Surgical management (resection)

Hepatocellular carcinoma (HCC) is the fifth most common neoplasm worldwide, affecting more than 600, 000 people annually (1). Though less prevalent in the United States, the estimated annual number of cases exceeds 16, 000. Moreover, despite a decline in alcoholic liver disease and increased use of hepatitis B immunization strategies, the incidence in our country is steadily rising and has doubled between 1975 and 1998, likely due to an increase in hepatitis C virus infection (2). In the majority of patients, HCC develops in fibrotic/cirrhotic livers, and cirrhosis represents the strongest predisposing factor. The natural history of untreated HCC varies depending on the stage at presentation and the degree of underlying liver disease. However, even in patients with early stages, the prognosis is grim if the disease is left untreated (3, 4). As primary medical therapy has failed to significantly improve survival, surgical resection and orthotopic liver transplantation (OLT) represent the only treatment options, offering a prospect for cure with 5-year survival rates of up to 50% (5–7) and 70% (8, 9), respectively. Unfortunately, only approximately 20% to 40% (10, 11) of patients are candidates for resection due to the burden of hepatic tumor, the presence of extrahepatic spread or the extent of underlying liver disease. Despite this, liver resections are increasingly being performed due to better perioperative care, improved imaging and advances in surgical technique.