Resection of Large Hepatocellular Carcinoma: Hanging Technique
Executive Summary
The surgical management of Hepatocellular Carcinoma (HCC) has evolved significantly, particularly for tumors categorized as "large" (5–10 cm) or "huge" (greater than 10 cm). Historically, these cases were often deemed unresectable due to high risks of intraoperative hemorrhage and mortality. However, the development of specialized liver-hanging maneuvers (LHM) has revolutionized outcomes.
Key advancements include:
Mortality and Blood Loss Reduction: Mortality rates for resections of large tumors have dropped from 10% in the 1980s to less than 0.7%, while intraoperative blood loss has been reduced from approximately 2,000 ml to 250 ml.
Methodological Shift: The transition from conventional full mobilization to the Anterior Approach (AA) and eventually to Hanging Maneuvers allows for parenchymal transection without early mobilization of the liver. This minimizes risks such as tumor rupture, cell dissemination, and massive bleeding from the inferior vena cava (IVC).
Technique Superiority: While the Belghiti Hanging Maneuver introduced the use of a retrohepatic tunnel for liver suspension, it involves a blind dissection with a 4–6% risk of massive bleeding. The Chen Double-Hanging Maneuver offers a safer alternative by utilizing a true avascular space on the right side of the IVC, achieving a 100% success rate in tunnel formation and superior hemostasis.
Evolution of Surgical Approaches for Large HCC
Large and huge tumors account for approximately 70% of HCC diagnoses. While once considered inoperable, theoretical safety has been established through the understanding that larger tumors often require the resection of less tumor-free tissue than smaller tumors during anatomic resections.
Limitations of Conventional Techniques
Full Mobilization: Conventionally, right hepatectomy requires full mobilization of the right hemi-liver before parenchymal transection. This is often impossible with huge tumors or diaphragmatic invasion. Risks include:
Tumor rupture from excessive pull.
Tumor cell dissemination from manipulation.
Massive bleeding from tearing short hepatic veins from the IVC.
Standard Anterior Approach (AA): Transection starts from the anterior surface toward the IVC without primary mobilization. The primary drawback is poor exposure, making it difficult to control bleeding from deeper parenchymal tissues.
The Liver-Hanging Maneuver (LHM)
The LHM was proposed to overcome the exposure challenges of the anterior approach. It involves passing a tape through the retrohepatic space between the anterior surface of the IVC and the liver parenchyma.
Belghiti-Hanging Maneuver
Mechanism: A long vascular clamp is passed blindly through the retrohepatic space, starting from the infrahepatic portion of the IVC and emerging between the right and middle hepatic veins.
Anatomical Basis: Relies on a longitudinal avascular plane between the IVC and the liver, first suggested by Couinaud in 1981.
Advantages:
Reduced operative time and blood loss.
Avoidance of liver rotation (lowering dissemination risk).
Better hemostasis of the deeper section plane and IVC protection.
Challenges: The blind dissection is technically demanding. Approximately 7–15% of the passage is not truly avascular, and the retrohepatic IVC may be compressed or bent in cirrhotic patients, leading to a reported massive bleeding rate of 4–6%.
Chen’s Double-Hanging Maneuver
This improved technique involves building a retrohepatic tunnel through a true avascular space containing only loose connective tissue on the right side of the IVC.
Modified Single-Hanging Maneuver: A variation using a single tape on the remnant side can be applied in laparoscopic or robotic-assisted surgeries (applied in over 100 cases) when the liver can be partially mobilized or space is sufficient.
Clinical Case Study: 15 cm Huge HCC
A case study of a 68-year-old female HBV carrier illustrates the practical application of Chen’s Double-Hanging Maneuver.
Preoperative Assessment and Management
Diagnosis: 15 cm tumor in the right lobe, suspected diaphragm invasion, and portal vein pressure/thrombus.
Liver Function: Child-Pugh A (score 6); Indocyanine green retention (ICGR15) at 4.8% (normal).
Volumetrics: 3-D CT reconstruction showed a Future Liver Remnant (FLR) to body weight ratio of 1.2%, making resection safe despite the 1444.6 cm³ tumor volume.
Medical Intervention: Immediate initiation of Entecavir (0.5 mg daily) to reduce postoperative complications and prolong tumor-free survival.
Surgical Execution and Outcome
Approach: Open surgery via right subcostal incision. Laparoscopy was ruled out due to tumor size and diaphragm adhesion.
Performance:
Parenchymal Transection Time: Less than 30 minutes.
Total Intraoperative Hemorrhage: 150 ml.
Tape Roles: Guided the transection plane, controlled hemorrhage, protected the middle hepatic vein and IVC, and minimized tumor pressure to prevent spreading.
Recovery:
Postoperative recovery assisted by omega-3 fatty acid-based parenteral nutrition.
Discharged 7 days after surgery.
Normal liver function restored within 3 days.
13-Month Follow-up: No recurrence or metastasis; HBV-DNA controlled at normal levels (<100 copies/ml).
Technical Conclusion
The liver double-hanging maneuver through the retrohepatic tunnel on the right side of the IVC is established as a safe, easy, and anatomically superior procedure for major right hepatectomy. It effectively addresses the risks associated with blind dissection and poor exposure, allowing for the successful removal of huge HCC masses that were previously considered untreatable.
