Impact of the thoracoabdominal approach on peri- and postoperative outcomes of hepatectomy for hepatocellular carcinoma

Background: Resection of hepatocellular carcinoma (HCC) located in the right liver often requires hepatic mobilization. However, exposure of the HCC may be restricted when using the conventional abdominal approach (AA). In such cases, a thoracoabdominal approach (TA) can provide a good operating field. Although several studies have reported on the TA for hepatectomy for HCC, none have been published since 2003. Accordingly, this issue seemed to have been resolved, based on the advantages of this approach. However, surgical instruments are constantly improving and hepatectomy may be possible without the TA. Methods: Data were retrospectively collected from 284 consecutive patients who underwent primary hepatectomy for HCC located in the right liver between January 1991 and December 2009. We compared the perioperative outcomes between patients who underwent the TA (n = 111) and those who underwent the AA (n = 173). Results: Patient characteristics of both groups were comparable. The morbidity rate (Clavien grade ≥ 1) was significantly greater with the TA than with the AA (64.2 vs. 49.2%, p = 0.01), as was operative time (median = 370 vs. 315 min, p = 0.001) and hospital stay (median = 25 vs. 21 days, p = 0.005). There were no differences in hospital mortality or overall or disease-free survival. Conclusions: The TA provides no additional benefits over the AA in terms of safety and postoperative outcomes. We recommend that the TA should be used in exceptional circumstances because it resulted in a higher morbidity rate and longer operative time and postoperative hospitalization compared with the AA.