Hepatic hemangioma is a common benign tumor of the liver, including sclerosing hemangioma, vascular endothelial cell tumor, capillary hemangioma and cavernous hemangioma. Cavernous hemangioma is the most common. The most common type of hemangioma is cavernous hemangioma, which is commonly referred to as hepatic hemangioma. It can occur at any age but is mostly found in adults, mostly between the ages of 30 and 60, and more often in females than males. It was previously thought to be single, but since the introduction of ultrasound imaging, multiple tumors are often observed. Hepatic hemangiomas can occur in both the right and left lobes of the liver, with the right lobe being more common. Hepatic hemangiomas vary in size from the size of a needle tip to the size of a human head, with the larger ones occupying the entire abdominal cavity. Most of them are smaller than 4 cm, but the largest one is reported to be up to 60 cm and weighs 20 kg. Generally speaking, those with a diameter of ≥10 cm are regarded as giant hepatic hemangiomas. Zuo Shi, Department of Hepatobiliary Surgery, Affiliated Hospital of Guizhou Medical University, China Clinical manifestations: The clinical manifestations of hepatic hemangiomas are related to the site of tumor growth, size, speed of growth, the impact of the tumor on the liver, and the occurrence of complications. It grows slowly and has a long course of disease. Clinical manifestations are divided into hidden type and symptomatic type. Concealed type: the majority of patients are found by chance during physical examination and abdominal dissection because of small tumor size and asymptomatic. Especially in recent years, the popularization of non-invasive examination methods has increased the detection rate. Symptomatic type has various symptoms: vague pain and discomfort in the epigastrium, anorexia, nausea, vomiting, similar to chronic liver, biliary, pancreatic and gastrointestinal diseases; or prolonged fever, chills, night sweats, similar to liver abscess, tuberculosis, which may be related to hemorrhage, thrombosis or infection in the tumor. When the tumor of hepatic hemangioma is small, it usually will not oppress the neighboring organs. When the tumor increases in size, it may compress and push the neighboring organs, and various symptoms may appear. For example, if it presses the lower esophagus, stomach and duodenum, it will cause dysphagia, abdominal distension, abdominal pain, belching, etc. If it presses the liver and biliary tract, it can lead to gallbladder effusion and obstructive jaundice; if it presses the portal vein, it can lead to portal hypertension; if it presses the inferior vena cava, it can lead to ascites, and it can affect the delivery of pregnant women. Indications for surgical treatment of hepatic hemangioma The indications for surgical treatment of hepatic hemangioma should be strictly controlled. It is generally believed that: 1) there are very clear symptoms (excluding other diseases that may cause similar symptoms); 2) the tumor is ruptured or accompanied by high-flow arteriovenous fistula and coagulation dysfunction; 3) it is not possible to exclude other hepatic tumors; 4) hemangiomas (1) the tumor body is >10cm, and grows fast in the short term; 2) located in the left outer lobe or the edge of the right lobe, the tumor body is >5cm; 3) the tumor body is nearly half of the tumor body grows prominently outside of the liver, the tumor body is >5cm. However, when the tumor diameter is 5cm-10cm and combined with the following conditions, it is regarded as a relative indication for surgery, and treatment should be considered when the patient’s study, work and life are seriously affected by the psychological pressure caused by the existence of the disease. 1) adjacent to the first and second hepatic portals; 2) tumor growth rate of >2cm in diameter per year; 3) tumor protruding from the edge of the liver, especially located below the costal arch; 4) combined with other surgical disorders such as gallbladder stones. For hemangiomas located in the central part of the liver or caudal lobe, as their surgical treatment may require the removal of large pieces of liver tissue, the complications and mortality rate of surgery are still difficult to be accepted by patients. Therefore, we do not advocate active surgery, but should closely follow up and observe, and tend to strictly control the indications for surgery. Surgical modalities of hepatic hemangioma 1) Minimally invasive treatments such as radiofrequency and microwave: radiofrequency ablation under ultrasound guidance and microwave tumor coagulation and inactivation of hepatic hepatic hemangioma, the indications for this method are: ① single asymptomatic hepatic hemangioma, ② multiple asymptomatic hepatic hemangiomas, ③ symptomatic single and multiple hepatic hemangiomas, ④ hepatic hemangiomas with fast growth rate, and ⑥ hepatic hemangiomas that are left behind after surgical treatments. This technique treats cavernous hemangioma of liver as a minimally invasive and low-risk treatment measure, with an overall remission rate of 92.9%; it is less painful for patients and can be repeated. (2) Partial hepatectomy: Depending on the size and location of the tumor, there are segmental resection, lobectomy, multilobectomy, hemilobectomy and so on. Partial hepatectomy is still an effective treatment for giant CHL. Some studies have suggested that tumor volume is an important risk factor for hepatic partial hepatectomy in giant CHL, and careful preoperative preparation to reduce tumor volume and intraoperative blood loss can increase the safety of the operation. However, partial hepatectomy also has the following disadvantages: removal of part of the normal liver tissue, greater trauma, more intraoperative blood loss, and relatively high incidence of postoperative complications. Especially for the resection of tumors with difficult anatomical sites, it is more difficult and dangerous. (3) Extraperitoneal resection of hepatic hemangioma: Hepatic hemangioma often grows to the liver parenchyma in an expansive manner, and is often wrapped by a pseudo-coating, and there is a loose connective tissue gap outside the coating, which forms a more obvious demarcation with the normal liver tissues, so extraperitoneal resection is precisely to carry out a blunt detachment along this gap. This procedure has the following advantages: ① clear anatomy, small collateral damage, can avoid damage to the bile ducts and blood vessels; ② surgical operation is simple, safe and reliable, do not have to resect the normal liver tissue; ③ short operation time, intraoperative bleeding is significantly reduced. Moreover, liver hemangiomas located in anatomically difficult areas can be safely removed. However, this procedure also has the following shortcomings: close to the tumor separation, there is a risk of tumor rupture and hemorrhage; for small size, deep in the liver parenchyma of hepatic hemangioma due to anatomical ambiguity is not suitable for the use of this method. (4) Laparoscopic hepatic hemangioma resection: Laparoscopic surgery is less traumatic, with faster postoperative recovery and shorter hospitalization time, and some scholars have tried it for the treatment of hepatic hemangioma. At present, there is still a lack of ideal laparoscopic hepatic dissection instruments, and the price of the instruments and apparatus used is expensive, and it is difficult to stop bleeding and control the hepatic dissection, coupled with the long operation time and the higher requirements for the doctor’s skills and experience, therefore, this treatment is still in the exploratory stage. (5) Hemangioma suturing: the procedure can reduce the size of the tumor and improve the symptoms. Wu Mengchao et al. believed that tumors <15 cm in diameter, multiple small hemangiomas or scattered small hemangiomas in other lobes of the liver after resection of the main tumor can be treated with this method, and when suturing, the anterior-posterior direction of the liver should be taken as the axis, which is not only convenient for the operation but also reduces the erroneous suture of the portal vein and the biliary branches. However, this method may cause bleeding of the tumor after suturing, and the tumor is easy to reappear without being resected. It has been reported that the recurrence rate is as high as 40% within 3 years after suturing. (6) Liver transplantation: Liver transplantation can be used for giant or diffuse hepatic hemangiomas, especially those with Kasabach-Merritt syndrome. It has been reported in China that in situ liver transplantation was successfully performed for a patient with giant hepatic hemangioma, in which the resected liver was 40cm×30cm×30cm and weighed 6.1Kg, with no postoperative complications, and the patient's quality of life is now good. Hochw ald et al. reported a case of giant hepatic hemangioma with Kasabach-Merritt syndrome was cured by tumor debulking, so the choice of liver transplantation or tumor debulking is still controversial.