The feasibility of surgery depends on the stage of hepatocellular carcinoma at time of diagnosis.

• Liver transplantation is the replacement of the diseased liver with a cadaver liver or a live donor lobe.
• Historically, the survival rates after liver transplantation have been low (20%-36%). Recent improvement in the survival rates (44% to 78%) due to the adoption of Milan criteria at US transplantation centers. If the tumor has metastasized, the immuno-suppressant post-transplant drugs decrease the chance of survival.^[1][2][3]

• Before transplantation, liver support therapy might be indicated ( called bridging-to-transplantation).
• Artificial liver support like liver dialysis or bioartificial liver support concepts are currently under preclinical and clinical evaluation.
• Virtually all liver transplants are done in an orthotopic fashion, that is the native liver is removed and the new liver is placed in the same anatomic location.
• The transplant operation may be conceptualized as consisting of the following:^{[4][5][6][7][8]}
  • Hepatectomy (liver removal) phase
  • Anhepatic (no liver) phase
  • Postimplantation phase
• The operation is done through a large incision in the upper abdomen.
• The hepatectomy involves division of:^[9][10]
  • All ligamentous attachments to the liver
  • Common bile duct
  • Hepatic artery
  • Portal vein
• Usually, the retrohepatic portion of the inferior vena cava is removed along with the liver, although an alternative technique preserves the recipient’s vena cava (“piggyback” technique).
• The donor’s blood in the liver is replaced by an ice-cold organ storage solution, such as UW (Viaspan) or HTK until the allograft liver is implanted.
• Implantation involves anastomoses (connections) of the inferior vena cava, portal vein, and hepatic artery.
• After blood flow is restored to the new liver, the biliary (bile duct) anastomosis is constructed, either to the recipient’s own bile duct or to the small intestine.
• The surgery usually takes between five and six hours, but may be longer or shorter due to the difficulty of the operation and the experience of the surgeon.
• The large majority of liver transplants use the entire liver from a non-living donor for the transplant, particularly for adult recipients.^[11][12]
• A major advance in pediatric liver transplantation was the development of reduced size liver transplantation, in which a portion of an adult liver is used for an infant or small child.
• Further developments in this area included split liver transplantation, in which one liver is used for transplants for two recipients, and living donor liver transplantation, in which a portion of healthy person’s liver is removed and used as the allograft.
• Living donor liver transplantation for pediatric recipients involves removal of approximately 20% of the liver (Couinaud segments 2 and 3).

• If diagnosed early, surgical resection with a safety margin can be considered to remove a small or slowly growing tumors. This treatment offers the best prognosis for long-term survival. The 5 year over all survival rate for patients who undergo surgical resection is 27% to 70%.^[1] Unfortunately, due to the severity of the tumor and poor liver functions, it’s only possible in 10-15% of hepatocellular carcinoma cases. Resection in cirrhotic patients carries high morbidity and mortality rates.

Absolute contraindications:^[8]

• Metastasis outside the liver, past the curative stage
• Hepatocellular carcinoma with metastasis (Stage 1V)
• Acute Liver Failure with persistently elevated intracranial pressure ICP >50mmHg( due to hepatic encephalopathy)
• Hemangiosarcoma
• Hilar cholangiocarcinoma with liver involvement
• Sepsis
• Active alcohol or drug abuse
• Anatomic anomalies that may be a deterrent to transplantation
• Poor adherence to medical treatment
• Absence of social support

Relative contraindications:^{[8][13][14][15][16][17][18][19][20][21][22]}

• Infection with HIV (AIDS)
• Age >65 years
• Any serious pathologies of the lung or heart that cannot be corrected
• BMI ≥40
• Alcoholic liver disease:Only performed if abstinent for ≥ 6 months
• Presence of social support
• Participation in an alcohol abstinence and rehabilitation program

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