Hepatic hemangioma is a benign tumor with no evidence of malignant potential. Since no definitive and effective drug treatment options have been identified for hemangioma, surgical treatment is the main treatment option. Surgical treatment, as an invasive treatment, carries certain risks and should be carefully considered and evaluated for the treatment of benign tumors that are not life threatening in the short term. In fact, most hepatic hemangiomas have a long and stable course, and only a small percentage require surgical treatment. There is a broad consensus that patients with asymptomatic hepatic hemangiomas ≤5 cm in diameter do not require any treatment, and some scholars have even suggested that follow-up may be withheld to save medical resources. The need for surgical resection of hepatic hemangiomas >5 cm in diameter requires further evaluation. 1. Indications for treatment The indications for surgery of hepatic hemangioma are strictly controlled, including: severe symptoms clearly associated with hemangioma; malignancy cannot be excluded; tumor rupture and bleeding; rapid tumor enlargement; and complications such as Kasa-bach-Merrit syndrome. The most common clinical symptom of hepatic hemangioma is epigastric pain and discomfort, which may be related to compression of the Glisson sheath by the tumor, infarction or bleeding within the tumor. However, the indication for surgery based on this symptom alone is questionable because other possible concomitant gastrointestinal diseases such as peptic ulcer, gallbladder stone, esophageal reflux gastritis, irritable bowel syndrome, etc. can also cause similar symptoms, while some patients may also experience abdominal pain due to excessive mental burden. Meanwhile, most patients with hepatic hemangioma have satisfactory improvement of symptoms after surgical treatment, but about 25% of patients still have abdominal pain and other symptoms after surgery. Therefore, for such patients, we should first investigate other diseases, carefully screen them, and provide psychological guidance and appropriate analgesic treatment, rather than blindly choosing surgical treatment based only on the patient’s complaints; even if surgery is finally chosen, we should inform that there is a possibility that the symptoms may not improve, so as to avoid the postoperative dilemma. As mentioned earlier, regardless of the size of the hemangioma, as long as the patient is asymptomatic or mildly symptomatic, no treatment is necessary and regular follow-up is sufficient. However, in patients with large and rapidly growing hemangiomas located under the hepatic envelope, the potential risk of spontaneous or traumatic rupture may be an indication for surgery. However, it is still controversial how to define the specific growth rate. Some people believe that surgery can be performed when the tumor diameter is >5 cm and the growth rate is >2 cm per year. There are various treatment methods for hepatic hemangioma, including hemangioma suture, hepatic artery ligation, hemangioma debridement, hepatectomy, liver transplantation, hepatic artery interventional embolization, radiofrequency ablation and even drug treatment. With the development of surgical techniques, hemangioma suturing and hepatic artery ligation are now mostly not commonly used. Liver transplantation is mainly used for diffuse or unresectable giant hemangiomas with liver failure or Kasabach-Merritt syndrome, and is rarely used due to donor shortage. Drugs for the treatment of hepatic hemangiomas such as vascular endothelial growth factor (VEGF) inhibitors sorafenib and bevacizumab have only been reported in isolated cases and their efficacy is still being explored. The most clinically used and most effective treatment method is still surgical resection including hemangioma debulking and hepatectomy. In addition, with the development of interventional technology, hepatic artery interventional embolization and radiofrequency ablation have the advantages of minimally invasive, rapid recovery and low complication rate, and are increasingly used in clinical practice. It should be clear that no matter which treatment method is chosen, the indications for treatment and surgical resection are the same, and the indications should never be relaxed for the sake of so-called “minimally invasive” and “efficacy”.