title: Laparoscopic redo surgery for recurrent hepatocellular carcinoma in cirrhotic patients: feasibility, safety, and results.
abstract: BACKGROUND
  Recurrence of cancer and the need for several surgical treatments are the Achilles' heel of the treatment for hepatocellular carcinoma (HCC) in cases of cirrhosis. The difficulty of reintervention is increased by the formation of adhesions after the previous hepatectomy that can make a new surgical procedure more difficult and less safe. With a minimally invasive approach, the formation of postoperative adhesions seems to be minimized, and the adhesiolysis procedure seems to be faster and safer in terms of blood loss and risk of visceral injuries.
  
  
  METHODS
  This report describes a series of 15 patients submitted to a laparoscopic reintervention (hepatic resection or radiofrequency ablation) for a recurrence of HCC after a previous open (group 1) or laparoscopic (group 2) procedure for a primary tumor. It aims to explain the feasibility, safety, and results of repeated laparoscopic liver surgery.
  
  
  RESULTS
  The rates for overall postoperative mortality and morbidity were respectively 0% and 26.6% (4/15). No patients had a severe postoperative complication. Only one patient in group 2 presented with moderate ascites postoperatively, whereas two patients in group 1 reported atelectasis requiring physiotherapy and one experienced pneumonia, which was treated with antibiotics. In this series, the findings indicated that patients submitted first to an open hepatic resection (group 1) experience more intraabdominal adhesions. Moreover, in group 1, hypervascularized adhesions typical of cirrhotic patients were several and thicker, with a major potential risk of bleeding and bowel injuries at the time of reintervention. Although for group 2 the length of the intervention was shorter, for group 1, the operating times and safety in terms of bowel injuries were acceptable, demonstrating the feasibility of iterative laparoscopic surgery also for cirrhotic patients previously treated by the open surgical approach. The operative time for the second surgical procedure was shorter and the adhesiolysis easier for the patients previously treated with the laparoscopic approach (group 2). This underscores the advantages of the minimally invasive approach for managing the long oncologic history of cirrhotic patients.
  
  
  CONCLUSIONS
  Laparoscopic redo surgery for recurrent HCC in cirrhotic patients is a safe and feasible procedure with good short-term outcomes, but further prospective studies are needed to support these results.
authors.affiliation: Department of General and Hepato-Pancreato-Biliary Surgery, S.M. Loreto Nuovo Hospital Naples, via Cimarosa 2a, 80127, Naples, Italy. chirurgia.loretonuovo@tin.it
authors.forename: Giulio
authors.initials: G
authors.lastname: Belli
authors.forename: Luigi
authors.initials: L
authors.lastname: Cioffi
authors.forename: Corrado
authors.initials: C
authors.lastname: Fantini
authors.forename: Alberto
authors.initials: A
authors.lastname: D'Agostino
authors.forename: Gianluca
authors.initials: G
authors.lastname: Russo
authors.forename: Paolo
authors.initials: P
authors.lastname: Limongelli
authors.forename: Andrea
authors.initials: A
authors.lastname: Belli
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007813:Laparotomy; D008103:Liver Cirrhosis / Q000601:surgery*; D008113:Liver Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology; D012086:Reoperation; D000267:Tissue Adhesions / Q000601:surgery; D016896:Treatment Outcome