Hepatocellular liver cancer (HCC, hereafter referred to as liver cancer) is one of the five most common human tumors, and liver cancer in China accounts for 40% of liver cancer worldwide. Due to the prevalence of hepatitis C, liver cancer has been on the rise in Europe and the United States in recent years. Despite the great development of medical technology in the past century, the only methods that can potentially cure liver cancer are surgical treatments, including partial hepatectomy and liver transplantation. The development of non-invasive diagnostic techniques for liver cancer and screening of high-risk groups have led to the detection of more small hepatocellular carcinomas (≤125px). Partial hepatectomy is the conventional treatment for small hepatocellular carcinoma with normal liver function. It is a first-line treatment for small hepatocellular carcinoma in many regions because it requires no waiting time, is less expensive, and is less invasive than liver transplantation. However, recurrence occurs in some patients after resection, with a 5-year recurrence rate of about 53-60%, and adjuvant therapy has not been shown to reduce recurrence. Theoretically, liver transplantation is the most ideal treatment for small hepatocellular carcinoma because it not only maximizes tumor resection, but also removes the entire sclerotic liver that causes multicentric occurrence of hepatocellular carcinoma and intrahepatic recurrence and metastasis, as well as eliminating a host of complications due to cirrhotic portal hypertension. The selection of liver transplant recipients according to the Milan criteria (i.e., no single tumor more than 5 cm in diameter or no more than 3 lesions with a maximum diameter of 3 cm without vascular invasion) can reduce tumor recurrence and metastasis after liver transplantation, thereby improving survival rates. in 1996, Mazzaferro, in a retrospective analysis of 48 liver transplants for small liver cancers with cirrhosis at an average follow-up of 4 years, found The survival rate was 75% and the recurrence-free survival rate was 83%, which is encouraging. Compared to partial hepatectomy, liver transplantation for small hepatocellular carcinoma has a lower postoperative recurrence rate. A study in Hong Kong showed that the 5-year tumor-free survival rate for partial hepatectomy for small hepatocellular carcinoma was 36% compared to 60% for liver transplantation, which is an important reason why many centers choose liver transplantation for small hepatocellular carcinoma. For unresectable hepatocellular carcinoma with liver failure, liver transplantation is recognized as the best treatment strategy. However, the choice of partial hepatectomy or liver transplantation for patients with small hepatocellular carcinoma with normal liver function is controversial. Another alternative strategy for small hepatocellular carcinoma is partial hepatectomy followed by liver transplantation after recurrence or deterioration of liver function, i.e., salvage liver transplantation. The feasibility of remedial liver transplantation strategy for small hepatocellular carcinoma depends on whether liver transplantation can be performed after partial hepatectomy for tumor recurrence. The corresponding tumor-free survival rates were 74%, 50%, 36%, and 22%. The study showed that partial hepatectomy is the best first-line treatment for Child A patients with small hepatocellular carcinoma, with good 5-year survival rates, and that most recurrences are suitable for remedial liver transplantation, and that partial hepatectomy followed by remedial liver transplantation may be a feasible strategy for Child A small hepatocellular carcinoma. Hepatocellular carcinoma is a feasible strategy. In a similar study, 279 patients with small hepatocellular carcinoma meeting Milan’s criteria had recurrence after 5 years of partial hepatic follow-up and 60% could undergo liver transplantation. Improved techniques for early diagnosis of hepatocellular carcinoma have made remedial liver transplantation strategies possible. Regular follow-up after partial hepatectomy must be observed with periodic AFP, ultrasound, CT or MRI in case of suspected recurrence, and timely remedial liver transplantation. Due to the global scarcity of donor livers, many liver cancer patients lose their transplantation opportunities while waiting for a donor that leads to tumor progression and contraindication to liver transplantation. If liver cancer is not treated, tumor enlargement increases by 70%, vascular invasion increases by 21%, and intrahepatic metastasis increases by 9% during the 1-year waiting period for transplantation, thus depriving some liver cancer patients of transplantation opportunities. the chance of losing transplantation opportunities during the 6-month waiting period is 23%, and the chance of losing transplantation opportunities during the 1-year waiting period is 30%-50%. Therefore, good survival rates for liver transplantation for small hepatocellular carcinoma depend on two things: strict patient selection and a relatively short donor waiting time. Partial hepatectomy can prevent tumor progression in patients with hepatocellular carcinoma while waiting for a donor and serve as a transitional treatment, followed by remedial liver transplantation after recurrence or deterioration of liver function. Another indication for remedial liver transplantation is deterioration of liver function after partial hepatectomy, which is less likely to occur after partial hepatectomy for hepatocellular carcinoma in the setting of hepatitis B. In 135 patients with Child A transplantable small hepatocellular carcinoma who underwent partial hepatectomy, only 6 cases had liver function failure before recurrence and were downgraded from Child A to B or C after surgery. The reason for this may be due to the slow progression of cirrhosis caused by hepatitis B, which has a small chance of causing liver function decompensation. 2. The rationality of remedial liver transplantation strategy for small hepatocellular carcinoma: LLOVET et al. studied 164 cases of early hepatocellular carcinoma, of which 77 were partial hepatectomies and 87 were liver transplantations, and the intention-to-treat analysis revealed that the 1-, 3- and 5-year survival rates were 85%, 62%, 51% and 84%, 69% and 69%, respectively. and bilirubin were independent factors affecting prognosis after partial hepatectomy, and the five-year survival rate after partial hepatectomy for small hepatocellular carcinoma without portal hypertension was 74%, and partial hepatectomy was found to be superior to liver transplantation in appropriate cases. This study suggests that remedial liver transplantation is a reasonable treatment strategy for small hepatocellular carcinoma. Since some cases of small hepatocellular carcinoma do not recur after partial hepatectomy and do not require remedial liver transplantation, Cha et al. did not require liver transplantation in 48% of the 36 patients who met Milan’s criteria for partial hepatectomy of small hepatocellular carcinoma within 5 years, and the 5-year survival rate for patients who did not develop tumor recurrence was up to 90%, and if liver transplantation had been the treatment of choice instead of partial hepatectomy, it would have inevitably resulted in unnecessary liver transplantation in the portion of cases that did not recur. If liver transplantation is chosen over partial hepatectomy, unnecessary liver transplantation is bound to be performed in those cases where recurrence does not occur, and post-transplantation complications such as rejection, opportunistic infections, and malignancies in an immunosuppressed state may occur to a greater or lesser extent, and in some cases even require retransplantation. Remedial liver transplantation is a reasonable therapeutic strategy to conserve the donor in cases where the donor source is tight, and the remedial liver transplantation strategy is preferable in cases of low recurrence after resection. Recurrence after partial hepatic resection can be an option for re-excision, which can achieve similar results as the first resection, but when the tumor location is not suitable for resection, multiple tumors in the liver, and liver failure, remedial liver transplantation is the only treatment option. Some studies have used minimally invasive percutaneous treatments such as percutaneous radiofrequency tumor and percutaneous alcohol injection as palliative treatment during the waiting period. The main advantages include less impact on liver function, lower surgical mortality, reduced adhesions, relatively low cost, and preparation for post-recurrence remedial liver transplantation, but the efficacy of these treatments has not been confirmed by randomized controlled clinical trials. Majno et al. used a Markov decision analysis model to calculate a 26% savings in donor livers and a lower cost than the liver transplantation group. This is because a remedial liver transplantation strategy can save money by avoiding unnecessary liver transplantation. sarasin et al. performed a cost-effectiveness analysis using a Markov decision analysis model and found that the advantages of liver transplantation were offset by its risks when the waiting time exceeded 8 months, and that the cost-effectiveness ratio of liver transplantation was significantly higher than that of partial hepatectomy. 3. Living liver transplantation versus remedial liver transplantation for small hepatocellular carcinoma: Living liver transplantation is recognized as one of the most effective methods to alleviate the scarcity of donor liver sources, and adult living liver transplantation is safe for both donor and recipient as long as the cases are strictly selected. In Eastern countries due to traditional views and other reasons, living liver transplantation is of particular interest for small hepatocellular carcinoma resected first and remedial liver transplantation after recurrence or deterioration of liver function. In contrast, partial hepatectomy and liver transplantation have similar results and are relatively simple, less risky, and without ethical barriers. The rationality of subjecting a healthy donor to the risk of partial hepatectomy for a small hepatocellular carcinoma with normal liver function, when there is a simpler and safer option with comparable efficacy, is questioned if a living liver transplant is performed in the first place. Therefore, remedial liver transplantation is an ideal strategy, and in the event of tumor recurrence or deterioration of liver function after partial hepatectomy, it is more ethical to perform living liver transplantation, and families are more likely to accept the risks of living liver transplantation. Adult right hemihepatic living liver transplantation with successful surgery and long-term postoperative survival, with encouraging results. In addition, if small hepatocellular carcinoma recurs after partial hepatectomy for remedial liver transplantation, living liver transplantation is widely available and can be performed after detailed evaluation of the donor, with a shorter waiting time to avoid losing the transplantation opportunity due to tumor progression during the waiting process. Adam et al. counted 163 cases of partial hepatectomy (98 of which could be transplanted) and 195 cases of liver transplantation, and found through statistical analysis that the operative mortality rate of the partial hepatectomy liver transplantation group was 28.6%, which was significantly higher than that of the initial liver transplantation group (2.1%), and the tumor recurrence rate of the partial hepatectomy liver transplantation group (54%) was higher than that of the initial liver transplantation group (18%). The 5-year survival rate after initial liver transplantation (61%) was better than that of the partial hepatectomy liver transplantation group (41%), and it is believed that surgical adhesions after partial hepatectomy increase the difficulty of remedial liver transplantation. Majno et al. used a Markov decision analysis model with waiting time, rejection rate during waiting, recurrence rate after resection, and transplantability rate after recurrence as variables to compare small hepatocellular carcinoma with a single tumor nodule at liver function compensation after partial hepatectomy, liver transplantation, or partial hepatectomy, with a life expectancy of 8.8 years in the liver transplantation group versus 7.6 years in the remedial transplantation group, and concluded that in selecting ideal cases (annual recurrence rate of 15% and 80% transplantability rate after recurrence) transplantation is the best option if the waiting time for donor liver does not exceed 6 months, and remedial transplantation can be considered if the waiting time for donor liver exceeds 12 months. Hepatocellular carcinoma often occurs in Western countries and Japan on the basis of causing cirrhosis, and because there is no effective prevention and treatment of hepatitis recurrence after transplantation like the application of lamivudine and hepatitis B immunoglobulin for hepatitis B, almost all patients will have hepatitis C recurrence after hepatitis C liver transplantation, and hepatitis C develops into cirrhosis more rapidly than hepatitis B. Alberto et al. performed 125 patients with a background of hepatitis C Alberto et al. found histological evidence of hepatitis C-induced liver injury in 94% of cases at an average follow-up of 43 months (July-96 months), with severe donor liver injury (including cirrhosis, fibrous biliary hepatitis, and severe hepatic necrosis) occurring in 15%, 33%, and 44% of patients at 3, 5, and 7 years post-transplantation, with 52% of these patients subsequently developing hepatic decompensation Therefore, hepatitis C recurrence is an important factor affecting the prognosis of liver transplantation. The difference in the impact of hepatitis B and C on partial hepatectomy and liver transplantation has not been considered in most of the studies, which may be one of the reasons for the debate on remedial liver transplantation. 5. Conclusion: The study of remedial liver transplantation for small hepatocellular carcinoma is still in the exploratory stage, and it is difficult to conduct prospective randomized controlled clinical trials because of the many factors involved, and its feasibility and rationality need to be confirmed by randomized studies based on intention-to-treat analysis. Patients with partial hepatectomy and remedial liver transplantation for small hepatocellular carcinoma must be strictly selected, and those with high risk factors for recurrence of hepatocellular carcinoma such as hepatitis C background and portal hypertension choose liver transplantation rather than partial hepatectomy. Partial hepatectomy can act as a bridge to prevent tumor progression while waiting for a donor, and remedial liver transplantation after recurrence or deterioration of liver function is a feasible and reasonable strategy for the treatment of small hepatocellular carcinoma with normal liver function in China, where liver donor is becoming increasingly tight and the waiting time for transplantation has increased.