Hepatocellular carcinoma (hereafter referred to as liver cancer) is the sixth most common cancer in humans worldwide and the third most common killer among malignancies that cause human death. Although the cause of liver cancer is not fully understood, viral hepatitis is extremely closely related to the development of liver cancer. In the West, liver cancer patients mainly originate from patients who have hepatitis C. One third of the patients with cirrhosis caused by hepatitis C will eventually develop liver cancer. In our country, liver cancer mainly originates from people with hepatitis B background. In the last 20 years, various new technologies have emerged to provide new methods for the treatment of liver cancer. However. Surgical resection remains the primary route and the most reliable hope to obtain a cure for this deadly disease. Surgical treatment of liver cancer is usually a major operation. In the past 20 years or so, there have been many advances in surgical techniques and pre- and post-surgical treatment, resulting in a significant decrease in post-surgical complications and mortality. It is very important for the public to fully understand the importance of surgery in liver cancer treatment to improve the overall outcome of liver cancer treatment. The liver is located in the upper right side of our abdomen. From the front, the back of the liver has a large blood vessel called the inferior vena cava passing through it to recycle the blood flow out of the liver. It has the base of the gallbladder exposed at its anterior edge. Roughly, a line is drawn from between the inferior vena cava and the base of the gallbladder, and the liver can be divided into two parts: the left half of the liver and the right half of the liver. The regional division of the liver is important for the surgeon’s decision on the surgical plan. The liver has very complex physiological functions. Today, artificial hearts and kidneys have been able to replace diseased organs for long periods of time to sustain human life, but modern technology is not yet able to create an artificial liver that can replace the liver for long periods of time. It is the great responsibility of every liver cancer surgical treatment team to fully understand the liver function of each surgical patient, accurately judge the impact of one surgery on the liver, carefully design each step of the liver surgery process, and strictly control the quality of treatment before and after surgery. Overall assessment before liver cancer resection Liver cancer resection is of course to operate on the liver. However, most liver cancer patients have underlying liver diseases (e.g. chronic hepatitis) and some have other diseases (e.g. diabetes, hypertension, etc.), therefore, the overall assessment before surgery is crucial. This includes assessment of whether the patient has significant co-morbidities, the size, number, and location of the tumor in the liver, the functional status of the liver, and even the biological characteristics of the tumor. Whether a patient has co-morbidities of other vital organs directly affects whether the patient can undergo a major abdominal surgery. And the size, number and location of the tumor determine the difficulty of the surgery. With advances in surgical techniques, a well-trained hepatic surgical team usually has no difficulty in removing intrahepatic tumors, but the need to ensure both that the tumor is removed with adequate margins and that there is sufficient remaining liver tissue with adequate hepatic artery and portal vein blood supply, good hepatic venous return, and unobstructed bile drainage so that these remaining liver tissues have adequate function, often challenging the wisdom and skill of the hepatic surgeon. For livers without cirrhosis, 20-30% of the remaining liver tissue is sufficient to ensure that the patient can safely survive the surgery, while for patients with liver fibrosis and post-hepatitis B cirrhosis, preservation of more than 40% of the liver is often necessary. With three-dimensional imaging technology, surgeons today are able to accurately calculate the expected extent of surgical resection and the expected remaining liver volume before surgery. In addition to those high-tech tools, doctors also pay close attention to medical history, symptoms and physical examination. For example, a patient who has had hepatic encephalopathy (hepatic coma), upper gastrointestinal bleeding, frequent ascites, or significant abdominal wall varices usually indicates severe portal hypertension, and the surgeon must evaluate the patient’s ability to tolerate surgery through a series of blood chemistries and other tests. Routine MRI scans, combined with intraoperative ultrasound detection techniques, allow for the precise localization of tiny 1-2 cm lesions for targeted removal. Through imaging techniques and objective indicators such as laboratory tests, doctors often classify liver cancer into different stages before surgery. Currently, the Barcelona staging system is commonly used, which divides liver cancer into 5 stages and serves as a guide for doctors to make decisions on treatment options. Preoperative Preparation for Massive Liver Resection A massive liver cancer, or a multinodular liver cancer occupying half of the liver, usually requires the removal of a larger volume of liver, which can be preserved in a smaller volume, making the surgery risky and careful preoperative preparation crucial. The emerging technique is to first ligate or block the portal vein of the lobe of the liver occupied by the tumor (usually the right lobe of the liver), and at the same time separate the tissue between this side of the liver and the liver that needs to be preserved, so that the portal blood supply from the tumor can be reduced to a minimum or cut off, and the lobe of the liver that must be preserved can thus grow rapidly and increase in size, after which half of the liver is removed and the volume of the preserved liver is increased. The volume of the preserved liver is then increased. The safety of the operation is improved. On the other hand, the rate of liver volume increase reflects the quality and compensatory capacity of the liver and the ability to recover liver function after surgery, which is closely related to the safety of surgery and has become another important indicator to assess the safety of surgery. For those livers with poor proliferative capacity, giant hepatectomy should be performed with extreme caution. Hepatic artery embolization chemotherapy combined with portal vein embolization The blood supply of hepatocellular carcinoma mainly comes from the hepatic artery. Blocking the hepatic artery supplying the tumor with embolic agents and chemotherapeutic drugs (or radioisotopes), i.e. hepatic artery embolization chemotherapy, has been applied for many years and is the classic treatment method to “cut off the food and grass” of the tumor, and is the main treatment method for liver cancer that cannot be removed surgically. Recently, it has been combined with portal vein embolization and found that compared to portal vein embolization alone, tumor necrosis was more complete, liver hyperplasia on the side to be preserved was more pronounced, postoperative recurrence occurred later, and overall patient survival time was longer. This conclusion needs to be confirmed by additional, more convincing studies, and further exploration is clearly valuable. Several issues regarding surgical technique Each region of the liver has its own separate system of blood supply, blood outflow, and bile drainage. Hepatocellular carcinoma that grows in a particular region has a tendency to invade the ductal system of the region in which it is located. Removing the liver cancer and the duct system in its area in whole according to the anatomical structure is called anatomical hepatectomy, while removing the liver cancer and its surrounding liver parenchyma in whole without considering anatomical factors is called non-anatomical hepatectomy. The former is time-consuming and difficult, while the latter is easy and quick. In the past, it was believed that there was no significant difference between the results of these two resection methods, and therefore the latter was more commonly used in China. Studies in recent years suggest that anatomic hepatectomy has better long-term outcomes than non-anatomic hepatectomy, with recurrence coming later and overall survival longer. In view of this, anatomical hepatectomy has been included as a recommended surgical procedure in some surgical treatment guidelines. Another question is, how far away from the tumor is the best margin for hepatocellular carcinoma? The answer is simple: the farther away, the more complete the resection. Some studies have shown that patients whose margins are 2 cm away from the tumor have a later recurrence and longer survival time than those whose margins are 1 cm away. However, most liver cancers are combined with different degrees of cirrhosis, and the more liver parenchyma is removed, the greater the risk of postoperative liver insufficiency. Moreover, if the tumor is adjacent to important ducts that must be protected, it is unrealistic to pursue a 2 cm cut margin or even a 1 cm cut margin. How to ensure a safe incision margin while preserving enough remaining liver parenchyma and protecting important intrahepatic structures is a permanent topic of surgical decision making, testing the surgeon’s wisdom, experience and boldness. Surgical treatment of hepatocellular carcinoma combined with portal vein thrombosis The invasion of portal vein by hepatocellular carcinoma and the formation of thrombosis in the lumen of portal vein is an extremely common pathological process of hepatocellular carcinoma, which is an extremely difficult part of hepatocellular carcinoma treatment. If the thrombus grows into the primary branches of the portal vein (i.e., the large left and right trunks of the portal vein) or the main trunk of the portal vein, patients rarely survive for more than one year, even after exhausting all current treatments. More than a decade ago, a Japanese medical team reported that in 18 patients treated with hepatic artery embolization followed by surgical resection, the 1-year survival rate was 82%. However, this result has not been confirmed by a larger series of studies to date. Professor Cheng Shuqun’s team at the Eastern Hepatobiliary Surgery Hospital is exploring new comprehensive treatment options for portal vein cancer embolization, and has made some impressive progress so far. Postoperative recurrence of hepatocellular carcinoma is a very common clinical problem. The biological characteristics of the tumor are the main factors that determine whether the recurrence is early or late after surgery. It is generally believed that large tumor, incomplete tumor envelope and extensive microvascular invasion of liver tissues around the tumor are the hallmarks of recurrence of hepatocellular carcinoma after surgery. There are two major sources of tumor recurrence, one is intrahepatic dissemination formed by migration through portal blood flow to other parts of the liver for growth, and the other is that hepatocellular carcinoma itself is multicentric in occurrence, which means that new lesions appearing after surgery are new tumors unrelated to the original lesions. For the management of recurrence, the treatment plan may be completely different from case to case, i.e. individualization of treatment. The treatment plan varies depending on the time of recurrence, tumor size, number, etc. Some foreign scholars advocate a cut-off of 18 months, with hepatic artery embolization chemotherapy (TACE) for recurrence within 18 months after surgery, and re-surgical resection for recurrence over 18 months. We do not believe that this cut-off is a good guide. Our strategy is to highly individualize the treatment plan and treat with TACE for clear intrahepatic multifocal recurrence, or highly suspected multifocal recurrence, while surgical resection, or destruction of the lesion by radiofrequency or microwave, is used even if the postoperative time is less than 18 months, when it is clear that the tumor is a single recurrence after exhaustive examination, including TACE. We also note that individual units abroad have reported that TACE alone is somewhat more effective than re-surgical resection for patients with partial recurrence, but we believe that this conclusion needs to be validated by more clinical practice. Like most solid tumor resections, surgical resection for hepatocellular carcinoma is an invasive treatment method. On the one hand, we need to thoroughly understand the mechanism of liver cancer and stop the occurrence and development of liver cancer, and on the other hand, we need to accelerate the emergence of minimally invasive or non-invasive, safe and efficient treatments, so that open surgery for liver cancer becomes history. We expect this day to come soon.