Since 1888, when Langenbuch successfully performed the first hepatectomy in the world, after more than 100 years of unremitting efforts, especially in the last two decades, with the updating of the concept of liver anatomy, the progress of basic research in hepatic surgery, the development of imaging, the advancement of anesthesiology, the innovation of surgical instruments and the improvement of perioperative management, hepatectomy has gradually become a standardized procedure and has been mastered by many trained surgeons. It has become a standardized procedure and has been mastered by many well-trained surgeons, even to the extent that it is considered by some experts as a “no-go area for liver surgery”. However, it is undeniable that hepatectomy, especially large hepatectomy and some specific areas of hepatectomy, still has a high complication rate and some surgical mortality. Overall, hepatectomy is still a high-risk procedure that needs to be further improved in terms of clinical safety. Intraoperative bleeding, postoperative liver failure, and medical spread of malignant tumors are the main problems of high risk hepatectomy. In addition, the simultaneous surgical treatment of patients with hepatocellular carcinoma combined with portal hypertension is a complex issue related to the safety of surgery. (a) Intraoperative bleeding: The history of liver surgery can be described as the history of surgeons’ struggle with bleeding, in the early years, the mortality rate of hepatectomy was as high as 30-40%, the main cause of which was hemorrhage. In recent years, with the accumulation of surgical experience and the improvement of technical level, although the number of deaths due to hemorrhage has been greatly reduced, it is not uncommon. The main causes of intraoperative hemorrhage include vascular injury, extensive adhesions between tumor and surrounding organs, and coagulation dysfunction. Most of the hemorrhage caused by vascular injury is due to the special location of tumor, such as tumor located in the hilar region or caudate lobe, or when performing hemihepate or enlarged hepatectomy, during the process of dealing with thicker blood vessels, due to unclear anatomy or improper method, the blood vessels are damaged and cause hemorrhage. In addition, bleeding from hepatic vein branches during hepatic resection is also tricky and can have serious consequences if not done carefully. The key to prevent intraoperative vascular injury is careful preoperative preparation and patient and meticulous intraoperative operation. This requires the surgeon to be familiar with the anatomy of the liver and to carefully read the imaging pictures of the patient before surgery. For tumors in the hilar region, it is better to have angiographic information. In hospitals with conditions, CT or MRI vascular construction of the hilar region is feasible, and this examination is non-invasive, which can not only understand the tumor itself, but also clearly show the relationship between the tumor and the surrounding large vessels, which has important reference value for the operator to understand the difficulty of surgery and grasp the specific surgical plan. Adequate surgical field exposure is the guarantee to deal with intraoperative vascular injury and bleeding. The use of a “herringbone” incision under the bilateral rib margins and the application of a multifunctional frame puller can mostly meet the surgical requirements. For the right hepatic tumor near the second and third hilum, it is more effective if the right side is padded at 45°. During the process of revealing the vessels in the hilar region, it must be performed under direct vision. The dissection of the first hepatic hilar can be performed by using a transhepatic garden ligament approach, which can significantly reduce the operational difficulty of revealing the vessels in the hilar region. The main point of this method is that, after cutting the peritoneum on the surface of the ligament at the split of the hepatic garden ligament, a slight blunt separation with a “peanut rice” pusher can clearly reveal the structure of the ducts in the left hepatic hilum. The left branch of the portal vein and the left hepatic artery can be lifted with a traction band and dissected to the right along the above two vessels, which can easily reveal the ductal structures of the right hepatic hilar region and be treated accordingly. The second and third porta hepatis are more risky to reveal and more difficult to handle in case of bleeding, and there is also a risk of air embolism. Therefore, the surgeon must be patient and careful during the operation, and must not be impatient. If the tumor does not invade the second hepatic hilar, the root of the hepatic vein and the inferior vena cava can be well exposed after the liver is fully freed and the inferior vena cava ligament is cut. If it is difficult to reveal or the tumor has invaded the hepatic vein root or vena cava, the suprahepatic and infrahepatic inferior vena cava blocking bands can be prepositioned and bloodless hepatectomy technique can be used if necessary. Of course, if the tumor is distant from the second hepatic portal, the hepatic vein can be treated within the liver parenchyma during hepatic dissection. The short hepatic vein must be treated one by one under direct vision and the preserved end should be sutured to prevent bleeding by simply dislodging the ligature. In case of bleeding from hepatic vein injury, the surgeon must be calm and collected. For small hepatic vein injuries in the liver section, the operator can hold the liver up by hand and immediately press the rupture with fingertips, then repair it with non-invasive sutures after aspirating the surrounding blood. If the damaged vein segment is long, it can be carefully repaired by finger squeezing or compression with oval clamp with gauze on both sides of the rupture, using the method of suturing while withdrawing; for hepatic vein injury near the second hepatic portal, the liver tissue next to the rupture can be sutured together to cover it to avoid re-tearing. If there is still liver tissue on both sides of a small incision located deep in the inferior vena cava of the hepatic wound, the hemorrhage can be stopped by directly suturing the liver tissue on both sides together. During the operation, the anesthesiologist should be asked to reduce the respiratory amplitude and central venous pressure appropriately, which can decrease the hepatic venous pressure and reduce bleeding from the hepatic vein. It is worth mentioning that intraoperative ultrasound is of great value to understand the course of intrahepatic ductal structures and their tumor relationships, and to avoid damaging blood vessels during hepatic dissection. For tumors with extensive adhesions to surrounding organs, especially those with extensive adhesions to or invasion of the diaphragm; especially those located in the right half of the liver, the traditional method of freeing the diseased side of the liver before hepatectomy is not only difficult to operate, but also often results in extensive bleeding from the surgical separation surface, which is difficult to control. For bleeding caused by coagulation dysfunction, adequate amount of fresh plasma, prothrombinogen complex, fibrinogen, etc. should be supplemented in time and the operation should be ended as soon as possible, otherwise DIC is highly likely to occur and the patient will fall into passivity. (II) Postoperative liver failure In China, primary hepatocellular carcinoma is the most important indication for hepatectomy. Most patients with hepatocellular carcinoma are accompanied by chronic liver disease, and the liver reserve function has been damaged to different degrees. Therefore, post-hepatectomy liver failure is an important cause of perioperative death in patients with hepatocellular carcinoma. Therefore, to raise the awareness of protection against perioperative liver failure in patients with hepatocellular carcinoma and to take active and effective measures is an important way to further improve the safety of hepatectomy. The protection of liver failure involves many aspects, and it runs through the whole treatment process of preoperative, intraoperative and postoperative period, but it should be started from the following three aspects: (1) Preoperative evaluation of liver reserve function and active measures to increase patients’ surgical tolerance; (2) Intraoperative protection of residual liver function as much as possible, reducing bleeding and maintaining relative stability of hemodynamics; (3) Postoperative application of liver protection drugs. actively prevent and timely manage various complications. In recent years, we have chosen Child-Pugh liver function grading and indocyanine green 15-minute retention rate (ICGR15) as the basic index for the selection of hepatic resection, and the patients rarely died of liver failure after surgery, referring to the Japanese experience and combining with the actual practice of our department. It should be noted that in patients with Child-Pugh B liver function, the extent of hepatic resection is often one step lower than that of Child-Pugh A when selecting the procedure based on the ICGR15 results. For example, if a patient has Child-Pugh B liver function, even if the ICGR15 is normal, at most a combined resection of two hepatic segments of the right lobe of the liver Couinaud or a left hemicolectomy will be chosen, and if the ICGR15 is ≥40%, non-surgical treatments such as ultrasound-guided microwave curing or anhydrous alcohol injection therapy are often chosen. Of course, the surgical difficulty of hepatectomy varies from site to site, so it is necessary to make a comprehensive judgment by taking into account the anatomical site of the tumor.