Surgical treatment of primary liver cancer PLC includes hepatectomy and liver transplantation. The basic principles of hepatectomy include: (1) Completeness: complete resection of tumor and no residual tumor at the cut edge; (2) Safety: maximum preservation of normal liver tissue and reduction of surgical mortality and surgical complications. The liver function reserve should be evaluated before surgery, usually using graded evaluation of liver parenchymal function, using CT and calculating the residual liver volume. 4.1 Hepatectomy 4.1.1 Classification of methods of liver resection Methods of liver resection include radical resection and palliative resection. Radical resection means: (1) no more than 2 tumors on several days; (2) no portal trunk and primary branches, common hepatic duct and primary branches, hepatic vein trunk and inferior vena cava cancer thrombus; (3) no intra- or extra-hepatic metastasis; complete resection of tumors seen by the naked eye and no residual cancer on the cut edge; (4) no tumor residue on postoperative imaging, and serum AFP decreases to normal within 2 months of postoperative follow-up for those with positive AFP before surgery. 4.1.2 Indications for surgery of primary liver cancer With the advancement of modern liver surgery technology, tumor size is not a key limiting factor for surgery. Whether it can be resected and the efficacy of resection are not only related to the size and number of tumor, but also very closely related to liver function, degree of cirrhosis, tumor site, tumor boundary, the presence of intact envelope and venous cancer thrombus, etc. 4.1.3 Indications for PLC surgery promulgated by the Chinese Society of Surgery Hepatology Group (1) General condition of the patient (required conditions): good general condition, no significant organic lesions of heart, lung, kidney and other important organs; normal or only mildly impaired liver function (Child-Pugh grade A), or liver function grade B, recovered to grade A after short-term liver care treatment; liver reserve function (Child-Pugh grade A), or liver function grade B. The liver reserve function (such as ICGRl5) is basically within the normal range; there is no unresectable extrahepatic metastatic tumor. (2) The local lesions that are feasible for radical hepatectomy must meet the following conditions: ① single hepatocellular carcinoma with smooth surface, clear surrounding boundaries or pseudo-envelope formation, liver tissue destroyed by tumor, or liver tissue destroyed by tumor but with obvious compensatory enlargement of the tumor-free side of the liver up to 50% or more of the whole liver tissue; ② multiple tumors with <3 nodes and confined to 1 segment or 1 lobe of the liver. (3) Local lesions that are feasible for palliative hepatectomy must meet the following conditions: ① 3 to 5 multiple tumors, beyond half of the liver, with multiple limited resections; ② tumors confined to 2 to 3 adjacent liver segments or half of the liver, with apparent compensatory enlargement of tumor-free liver tissue to more than 50% of the whole liver; ③ hepatocellular carcinoma in the central region of the liver (middle lobe or segment IV, V, VIII), with apparent compensatory enlargement of tumor-free liver tissue to more than 50% of the whole liver (4) Palliative hepatectomy The following cases are also involved: PLC with portal vein and/or vena cava thrombosis, PLC with bile duct thrombosis, PLC with cirrhotic portal hypertension, and resection of difficult-to-cut hepatocellular carcinoma. Each condition has its corresponding indication for surgical treatment (Table 1). In addition, for hepatocellular carcinoma that is not suitable for palliative resection, palliative non-resective surgical treatment should be considered, such as intraoperative hepatic artery ligation and/or hepatic artery and portal vein cannulation chemotherapy. For the treatment of microscopic intrahepatic lesions deserves attention. Some microscopic lesions are not detected by imaging or intraoperative exploration, resulting in a higher recurrence rate after hepatic resection. If incomplete resection is suspected, then postoperative TACE is the ideal choice, because in addition to the significance of treatment, it also has the significance of checking residual cancer foci. If there are residual cancer foci, timely remedial measures should be taken. In addition, postoperative cases should be examined for hepatitis viral load (HBVDNA/HCVRNA), and if indicated, antiviral therapy should be administered to reduce the possibility of recurrence of hepatocellular carcinoma. 4.2 Liver transplantation 4.2.1 Liver transplantation selection criteria At present, about 4000 cases of liver transplantation are performed in China every year, among which up to 40% are PLC patients. In China, PLC liver transplantation is only used as a complementary treatment for patients who cannot be surgically resected, cannot be treated with radiofrequency, microwave and TACE, or whose liver function cannot be tolerated. Regarding the indications for liver transplantation, Milan criteria and UCSF criteria are widely used internationally; while there is no unified standard within the same, several units have proposed different criteria, mainly Shanghai Fudan criteria, Hangzhou criteria and Chengdu criteria, etc. The requirements for the absence of large vessel invasion, lymph node metastasis and extrahepatic metastasis are relatively consistent, but the requirements for the size and number of tumors are different. The criteria proposed by Chinese scholars have expanded the scope of indications for PLC liver transplantation, which can benefit more PLC patients by surgery and may be more in line with the perinatal situation and patients' reality in China, but a relatively unified Chinese standard based on high level of evidence-based medicine has yet to be formed. 4.2.2 Prevention of recurrence after liver transplantation It is generally believed that appropriate postoperative chemotherapy and antiviral therapy may reduce recurrence of liver cancer and improve survival, but further research is needed. 4.2.3 Selection of liver transplantation and liver resection Surgical treatment means are mainly liver resection and liver transplantation, and there is no uniform standard for how to select them. It is generally believed that: for limited hepatocellular carcinoma, liver resection should be preferred if the patient is not accompanied by cirrhosis; if combined with cirrhosis, liver function loss and eligible for transplantation, liver transplantation should be preferred. For resectable limited hepatocellular carcinoma with good liver function compensation, whether liver transplantation can be performed is more controversial. European experts support the preference for liver transplantation on the grounds that the recurrence rate of hepatic resection is away and that long-term survival and tumor-free survival rates are significantly better in patients with liver transplantation meeting the Milan criteria than in patients with hepatic resection. In the case of a particular patient, a comprehensive evaluation and analysis is emphasized to develop the surgical approach on a case-by-case basis. In addition, preoperative angiography should be performed for resectable hepatocellular carcinoma, even if the imaging presentation is limited resectable hepatocellular carcinoma, because it can detect lesions that cannot be detected by other imaging means and also clarify the presence or absence of vascular invasion.