,000 person-years [ 3 ]. Recurrence rates for HCC range between 50–80%, making repeat resection the preferred choice over other strategies like radiofrequency ablation (RFA), trans-arterial chemoembolization (TACE), chemotherapy, or targeted therapy, all of which offer limited treatment efficacy in cases of recurrence [ 6 , 13 ]. Repeat hepatectomy is regarded as a potentially curative approach for recurrent HCC, despite its inherent challenges. These challenges include repeated incisions through scar tissue, adhesions formed within the liver and hepatoduodenal ligament due to prior surgeries and altered anatomical structures post-reoperation [ 14 , 15 ]. Insufficient adhesiolysis poses risks of inadvertent organ injury and may compromise the effectiveness of the Pringle maneuver, potentially leading to uncontrollable bleeding during the hepatectomy procedure [ 16 ]. Our primary findings indicate that repeat resection using a laparoscopic approach in patients with prior hepatectomy, regardless of whether it was a traditional or laparoscopic approach, proves to be both safe and effective. Notably, this method does not extend operative times or elevate perioperative complications. Short-term outcomes appear to be comparable, if not superior, to patients undergoing open hepatectomy, with a noteworthy reduction in hospital stay attributed to the less invasive nature of the procedure. Initially, concerns arose about prolonged operative times during repeat laparoscopic liver resection due to the anticipated need for adhesiolysis and tumor exposure. However, our comprehensive timing methodology, starting at incision and concluding at skin closure, revealed that the operative time spent on adhesiolysis was compensated for by the closure duration in the era of repeat open hepatectomy. Utilizing a laparoscopic approach for recurrent HCC did not impose heightened physiological stress on patients, particularly concerning anesthesia duration. Notably, there was no increase in red blood cell transfusions in the laparoscopic group, signifying that blood loss remained controlled, attributed to meticulous parenchymal dissection and effective bleeding control. The application of pneumoperitoneum exerted pressure, preventing further venous oozing throughout the procedure. Despite equivalent blood loss, the laparoscopic group exhibited incidences of plasma infusion, a phenomenon linked to blood transfusions in previous literature and managed in our institution through goal-directed fluid management. Preemptive plasma infusion based on high stroke volume variation (SVV) aimed at preventing post-operative organ injury and, consequently, increased plasma infusion rates. Recent studies have advocated for protocolized plasma infusion based on SVV to prevent acute kidney injury in laparoscopic hepatectomy, a protocol we diligently adhered to for optimal patient care [ 17 ]. While laparoscopic hepatectomy for primary HCC has demonstrated its safety and efficacy, thereby facilitating quicker post-operative recovery and shorter hospital stays due to reduced blood loss and fewer complications [ 18 ], repeat laparoscopic hepatectomy presents heightened complexities. Challenges arise from adhesions resulting from prior surgeries and limited working space, especially if adequate adhesiolysis before hepatectomy is unsuccessful. However, our experience suggests that in-situ incisions with meticulous dissections or combined mini-laparotomies are viable approaches for individuals with a history of major abdominal operations [ 19 ]. In our practice, laparoscopic-assisted adhesiolysis proves beneficial in achieving an adequate surgical plane exposure. The cooperation of the pneumoperitoneum and the weight of adhesive organs facilitate step-by-step adhesiolysis without risking injury to hollow organs. Furthermore, advancements in anti-adhesive agents such as Seprafilm have notably reduced severe adhesions in patients undergoing a second operation. Our approach combines gentle blunt dissection with precise sharp cutting, enabling adequate adhesiolysis without causing injury to hollow organs. The regenerative process of the liver following hepatectomy alters the orientation of normal vascular structures, creating anatomical complexity during parenchymal dissection. Intraoperative ultrasound has demonstrated efficacy as a simple yet effective technique for tumor localization and defining the precise surgical plane for hepatectomy [ 20 ]. Utilizing repeat localization and accessing the resection plane and surgical margin during the release phase of the Pringle maneuver becomes crucial in overcoming post-hepatectomy liver regeneration-associated disorientation and preventing inadvertent injury to the Glissonean pedicles. Advancements in preoperative navigation methods have proven invaluable in surgical planning. The three-dimensional reconstruction of vessels and the biliary tree aids in preventing incidental iatrogenic injury [ 21 ]. Despite the challenges posed by disoriented vascular structures, our increased experience in hepatectomy enables us to rapidly adapt and comprehend these changes through a comprehensive preoperative review. Additionally, the use of repeat intraoperative ultrasound and ICG (indocyanine green) scope navigation assists in correlating preoperative imaging with intraoperative structural changes, ensuring greater surgical precision [ 22 ]. The intermittent Pringle maneuver, involving 15 − 5 minutes of occlusion and release periods, plays a crucial role in minimizing bleeding during hepatectomy. Liver hypertrophy following regeneration, well-documented in previous studies [ 23 ], renders the liver more susceptible to bleeding during surgical intervention. In the context of Repeat Laparoscopic Liver Resection (RLLR), the Pringle maneuver is pivotal in creating a dry surgical plane, thus averting bleeding-related complications like hypovolemia and hypotension. Through accumulated experience from multiple laparoscopic hepatectomies, our understanding of the relative positions between the hepatic hilum and adhesions has enabled us to identify the Foramen of Winslow and execute the Pringle maneuver using Huang’s loop in most cases. The enhanced operative field provided by scopes aids surgeons in clearer organ differentiation, yet necessitates limited dissection in each field, requiring repeated orientation before proceeding. In instances where Pringle maneuver execution was unsuccessful for two patients, the utilization of the bulldog clamp for at least hemi-vascular control facilitated parenchymal-sparing resection in the anterior segment. Our experience, reflected in the laparoscopic group's morbidity greater than grade III at 5.4% and 5% in the open group, displayed no statistical significance. Perioperative mortality remained at 0%. With accumulated experience and a stepwise approach in laparoscopic repeat hepatectomy, we've been able to offer a safer treatment option for patients with recurrent liver cancer. Our data showcased that the safety and absence of conversions in laparoscopic repeat liver resection were on par with traditional approaches. The initial case of laparoscopic repeat liver resection was conducted during the 77th laparoscopic operation. As per previous literature reviews, learning curve analyses for laparoscopic hepatectomy suggest that around 60 cases can be considered a mature phase [ 24 ]. We propose considering Laparoscopic Repeat Liver Resection (LRLH) for patients with recurrent HCC when the surgical team attains maturity in laparoscopic hepatectomy. There has been a noticeable shift in the treatment preference for recurrent HCC, among both patients and surgeons. Though our follow-up period remains relatively short, existing studies support the superior outcomes of repeat hepatectomy in recurrent HCC. Achieving a comparable ratio of R0 resections in laparoscopic repeat liver resection suggests its recommendation for patients seeking curative treatment in the hands of an experienced surgical team. Limitations While our study aims to be comprehensive, its retrospective nature might harbor selection biases, though the preference for laparoscopic procedures might counteract this. The study's small sample size and short follow-up duration could limit accurate depiction of oncological outcomes. Randomized studies with extended follow-ups would substantiate our findings. Conclusion Repeat laparoscopic liver resection proves feasible and safe for patients with recurrent intrahepatic HCC with shorter post-operative hospital stay. It doesn't prolong operative time for experienced surgical teams and could potentially shift treatment trends for recurrent HCC. Successful outcomes hinge on adequate adhesiolysis, intraoperative ultrasound guidance, ICG scope use for tumor localization, and effective Pringle's maneuver for hemorrhage control during parenchymal transection. A matured surgical team could confidently provide the treatment choice to the patients after at least 80 cases of laparoscopic liver resection even in the pioneer setting. Declarations Conflict of Interest The authors declare that there are no commercial or financial relationships that could be construed as a potential conflict of interest in this manuscript. Author Contributions Y.C.C wrote the manuscript; Y.C.C and R.S.S designed the research; P.H.C and S.W.C collected the data；C.Y.C analyzed the data. Funding The study was supported by Keelung Chang Gung Memorial Hospital and National Yang Ming Chiao Tung University Joint Research Program (CORPG2P0031). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Availability of data and materials The data that support the findings of this study are available from the corresponding author upon reasonable request Acknowledgments The author acknowledges all the patients participate in this study and the team participating in the perioperative care. Competing interests The authors declare no competing interests. Ethical approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki. Because of the retrospective nature of this study, need for approval of the study was waived by ethics committee of Chang Gung Memorial Hospital. All methods were carried out in accordance with relevant guidelines and regulations in the ethics and consent to participate under declaration section. Due to the retrospective nature of this study, the informed consent was agreed to be waived by the Ethics Committee/Institutional Review Board of Chang Gung Memorial hospital. Consent for publication Not applicable. References Bertuccio P, Turati F, Carioli G, Rodriguez T, La Vecchia C, Malvezzi M, Negri E: Global trends and predictions in hepatocellular carcinoma mortality. J Hepatol 2017, 67: 302-309. 111 年國人死因統計結果 [https://www.mohw.gov.tw/dl-83733-80fb9ab8-ea2d-4e3e-ba06-f70f28aca036.html] Shao Y-Y, Wang S-Y, Lin S-M, Chen K-Y, Tseng J-H, Ho M-C, Lee R-C, Liang P-C, Liao L-Y, Huang K-W, et al: Management consensus guideline for hepatocellular carcinoma: 2020 update on surveillance, diagnosis, and systemic treatment by the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3950020","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":272967556,"identity":"1bd7eda2-c983-4296-a36b-7e815b94afc2","order_by":0,"name":"YiChan Chen","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"YiChan","middleName":"","lastName":"Chen","suffix":""},{"id":272967557,"identity":"d5ad3aad-3730-468a-bc17-3b99af6f36ec","order_by":1,"name":"Ruey-Shyang Soong","email":"","orcid":"","institution":"Taipei Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ruey-Shyang","middleName":"","lastName":"Soong","suffix":""},{"id":272967558,"identity":"3629f221-37f8-4954-9d05-9b47e1d1ff0f","order_by":2,"name":"Po-Hsing Chiang","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Po-Hsing","middleName":"","lastName":"Chiang","suffix":""},{"id":272967559,"identity":"76da22f2-db50-4b4b-945c-bc487781a5c1","order_by":3,"name":"Shion Wei Chai","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shion","middleName":"Wei","lastName":"Chai","suffix":""},{"id":272967560,"identity":"0e890b30-06cd-4898-bf2a-743b4fa06e30","order_by":4,"name":"Chih-Ying Chien","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYBACA4YDCQcSGBjkDCBcC+K1GBswMIO4EsRogYDEDWAtDERoMWc88PDAw5xt6dvZ+49u+FEgwcDf3p2AV4tlA9Bhidtu5+7sOcx2swfoMIkzZzfgd9gBqJYNN5LZbvAAtRhI5BKnJd0AqOXmH1K0JIC03CbJFsMNZw6b3ZYxkOAh7JcbZ5I//tx2W97geOOzm2/+2Mjxt/fi1wIMoAQUPg9+5SDA336AsKJRMApGwSgY2QAAY9hVRtQie+0AAAAASUVORK5CYII=","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":true,"prefix":"","firstName":"Chih-Ying","middleName":"","lastName":"Chien","suffix":""}],"badges":[],"createdAt":"2024-02-12 03:03:52","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3950020/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3950020/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51238319,"identity":"342e12bc-53a6-440a-91af-87d726e49f56","added_by":"auto","created_at":"2024-02-16 16:48:49","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":313935,"visible":true,"origin":"","legend":"\u003cp\u003eFollow up strategy for the patients diagnosed Hepatocellular carcinoma (HCC) underwent curative intent treatment.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3950020/v1/28342c69edead8501872976e.jpg"},{"id":51238321,"identity":"c864342e-94e3-40e7-b093-55cb0996956c","added_by":"auto","created_at":"2024-02-16 16:48:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":234330,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Flow chart of patient selection process for repeat hepatectomy in recurrent HCC: hepatocellular carcinoma, TACE: trans-arterial chemo-embolization, RFA: radiofrequency ablation.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3950020/v1/6d8a624d3801c370721beeea.jpg"},{"id":51238320,"identity":"4d687cba-babb-4f9f-98cc-4a2c36ff677d","added_by":"auto","created_at":"2024-02-16 16:48:50","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":173941,"visible":true,"origin":"","legend":"\u003cp\u003eTrend of surgical management for resectable recurrent HCC in our institution\u003c/p\u003e\n\u003cp\u003eHCC: Hepatocellular carcinoma\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3950020/v1/dcc1013b04fac39632b58384.jpg"},{"id":54217119,"identity":"e2886175-7934-4a18-b822-7e952acab96a","added_by":"auto","created_at":"2024-04-06 15:22:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1058387,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3950020/v1/b06214a2-c86a-4720-94e9-311e1fb9d8bc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Revisiting the Surgical Approach for Recurrent Hepatocellular Carcinoma: Insights from a Single Institute's Experience in Overcoming Challenges","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHepatocellular carcinoma (HCC) ranks as the 3rd leading cause of cancer-related mortality globally, with a noticeable increase in mortality over recent decades [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Taiwan, characterized by a high prevalence of Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, experiences an elevated incidence of HCC, standing as the 2nd leading cause of cancer-related deaths in the country [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Employing a multidisciplinary approach aligned with the Barcelona Clinic Liver Cancer (BCLC) classification is widely acknowledged and seeks to enhance the treatment outcomes for HCC [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile liver resection can yield 60 to 80 percent 5-year overall survival rates in early-stage HCC, recurrence rates surge in patients\u0026rsquo; post-primary treatment, reaching up to 80% according to various reports [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Among the treatment options for recurrent HCC, repeat resection emerges as a promising avenue for improved survival [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe safety and feasibility of laparoscopic liver resection (LLR) in treating hepatocellular carcinoma have been established in international consensus meetings [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, laparoscopic repeat liver resection (LRLR) is perceived as a more challenging procedure due to adhesions from prior operations, altered normal structural orientation, and the need for highly selective patients and experienced surgeons [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These complexities often hinder a surgeon's decision to opt for a repeat laparoscopic approach. Notably, recent advancements in technologies such as indocyanine green (ICG) scopes, robotic surgery, intra-operative image guidance, and enhanced bleeding control, as discussed in the latest international laparoscopic liver surgery (ILLS) consensus, signify the evolving landscape of laparoscopic liver resection [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Moreover, the most comprehensive multicentric propensity score-matched observational study has reaffirmed the feasibility and safety of LRLR [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe decision to adopt a laparoscopic approach for recurrent intrahepatic malignancies is significantly influenced by surgeons' experience and familiarity with the procedure. Furthermore, most literature on LRLR originates from high-volume centers [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Previously considered a relative contraindication, especially for novice laparoscopic liver surgeons, laparoscopic repeat liver resection challenges traditional concepts. In this retrospective study, we aim to explore the optimal timing for the surgical team to undertake the initial repeat laparoscopic liver resection and compare the short-term perioperative outcomes between LRLR and open hepatectomy in a pioneer team to perform laparoscopic hepatectomy. This study marks the pioneering endeavor to investigate the optimal timing of the surgical team's transition from traditional surgery to a minimally invasive approach for patients with recurrent HCC.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Selection:\u003c/h2\u003e \u003cp\u003eA retrospective study spanning from January 2009 to December 2021 was conducted at Chang Gung Memorial Hospital, Keelung. Approval for this study was obtained from the Institutional Review Board of Chang Gung Memorial Hospital (IRB No. 02300984B0). The study enrolled patients who underwent surgical management for recurrent HCC and the selection of patients is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Open repeat liver resection was carried out by seasoned liver surgeons at the time of diagnosis. In contrast, laparoscopic repeat liver resection was performed by a dedicated team comprising two fixed surgeons, recognized pioneers in laparoscopic liver resection within our institution. Diagnosis of recurrence was established through preoperative dynamic abdominal computed tomography or magnetic resonance imaging. Assessment of preoperative liver function was conducted using basic liver function tests, Child-Pugh Score, and Indocyanine green (ICG) test. A multidisciplinary team consisting of medical doctors specializing in radiofrequency ablation (RFA), hepatobiliary surgery, radiology, radiation oncology, and medical oncology was involved in the pre-treatment evaluation of all patients. The choice of operative procedure was determined based on preserved liver function, tumor characteristics (location and size), and the patient's previous surgical history.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Procedure:\u003c/h2\u003e \u003cp\u003ePatients were positioned on a rotating table in the supine position with suspended legs, transitioning to a reversed Trendelenburg position during laparoscopic liver resection. For tumors located in the left lobe or anterior segment, upper arm extensions were utilized, while patients with tumors in the right posterior segment were positioned in the left hemi-lateral decubitus position. A Hasson method was employed to insert a camera port at the supra-umbilical position, and extended adhesiolysis was performed around the incision to create adequate operational space, addressing any noted adhesions. Subsequent trocars were inserted step by step following the initial port, utilizing electrical cutting, monopolar coagulation, or energy devices for further adhesiolysis and trocar insertion. Trocar placement was optimized based on tumor location to facilitate liver rotation and adhesion dissection from previous surgeries. Intraoperative navigation using the ICG scope (Stryker, Kalamazoo, MI, USA) and intraoperative ultrasonography guided parenchymal transection, ensuring adequate margins, especially for lesions not readily visible. Successful procedures were conducted via pure laparoscopic liver resection.\u003c/p\u003e \u003cp\u003e Hepatic parenchymal resection involved the crush-clamp method using Harmonic Hi10000 (Ethicon Endo-Surgery, Cincinnati, OH, USA), Cavitron ultrasonic surgical aspirator (CUSA), and a bipolar clamp coagulation system (Karl Storz Endoscope, Tuttlingen, Germany). Routine utilization of the Pringle maneuver by Huang's loop [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] was applied, with partial vascular control using Debakey Bulldog clamp (GerMed USA, New York, USA )in cases of severe adhesions around the hepatoduodenal ligament. Seprafilm membrane (Baxter, Deerfield, Illinois, USA) application aimed to prevent postoperative adhesions around the resection margin, inferior vena cava (IVC), hepatoduodenal ligament, and under the midline mini-laparotomy wound in all patients. Closed system drains employing the Jackson-Pratt draining system were inserted around the liver parenchymal cut surface at surgery's conclusion, later removed after postoperative days once diet intake commenced, and no bile leakage was detected. Prophylactic antibiotics were administered preoperatively, repeated every 4 hours during surgery, and continued for one postoperative day. All patients received multidisciplinary peri-operative pain management.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePerioperative Outcome:\u003c/h2\u003e \u003cp\u003eRecorded parameters included intraoperative blood loss, need for blood transfusion, and surgical duration, subsequently compared. Complications were graded according to the Clavien-Dindo classification[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and postoperative hospital stay duration was documented. Evaluation of tumor resection margins defined clear margins as at least 1 mm away from the tumor. Surgical morbidity encompassed readmission within 30 days, while surgical mortality constituted mortality within 3 months.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis:\u003c/h2\u003e \u003cp\u003eAll statistical analyses were conducted utilizing SPSS software (version 23; IBM Corp., Armonk, NY, USA). Non-normally distributed continuous variables were recorded as medians with interquartile range (IQR), and differences were assessed using the Mann-Whitney U test, while categorical variables were presented as numbers and frequencies (%) and compared using the Chi-squared test or Fisher's exact test. A significance level of P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (two-tailed) was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Result","content":"\u003cp\u003eA total of 57 patients were included in the study, comprising 37 in the laparoscopic group and 20 in the open hepatectomy group. Patient characteristics for both LRLR and open repeat liver resection (ORLR) are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The majority of patients were male, accounting for 32 male patients (86.5%) in the laparoscopic group and 13 male patients (65%) in the open hepatectomy group. Body mass index (BMI) was comparable between both groups. Most patients with recurrent HCC exhibited either HBV or HCV infection, with one patient in each group presenting combined HBV and HCV infection. Notably, the proportion of patients with HCV was significantly higher in the open group. All patients were classified as Child Pugh class A at the time of hepatectomy, displaying adequate Eastern Cooperative Oncology Group (ECOG)and American society of anesthesiologist (ASA) statuses. Within the LRLR group, the majority underwent laparoscopic hepatectomy as their initial operation, yet 11 patients (29.7%) previously underwent open hepatectomy. All patients were categorized as BCLC stage 0 or A during the era of repeat hepatectomy, regardless of laparoscopic or open approach.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLaparoscopic\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;20\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63[61\u0026ndash;70]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67.5[58\u0026ndash;73]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.508\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex, male (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32(86.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13(65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.088\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.35[23.06\u0026ndash;27.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.83[22.18\u0026ndash;24.83]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHepatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHBV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18(48.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.174\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHCV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11(29.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12(60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan style='font-size:16px;font-family:\"Calibri\",sans-serif;color:red;'\u003e0.026\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon B and non C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9(24.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLiver function\u003c/p\u003e\n \u003cp\u003eChild-Pugh Score*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrevious operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan style='font-size:16px;font-family:\"Calibri\",sans-serif;color:red;'\u003e\u0026lt;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLaparoscopic hepatectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26(70.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOpen hepatectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11(29.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eECOG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0[0\u0026ndash;1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0[0\u0026ndash;0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.304\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eASA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3[\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3[\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.294\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTumor size\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBCLC stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8(21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29(78.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16(80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e*Child-Pugh Score missing: 3.5%;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eBMI: body mass index HBV: hepatitis B virus, HCV: hepatitis C virus, ECOG: Eastern Cooperative Oncology Group, ASA: American society of anesthesiologist, BCLC stage: Barcelona Clinic Liver Cancer stage\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates that most patients underwent minor hepatectomy and lateral segmentectomy during repeat hepatectomy, with both groups utilizing intermittent Pringle\u0026rsquo;s maneuver intraoperatively. Notably, all patients in the laparoscopic group underwent a second operation. The ratio of major hepatectomy was slightly higher in the laparoscopic group compared to the open group, at 16.2% versus 10%.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSurgical characteristic\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLaparoscopic\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;20\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExtension of resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.127\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLateral segmentectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMinor hepatectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29(78.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13(65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMajor hepatectomy\u003c/p\u003e\n \u003cp\u003e(\u0026ge;\u0026thinsp;2 segments)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePringle maneuver\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003ePerioperative outcomes outlined in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e indicate comparable operative times and blood loss between both groups, without statistical significance. Although the requirement for red blood cell (RBC) transfusion was similar, the laparoscopic group demonstrated a significantly higher incidence of plasma transfusion (median: 2 vs 0, p\u0026thinsp;=\u0026thinsp;0.014). No conversions were observed in the laparoscopic group, and complication rates, 90-day readmission, mortality rates, and resectability were analogous between both groups. Notably, the laparoscopic group exhibited significantly shorter postoperative hospital stays (median: 5 vs 7, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePerioperative outcome\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLaparoscopic\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;20\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOperative time, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e230[184\u0026ndash;319]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e205.5[176\u0026ndash;294]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.553\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEstimated blood loss, mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e200[50\u0026ndash;400]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e200[125\u0026ndash;450]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.468\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerioperative blood transfusion, U\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePRBC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0[0\u0026ndash;0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0[0\u0026ndash;0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.681\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFFP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2[0\u0026ndash;2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0[0\u0026ndash;1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan style='font-size:16px;font-family:\"Calibri\",sans-serif;color:red;'\u003e0.014\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePlatelet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0[0\u0026ndash;0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0[0\u0026ndash;0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.656\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConversion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCDC\u0026thinsp;\u0026lt;\u0026thinsp;IIIa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35(94.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19(95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCDC\u0026thinsp;\u0026ge;\u0026thinsp;IIIa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHospital length of stays, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7[6.5\u0026ndash;10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan style='font-size:16px;font-family:\"Calibri\",sans-serif;color:red;'\u003e\u0026lt;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgical margin\u0026thinsp;\u0026lt;\u0026thinsp;1mm, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 days Readmission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.536\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMortality (90 days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ePRBC: packed red blood cell ,FFP: fresh frozen plasma, CDC: Clavien-Dindo Classification\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFurthermore, the distribution of procedures based on the year of operation is summarized in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. This graphical representation indicates a gradual increase in the number and proportion of laparoscopic repeat liver resections for recurrent HCC, accompanied by a decline in the number of open repeat liver resections. The first case of laparoscopic repeat liver resection was recorded in 2018, followed by a substantial increase in subsequent years.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHepatocellular carcinoma (HCC) stands as the 5th leading cause of cancer-related deaths globally and the second in Taiwan [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The heightened prevalence of hepatitis B and C infections significantly contributes to HCC's incidence, reaching 47.05 per 100,000 person-years [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Recurrence rates for HCC range between 50\u0026ndash;80%, making repeat resection the preferred choice over other strategies like radiofrequency ablation (RFA), trans-arterial chemoembolization (TACE), chemotherapy, or targeted therapy, all of which offer limited treatment efficacy in cases of recurrence [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Repeat hepatectomy is regarded as a potentially curative approach for recurrent HCC, despite its inherent challenges. These challenges include repeated incisions through scar tissue, adhesions formed within the liver and hepatoduodenal ligament due to prior surgeries and altered anatomical structures post-reoperation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Insufficient adhesiolysis poses risks of inadvertent organ injury and may compromise the effectiveness of the Pringle maneuver, potentially leading to uncontrollable bleeding during the hepatectomy procedure [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur primary findings indicate that repeat resection using a laparoscopic approach in patients with prior hepatectomy, regardless of whether it was a traditional or laparoscopic approach, proves to be both safe and effective. Notably, this method does not extend operative times or elevate perioperative complications. Short-term outcomes appear to be comparable, if not superior, to patients undergoing open hepatectomy, with a noteworthy reduction in hospital stay attributed to the less invasive nature of the procedure. Initially, concerns arose about prolonged operative times during repeat laparoscopic liver resection due to the anticipated need for adhesiolysis and tumor exposure. However, our comprehensive timing methodology, starting at incision and concluding at skin closure, revealed that the operative time spent on adhesiolysis was compensated for by the closure duration in the era of repeat open hepatectomy.\u003c/p\u003e \u003cp\u003eUtilizing a laparoscopic approach for recurrent HCC did not impose heightened physiological stress on patients, particularly concerning anesthesia duration. Notably, there was no increase in red blood cell transfusions in the laparoscopic group, signifying that blood loss remained controlled, attributed to meticulous parenchymal dissection and effective bleeding control. The application of pneumoperitoneum exerted pressure, preventing further venous oozing throughout the procedure. Despite equivalent blood loss, the laparoscopic group exhibited incidences of plasma infusion, a phenomenon linked to blood transfusions in previous literature and managed in our institution through goal-directed fluid management. Preemptive plasma infusion based on high stroke volume variation (SVV) aimed at preventing post-operative organ injury and, consequently, increased plasma infusion rates. Recent studies have advocated for protocolized plasma infusion based on SVV to prevent acute kidney injury in laparoscopic hepatectomy, a protocol we diligently adhered to for optimal patient care [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile laparoscopic hepatectomy for primary HCC has demonstrated its safety and efficacy, thereby facilitating quicker post-operative recovery and shorter hospital stays due to reduced blood loss and fewer complications [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], repeat laparoscopic hepatectomy presents heightened complexities. Challenges arise from adhesions resulting from prior surgeries and limited working space, especially if adequate adhesiolysis before hepatectomy is unsuccessful. However, our experience suggests that in-situ incisions with meticulous dissections or combined mini-laparotomies are viable approaches for individuals with a history of major abdominal operations [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In our practice, laparoscopic-assisted adhesiolysis proves beneficial in achieving an adequate surgical plane exposure. The cooperation of the pneumoperitoneum and the weight of adhesive organs facilitate step-by-step adhesiolysis without risking injury to hollow organs. Furthermore, advancements in anti-adhesive agents such as Seprafilm have notably reduced severe adhesions in patients undergoing a second operation. Our approach combines gentle blunt dissection with precise sharp cutting, enabling adequate adhesiolysis without causing injury to hollow organs.\u003c/p\u003e \u003cp\u003eThe regenerative process of the liver following hepatectomy alters the orientation of normal vascular structures, creating anatomical complexity during parenchymal dissection. Intraoperative ultrasound has demonstrated efficacy as a simple yet effective technique for tumor localization and defining the precise surgical plane for hepatectomy [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Utilizing repeat localization and accessing the resection plane and surgical margin during the release phase of the Pringle maneuver becomes crucial in overcoming post-hepatectomy liver regeneration-associated disorientation and preventing inadvertent injury to the Glissonean pedicles. Advancements in preoperative navigation methods have proven invaluable in surgical planning. The three-dimensional reconstruction of vessels and the biliary tree aids in preventing incidental iatrogenic injury [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Despite the challenges posed by disoriented vascular structures, our increased experience in hepatectomy enables us to rapidly adapt and comprehend these changes through a comprehensive preoperative review. Additionally, the use of repeat intraoperative ultrasound and ICG (indocyanine green) scope navigation assists in correlating preoperative imaging with intraoperative structural changes, ensuring greater surgical precision [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe intermittent Pringle maneuver, involving 15\u0026thinsp;\u0026minus;\u0026thinsp;5 minutes of occlusion and release periods, plays a crucial role in minimizing bleeding during hepatectomy. Liver hypertrophy following regeneration, well-documented in previous studies [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], renders the liver more susceptible to bleeding during surgical intervention. In the context of Repeat Laparoscopic Liver Resection (RLLR), the Pringle maneuver is pivotal in creating a dry surgical plane, thus averting bleeding-related complications like hypovolemia and hypotension. Through accumulated experience from multiple laparoscopic hepatectomies, our understanding of the relative positions between the hepatic hilum and adhesions has enabled us to identify the Foramen of Winslow and execute the Pringle maneuver using Huang\u0026rsquo;s loop in most cases. The enhanced operative field provided by scopes aids surgeons in clearer organ differentiation, yet necessitates limited dissection in each field, requiring repeated orientation before proceeding. In instances where Pringle maneuver execution was unsuccessful for two patients, the utilization of the bulldog clamp for at least hemi-vascular control facilitated parenchymal-sparing resection in the anterior segment.\u003c/p\u003e \u003cp\u003eOur experience, reflected in the laparoscopic group's morbidity greater than grade III at 5.4% and 5% in the open group, displayed no statistical significance. Perioperative mortality remained at 0%. With accumulated experience and a stepwise approach in laparoscopic repeat hepatectomy, we've been able to offer a safer treatment option for patients with recurrent liver cancer.\u003c/p\u003e \u003cp\u003eOur data showcased that the safety and absence of conversions in laparoscopic repeat liver resection were on par with traditional approaches. The initial case of laparoscopic repeat liver resection was conducted during the 77th laparoscopic operation. As per previous literature reviews, learning curve analyses for laparoscopic hepatectomy suggest that around 60 cases can be considered a mature phase [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. We propose considering Laparoscopic Repeat Liver Resection (LRLH) for patients with recurrent HCC when the surgical team attains maturity in laparoscopic hepatectomy. There has been a noticeable shift in the treatment preference for recurrent HCC, among both patients and surgeons. Though our follow-up period remains relatively short, existing studies support the superior outcomes of repeat hepatectomy in recurrent HCC. Achieving a comparable ratio of R0 resections in laparoscopic repeat liver resection suggests its recommendation for patients seeking curative treatment in the hands of an experienced surgical team.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eWhile our study aims to be comprehensive, its retrospective nature might harbor selection biases, though the preference for laparoscopic procedures might counteract this. The study's small sample size and short follow-up duration could limit accurate depiction of oncological outcomes. Randomized studies with extended follow-ups would substantiate our findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRepeat laparoscopic liver resection proves feasible and safe for patients with recurrent intrahepatic HCC with shorter post-operative hospital stay. It doesn't prolong operative time for experienced surgical teams and could potentially shift treatment trends for recurrent HCC. Successful outcomes hinge on adequate adhesiolysis, intraoperative ultrasound guidance, ICG scope use for tumor localization, and effective Pringle's maneuver for hemorrhage control during parenchymal transection. A matured surgical team could confidently provide the treatment choice to the patients after at least 80 cases of laparoscopic liver resection even in the pioneer setting.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflict of Interest\u003c/h2\u003e\n\u003cp\u003eThe authors declare that there are no commercial or financial relationships that could be construed as a potential conflict of interest in this manuscript.\u003c/p\u003e\n\u003ch2\u003eAuthor Contributions\u003c/h2\u003e\n\u003cp\u003eY.C.C wrote the manuscript; Y.C.C and R.S.S designed the research; P.H.C and S.W.C collected the data；C.Y.C analyzed the data.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe study was supported by Keelung Chang Gung Memorial Hospital and National Yang Ming Chiao Tung University Joint Research Program (CORPG2P0031). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request\u003c/p\u003e\n\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eThe author acknowledges all the patients participate in this study and the team participating in the perioperative care.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eEthical approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eBecause of the retrospective nature of this study, need for approval of the study was waived by ethics committee of Chang Gung Memorial Hospital. All methods were carried out in accordance with relevant guidelines and regulations in the ethics and consent to participate under declaration section. Due to the retrospective nature of this study, the informed consent was agreed to be waived by the Ethics Committee/Institutional Review Board of Chang Gung Memorial hospital.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBertuccio P, Turati F, Carioli G, Rodriguez T, La Vecchia C, Malvezzi M, Negri E: \u003cstrong\u003eGlobal trends and predictions in hepatocellular carcinoma mortality.\u003c/strong\u003e \u003cem\u003eJ Hepatol\u0026nbsp;\u003c/em\u003e2017, \u003cstrong\u003e67:\u003c/strong\u003e302-309.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003e111\u003c/strong\u003e\u003cstrong\u003e年國人死因統計結果\u0026nbsp;\u003c/strong\u003e[https://www.mohw.gov.tw/dl-83733-80fb9ab8-ea2d-4e3e-ba06-f70f28aca036.html]\u003c/li\u003e\n \u003cli\u003eShao Y-Y, Wang S-Y, Lin S-M, Chen K-Y, Tseng J-H, Ho M-C, Lee R-C, Liang P-C, Liao L-Y, Huang K-W, et al: 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improved feasibility and reproducibility.\u003c/strong\u003e \u003cem\u003eAnn Surg\u0026nbsp;\u003c/em\u003e2009, \u003cstrong\u003e250:\u003c/strong\u003e772-782.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hepatocellular carcinoma, minimally invasive hepatectomy, repeat hepat","lastPublishedDoi":"10.21203/rs.3.rs-3950020/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3950020/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction:\u003c/p\u003e\n\u003cp\u003eHepatocellular 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.\u003c/p\u003e\n\u003cp\u003ePatients and methods:\u003c/p\u003e\n\u003cp\u003eWe 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.\u003c/p\u003e\n\u003cp\u003eResults:\u003c/p\u003e\n\u003cp\u003eNotably, both groups exhibited similar operative times and perioperative outcomes, with significantly reduced hospital stays observed in the laparoscopic cohort (median: 5 vs 7, p\u0026lt;0.001). The introduction of laparoscopic techniques also sparked a strategy shifting in our surgical approach to recurrent HCC.\u003c/p\u003e\n\u003cp\u003eConclusion:\u003c/p\u003e\n\u003cp\u003eOur 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.\u003c/p\u003e","manuscriptTitle":"Revisiting the Surgical Approach for Recurrent Hepatocellular Carcinoma: Insights from a Single Institute's Experience in Overcoming Challenges","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-16 16:48:45","doi":"10.21203/rs.3.rs-3950020/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e9c10715-6b85-4b3c-8fa1-d11a48e32979","owner":[],"postedDate":"February 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-06T15:14:54+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-16 16:48:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3950020","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3950020","identity":"rs-3950020","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}