The indications for treatment of hepatic hemangioma are mainly based on the clinical symptoms of the patient, the size, location and nature of the tumor, as well as the patient’s occupation, gender and age. The common clinical symptoms of hepatic hemangioma are discomfort and hidden pain in the upper abdomen, abdominal distension, loss of appetite, etc., which are caused by the tumor pulling the hepatic periosteum or compressing the gastrointestinal tract and other adjacent tissues and organs. Once the disease is diagnosed, patients often have a heavy mental burden. Therefore, patients with clear symptoms or strong demand for treatment due to psychological factors should be actively disposed of. The key factors in the management of hepatic hemangioma are tumor size and location. Overseas, those with a diameter of >4cm are called giant hepatic hemangiomas, and most scholars in China tend to call those with a diameter of >10cm giant hepatic hemangiomas, and those with a diameter of >15cm extra-large hepatic hemangiomas. Since small hemangiomas are asymptomatic and have almost no complications such as rupture and hemorrhage, patients with tumors <5cm can be followed up for observation. Large hepatic hemangiomas, especially those located in the hepatic margins or portals, are prone to rupture and hemorrhage, or compress the bile ducts and blood vessels in the portals, and are often accompanied by coagulation disorders caused by Kasabanch-Merrit syndrome, so early treatment is recommended. The more consistent opinion in China is: when the tumor diameter is 5-10cm, it is regarded as a relative indication for treatment, but when it is accompanied by an obvious tendency to increase in size, it is appropriate to deal with it; when the diameter of the tumor is >10cm, no matter whether it is symptomatic or not, it should be recommended to elective surgery. The nature of the tumor sometimes cannot be determined by imaging alone. For those who cannot exclude malignant tumors, especially small hemangiomas that cannot be distinguished from tumors, combined with a history of chronic hepatitis or positive tumor markers, under the premise of full communication with patients, surgery should be actively treated. Anyone who engages in strenuous sports, such as boxers and soccer players who are at risk of traumatic rupture, may be considered for management of hemangiomas. Estrogen and progesterone can stimulate the growth of hepatic hemangiomas, so aggressive surgical resection of large hemangiomas in young women is warranted. Regular observation is the mainstay for elderly patients >60 years of age, especially if they are comorbid with severe lesions in other organs. Surgical treatment Surgical treatment of hepatic hemangiomas includes a variety of modalities such as surgery, hepatic artery embolization, radiofrequency ablation, radiation therapy, intraoperative microwave curing, cryotherapy and sclerotherapy. Regardless of the treatment chosen, the indications should be consistent. Since the clinical classification and treatment protocols for hepatic hemangiomas are not yet standardized, there is a lack of a consistent clinical pathway for patients and physicians to choose from. For patients without contraindications to surgery, surgical treatment is preferred because it is the most thorough and effective treatment as it completely removes the lesion, whereas other modalities only reduce the size of the tumor, and there are complications such as hemorrhage, bile leakage, and infection. Surgical treatment of hepatic hemangioma has a hundred-year history. To date, the main surgical modalities are hepatic hemangioma extraperitoneal debulking, anatomical hepatectomy, laparoscopic hepatic hemangioma surgery and hepatic hemangioma suturing. Extraperitoneal debulking takes advantage of the thin fibrous membrane between the hemangioma and the surrounding liver tissue to debulk the hemangioma along the interface, which can reduce bleeding, completely resect the lesion, and maximally preserve the normal liver tissues to achieve the purpose of “cutting the tumor but not cutting the liver”, and it has become an ideal procedure for the treatment of hepatic hemangiomas. For huge hepatic hemangiomas involving important intrahepatic structures, extraperitoneal dissection or irregular lobectomy will lead to complications such as difficulty in hemostasis, postoperative bleeding and bile leakage, so anatomical hepatectomy can be used. According to the location and size of the tumor, anatomic hepatectomy is divided into segmental resection, lobectomy, hemilobectomy and multilobectomy. Anatomic hepatectomy is an effective treatment for giant hemangiomas, but it is traumatic and has many complications as part of the normal liver tissue has to be removed. According to our experience of resecting more than 300 cases of giant hepatic hemangioma in recent years, not only the patient’s systemic condition should be considered before surgery, but also the volume and quality of the residual liver should be evaluated, and we believe that the indocyanine green excretion test can accurately reflect the reserve function of the liver. Three-dimensional imaging of hepatic blood vessels is also feasible when available to understand the relationship between the tumor and large intrahepatic blood vessels and to improve the safety of surgery. Intraoperatively, we suggest adopting autologous blood transfusion, which can greatly reduce the amount of blood transfusion. In the last decade, laparoscopic hepatic hemangioma surgery has developed rapidly with the improvement of laparoscopic techniques and instruments and the deepening of the concept of minimally invasive treatment. With appropriate case selection, laparoscopic hepatic hemangioma surgery is safe and feasible with minimal trauma, rapid recovery, and fewer complications, which has been increasingly recognized. Laparoscopic liver surgery is quite demanding, requiring both experience in open hepatectomy and skillful laparoscopic maneuvers. For hepatic hemangiomas in special areas such as caudate lobe and middle hepatic lobe, which are prone to hemorrhage, performing laparoscopic surgery is still difficult and risky. Due to the difficulty of intraoperative gap resolution and hemostasis, laparoscopic hepatic hemangioma resection is not suitable for hemangioma debulking along the tumor peritoneum, and regular hepatectomy is an effective, reliable and safe choice. Whether laparoscopic hepatic hemangioma surgery is practical or not depends largely on the cost of treatment. Although the cost of surgery and materials is significantly higher than that of open surgery, the postoperative hospitalization time is shorter, and the cost of medication and treatment, etc. is lower than that of open surgery, and in fact, there is no significant difference in the total cost of hospitalization between the two types of surgery. Although the scope of laparoscopic hepatic hemangioma surgery is limited, however, with the development and breakthrough of laparoscopic technology, this surgical method will have a broad application prospect. Hepatic hemangioma suture is suitable for small hemangiomas that are multiple and scattered on the surface of the liver, and it is a safe, effective and simple treatment method. The application of suture ligation has been gradually reduced in recent years due to a certain recurrence rate after surgery. Because of the limited efficacy of non-surgical treatment of hepatic hemangiomas and the presence of the same kinds of complications as surgery, it is not routinely recommended for the treatment of hepatic hemangiomas. Only the more commonly used ones are hepatic artery embolization and radiofrequency ablation are described in this article. With the continuous development of interventional radiology, hepatic artery embolization has become an effective method for the treatment of hepatic hemangioma. Hepatic hemangioma is mainly supplied by the hepatic artery. The embolic agent reaches the abnormal blood vessel, destroys the endothelial cells, and the blood fraction disintegrates and stagnates, forming an extensive thrombus, followed by atrophy and fibrosis. Hepatic artery embolization can temporarily control the disease, but it is not a curative measure. Hepatic artery embolization can lead to serious complications such as intrahepatic bile duct necrosis, liver abscess, biliary cirrhosis and hepatic lobe atrophy, and its clinical application has certain limitations. Radiofrequency ablation is to use the thermal effect of high-frequency current to cause coagulative necrosis of tumor tissues under ultrasound-guided, laparoscopic and open conditions. Radiofrequency ablation is suitable for small hemangiomas located on the surface of the liver, far away from the hilum, diaphragm and gallbladder intestines, etc. It is minimally invasive and easy to perform. Because of the limitation of the site of radiofrequency ablation, and its incomplete effect on larger hemangiomas and easy to recur, it is mainly applied to patients with small hepatic hemangiomas who have a psychological burden in the clinic. With the development of surgical techniques and equipment, the treatment of hepatic hemangioma has made great progress, but the indications for the treatment of hepatic hemangioma and the choice of modality are still controversial. Currently, there is a tendency to over-treat hepatic hemangiomas surgically, and it should be recognized that less than 20% of patients actually require surgical treatment. Studies have shown that there is no difference in the quality of survival between surgery and follow-up observation in patients with hepatic hemangiomas <5 cm. For giant hepatic hemangiomas, if surgery is required, an experienced liver surgeon should be chosen to manage the patient. As a benign disease of the liver, the surgical management of hepatic hemangiomas should be multifaceted and comprehensive with a view to maximizing patient benefit. Bulk prospective clinical studies contribute to the standardization and improvement of clinical diagnosis and treatment standards of hepatic hemangioma, which is an urgent and important task for us liver surgeons.