title: Resection of large hepatocellular carcinoma using the combination of liver hanging maneuver and anterior approach.
abstract: BACKGROUND
  Resection of a large hepatocellular carcinoma (HCC) is difficult and is associated with a poor outcome. Herein we describe our experience with the use of a liver hanging maneuver (LHM) in conjunction with the anterior approach (AA) in patients with large HCC (>10 cm) and compare the perioperative outcome with the conventional method (CM) for hepatic resection.
  
  
  METHODS
  Patients who underwent major hepatic resections for large HCC (>10 cm) were categorized as group 1 (n = 14), treated with LHM and AA, versus group 2 (n = 11), treated with CM. Variables including patient age, tumor size, operative time and transection time, blood loss, blood transfusion requirements, and postoperative ICU and hospital stay were used to compare the two groups.
  
  
  RESULTS
  There were 14 and 11 patients in groups 1 and 2, respectively. The variables in group 1 and 2 of median tumor size, median operative time, median transection time, median ICU stay, and median hospital stay were comparable. In contrast, the intraoperative blood loss and the blood transfusion requirements were significantly higher in group 2. Patients under LHM and AA and CM had a median blood loss of 375 ml (237.5-850) and 1,000 ml (500-1,200), requirement of blood transfusion of 3 (21.42%) and 8 (72.7%), respectively. Postoperative complications were comparable in the two groups. There were no deaths in the series.
  
  
  CONCLUSIONS
  The liver hanging maneuver in conjunction with AA is a safe and highly feasible procedure, particularly in patients with sizable (>10 cm) tumors and tumors found to be adherent to the diaphragm and retroperitoneum. The use of the procedure eventuated in lower blood loss as well as fewer blood transfusion requirements when compared to the conventional method.
authors.affiliation: Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung, Kaohsiung, 833, Taiwan. ufel4996@ms26.hinet.net
authors.forename: Chih-Chi
authors.initials: CC
authors.lastname: Wang
authors.forename: Kailash
authors.initials: K
authors.lastname: Jawade
authors.forename: Anthony Q
authors.initials: AQ
authors.lastname: Yap
authors.forename: Allan M
authors.initials: AM
authors.lastname: Concejero
authors.forename: Chi-Yin
authors.initials: CY
authors.lastname: Lin
authors.forename: Chao-Long
authors.initials: CL
authors.lastname: Chen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical; D001803:Blood Transfusion / Q000706:statistics & numerical data; D006528:Carcinoma, Hepatocellular / Q000601:surgery*; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008113:Liver Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000628:therapy; D018709:Statistics, Nonparametric; D013997:Time Factors; D016896:Treatment Outcome