Limits and benefits of exclusive transthoracic hepatectomy approach for patients with hepatocellular carcinoma

Background/Aims: The purpose of this study was to evaluate the results of Ever resection in cirrhotic patients for liver hepatocellular carcinoma located near the diaphragm through an exclusive transthoracic approach. Methodology: Between 1995 and 1999, 19 cirrhotic patients with hepatocellular carcinoma underwent a liver resection through an exclusive transthoracic approach. This approach was indicated in 11 cases for previous upper abdominal surgery, including hepatobiliary surgery in 3 and before liver transplantation in 8. Results of the transthoracic approach were compared to 84 cirrhotic patients who underwent transabdominal limited resection of hepatocellular carcinoma matched for age, sex and localization of the tumor. Results: Resection was feasible by an exclusive transthoracic approach in 18 (95%) cases with a mean operating time of 201+/-53min. In 8 (44%) patients a Pringle maneuver was performed. No postoperative deaths were observed after the transthoracic approach. Pulmonary complications rate was significantly higher (P<0.001) after transthoracic resection compared to transabdominal resection (67% vs. 25%, P<0.001). In contrast, ascites were observed in only one (5%) of the transthoracic group compared to 35 (42%) in the transabdominal group (P<0.01). The resection margin was positive in 3 (17%) after transthoracic approach and in 1 (2%) patient after the transabdominal resection (P<0.02). In patients who underwent liver transplantation after the transthoracic approach, total hepatectomy was performed without increasing difficulties. Conclusions: The transthoracic approach is a safe procedure for resection of hepatocellular carcinoma located under the right diaphragm in cirrhotic patients. However, this approach allows only limited resection with a high risk of positive margin, resulting in a restriction of indications either for patients with previous major abdominal surgery than before liver transplantation.