Introduction

Hepatocellular carcinoma (HCC) is the most common primary liver cancer, comprising approximately 90% of liver cancer cases, and is one of the leading causes of cancer mortality globally. According to GLOBOCAN 2020 statistics, there are approximately 905,000 new cases of liver cancer and about 830,000 deaths each year, ranking sixth in incidence and the third among cancer-related causes of mortality [1].

In Vietnam, liver cancer is one of the most common types of cancer, with a high mortality rate, imposing a significant burden on the healthcare system. It occurs in males, particularly among middle-aged and elderly patients. The major risk factors for HCC include hepatitis B virus (HBV) infection, hepatitis C virus (HCV) infection, alcohol abuse, and chronic liver diseases, of which hepatitis B virus infection is considered a risk factor [2].

The clinical presentation of HCC is often nonspecific and subtle, leading to difficulties in early diagnosis. Many cases are detected at an advanced stage or incidentally during a health checkup. A study by Thuong et al. is [2] involving 150 patients with HCC at Hanoi Medical University Hospital showed that the average age of patients was around 60 years old, with male predominance. Notably, 30.7% of patients did not increase their α-fetoprotein (AFP) levels. Previous studies in Vietnam reported common symptoms such as right upper quadrant pain, fatigue, anorexia and weight loss; however, a considerable proportion of cases are still detected incidentally [3, 4].

Hepatectomy is one of the important curative treatments for HCC in patients with well-preserved liver function and localized tumors. In recent years, laparoscopic hepatectomy has become increasingly popular in the treatment of HCC. Many studies have shown that this method offers several advantages over open surgery, such as less intraoperative blood loss, lower blood transfusion requirements, and shorter hospital stays [5, 6]. However, selecting patients for laparoscopic hepatectomy depends on various factors, including liver function, as well as the number, size, and location of tumors.

In Vietnam, several studies have investigated the characteristics of HCC and treatment outcomes using various methods. However, studies focusing specifically on patients undergoing laparoscopic hepatectomy are still limited, especially at the two major surgical centers, Hanoi Medical University Hospital and Viet Duc University Hospital. Therefore, we conducted this study to evaluate the initial clinical outcomes of laparoscopic hepatectomy in patients with HCC.

Material and methods

Study participants

A retrospective descriptive study was conducted among consecutive patients with HCC who underwent laparoscopic hepatectomy at Hanoi Medical University Hospital and Viet Duc University Hospital between January 2021 and December 2025. Patients were identified from the surgical databases of the participating institutions. All consecutive patients with HCC who underwent laparoscopic hepatectomy and met the eligibility criteria were included in the analysis. The indication for laparoscopic hepatectomy was determined according to institutional surgical practice based on tumor characteristics, liver function status, and technical feasibility as documented in the medical records.

Inclusion criteria: Eligible participants met the following criteria: 1) a diagnosis of HCC established according to accepted clinical, laboratory, and imaging criteria; 2) underwent laparoscopic hepatectomy as the primary surgical treatment; and 3) had complete medical records with sufficient clinical, laboratory, imaging, operative, and follow-up data available for analysis.

Exclusion criteria: Patients were excluded if 1) their medical records lacked essential data required for the study, or 2) hepatectomy was performed for indications other than HCC, or 3) postoperative follow-up data were unavailable or incomplete.

Baseline characteristics

Baseline characteristics included demographic variables (age and sex). Hepatitis virus infection status was classified as HBV infection, HCV infection, co-infection (HBV/HCV), or no infection, based on serological testing. Family history was defined as the presence of HBV/HCV infection or HCC in first-degree relatives (yes/no). Alcohol consumption was defined as a history of regular alcohol intake (yes/no), and smoking history was recorded as current or former smoking (yes/no).

Clinical assessment

Mode of detection was classified as incidental detection (identified during routine health checkups or follow-up for chronic liver disease) or symptomatic presentation. Clinical symptoms at diagnosis included right upper quadrant pain, fatigue, anorexia, weight loss, and palpable liver mass, each recorded as present or absent.

Laboratory characteristics included serum AFP (ng/ml), aspartate aminotransferase (AST/GOT, U/l), alanine aminotransferase (ALT/GPT, U/l), total bilirubin (µmol/l), albumin (g/l), platelet count (×10⁹/l), and prothrombin time (PT, seconds or %). These variables were analyzed as continuous variables and, where appropriate, categorized based on clinically relevant thresholds.

Liver function was assessed using the Child-Pugh classification, which incorporates bilirubin, albumin, PT, ascites, and hepatic encephalopathy. Patients were categorized into Child-Pugh A (5-6 points), Child-Pugh B (7-9 points), and Child-Pugh C (10-15 points) [6, 7].

Tumor characteristics were evaluated using preoperative multiphase computed tomography (CT). The number of tumors was recorded as a discrete variable (single vs. multiple). Tumor size was defined as the maximum diameter (cm) of the largest lesion measured on CT; in patients with multiple tumors, the largest lesion was used for analysis. Tumor size was categorized into three groups: ≤ 3 cm, 3-5 cm, and ≥ 5 cm. Imaging features included arterial-phase hyperenhancement (present/absent) and washout in the portal venous or delayed phase (present/absent), which are considered typical radiological hallmarks of HCC [7, 8].

Surgical outcomes

Intraoperative variables included operative time (minutes), estimated blood loss (ml), and intraoperative complications (yes/no). Operative time was defined as the duration from skin incision to completion of surgery. Blood loss was recorded as the total estimated intraoperative volume. Intraoperative complications were documented when any adverse events occurred during surgery. Postoperative recovery variables comprised time to self-care (days), defined as the time to regain independence in basic daily activities. Duration of abdominal drainage (days) was calculated from surgery to drain removal. Length of hospital stay (days) was defined as the interval from surgery to discharge. Postoperative complications were classified according to the Clavien-Dindo classification into grades I-III. Short-term outcomes were assessed at one month postoperatively, including recovery status and the presence of complications [9].

Statistical analyses

The basic characteristics of the participants are shown according to gender and total number of patients. Continuous variables were assessed for normality using the Shapiro-Wilk test and are presented as mean ± standard deviation (SD) or median (interquartile range [IQR]) as appropriate. Categorical variables are presented as frequencies and percentages. Baseline demographic, clinical, surgical, and pathological characteristics were summarized descriptively. AFP levels were summarized as median (IQR) and compared across follow-up time points using the Friedman test. Categorical variables were compared using the chi-square test, Fisher’s exact test, or McNemar test as appropriate. Changes in continuous variables measured repeatedly during follow-up, including AFP, liver function parameters (AST, ALT, total bilirubin, and albumin), were analyzed using repeated-measures ANOVA for normally distributed data. When normality assumptions were not satisfied, appropriate non-parametric tests were applied.

Statistical analyses were performed using SPSS (IBM Corporation, US) version 29.0 for Mac. All statistical tests were based on two-sided probabilities, and a p-value < 0.05 is considered significant.

Results

Characteristics of participants

Table 1 presents the characteristics of the 78 patients included in the study, males predominated, accounting for 80.8%, while females represented 19.2%. The majority of patients were aged ≥ 60 years (46.2%), followed by those aged 40-59 years (42.3%) and < 40 years (11.5%). HBV infection was the most common underlying etiology (67.9%), whereas HCV infection and HBV-HCV co-infection were less frequent (5.1% and 1.3%, respectively); 25.6% of patients had no viral hepatitis. A family history of HBV/HCV infection or HCC was reported in 3.8% of cases. Regarding lifestyle-related risk factors, 30.8% of patients had a history of alcohol consumption, and 21.8% reported smoking. Most patients had a solitary tumor (85.9%), while 14.1% had multiple tumors (≥ 2 lesions). Tumor size was predominantly 3-5 cm (42.3%), followed by ≤ 3 cm (34.6%) and > 5 cm (23.1%). On CT, arterial-phase hyperenhancement was observed in 64.1% of cases, whereas 9.0% showed moderate enhancement and 26.9% demonstrated hypoenhancement. Washout during the portal venous phase was present in 82.1% of tumors. In terms of clinical presentation, 50.7% of cases were detected incidentally. Among symptomatic patients, right upper quadrant pain was the most common symptom (41.0%), followed by fatigue (26.9%) and anorexia (24.4%). Weight loss was reported in 12.8% of patients, and a palpable liver mass was rare (1.3%). Most patients had preserved liver function, with 98.7% classified as Child-Pugh A and only 1.3% classified as Child-Pugh B.

Clinical outcomes

Table 2 presents the operative and postoperative outcomes of the study population. The mean operative time was 164.9 ±59.8 minutes. Intraoperative blood loss occurred in 41.0% of patients, with a mean estimated volume of 347.2 ±217.8 ml. Regarding surgical approach, the majority of procedures were performed using four trocars (48.7%), followed by five trocars (41.0%), three trocars (9.0%), and six trocars (1.3%). Postoperatively, the mean duration of abdominal drainage was 5.8 ±1.9 days, and the average length of hospital stay was 7.7 ±2.8 days. Postoperative complications were assessed according to the Clavien-Dindo classification. Fourteen patients (17.9%) experienced no postoperative complications. Among those who developed complications, most were minor, with 57 patients (73.1%) classified as grade I and 7 patients (9.0%) classified as grade II. No grade III-V complications were observed. The most common postoperative complications were pleural effusion (32.1%) and residual fluid collection (32.1%), whereas bile leakage, postoperative liver failure, surgical site infection, and postoperative bleeding were uncommon.

Table 3 shows the pre- and postoperative laboratory characteristics of patients. Median AFP levels decreased significantly from 1450.5 ng/ml (IQR: 14.5-2027.8) preoperatively to 4.62 ng/ml (IQR: 3.05-53.04) postoperatively and 4.0 ng/ml (IQR: 2.3-6.5) at 3 months (p < 0.001). Liver enzymes showed a marked increase immediately after surgery, with AST rising from 55.6 ±11.5 U/l preoperatively to 264.7 ±32.5 U/l postoperatively, then declining to 96.8 ±9.6 U/l at 3 months (p < 0.001). Similarly, ALT increased from 61.8 ±15.5 U/l to 313.3 ±55.8 U/l postoperatively, followed by a decrease to 223.9 ±27.9 U/l at 3 months (p < 0.001) although levels remained above the preoperative values. Serum albumin levels decreased after surgery from 41.8 ±0.5 g/l to 33.8 ±0.7 g/l, with partial recovery to 35.7 ±0.3 g/l at 3 months (p < 0.001). In contrast, body weight remained relatively stable throughout follow-up, with no statistically significant change observed (p = 0.189).

Discussion

Hepatocellular carcinoma remains a leading cause of cancer-related mortality worldwide, with a particularly high burden in Vietnam due to the high prevalence of chronic HBV infection. In this study, we evaluated the clinical characteristics and short-term outcomes of patients undergoing laparoscopic hepatectomy, providing further evidence for the feasibility and effectiveness of this minimally invasive approach in the management of HCC in Vietnam.

The demographic profile of our study is consistent with the epidemiology of HCC. A predominance of male patients and older age groups, particularly those aged ≥ 60 years, was observed. This finding aligns with previous studies indicating that HCC occurs more frequently in men and typically develops in the setting of chronic liver disease [8, 10]. HBV infection was identified as the primary etiological factor, accounting for nearly 70% of cases. This reflects the epidemiological pattern in Vietnam and other Asian countries, where HBV remains the leading cause of HCC, in contrast to Western populations, where HCV infection and metabolic-associated fatty liver disease are more prevalent [7, 10].

This study had a high proportion of incidentally detected cases (50.7%). This likely reflects improved surveillance strategies in high-risk populations, such as patients with chronic hepatitis or cirrhosis. Early detection plays a critical role in expanding the pool of patients eligible for curative treatments, including surgical resection and liver transplantation [11, 12]. The relatively small tumor size and predominance of single lesions in our cohort further support the effectiveness of surveillance programs in identifying HCC at an earlier stage.

A notable finding of this study was the favorable perioperative outcome profile associated with laparoscopic hepatectomy. The mean operative time was 164.9 ±59.8 minutes, mean estimated blood loss was 347.2 ±217.8 ml, and the average postoperative hospital stay was 7.7 ±2.8 days. These results are generally comparable to those reported in contemporary laparoscopic hepatectomy series. For example, Ciria et al. reported operative times ranging from 150 to 300 minutes and blood loss between 200 and 500 ml in major laparoscopic liver resection studies [13]. Similarly, a meta-
analysis by Parks et al. demonstrated that laparoscopic hepatectomy was associated with reduced blood loss, shorter hospital stay, and lower postoperative morbidity compared with open hepatectomy [14]. Postoperative recovery was generally favorable. The mean duration of abdominal drainage was 5.8 days and severe complications were uncommon. These findings are consistent with previous reports demonstrating that minimally invasive liver surgery may facilitate postoperative recovery and reduce surgical trauma [13, 15]. However, the interpretation of complication rates in the present study warrants caution. The favorable outcomes may partly reflect the characteristics of the study population, as nearly all patients had preserved liver function (98.7% Child-Pugh class A), 85.9% had solitary tumors, and more than three-quarters of lesions measured ≤ 5 cm. These features are generally considered favorable for laparoscopic resection and likely contributed to the low morbidity observed.

The postoperative biochemical changes observed in this study were consistent with the physiological response to hepatic resection. AST and ALT levels increased markedly immediately after surgery, reflecting transient hepatocellular injury associated with liver parenchymal transection. Both enzymes subsequently declined during follow-up; however, ALT levels remained above baseline values at 3 months. This observation suggests that biochemical recovery may not have been complete within the study follow-up period and is consistent with previous reports indicating that restoration of hepatic function and regeneration of residual liver tissue may continue for several months after hepatectomy [16, 17]. Serum albumin levels decreased after surgery and partially recovered over time, reflecting the transient impairment and subsequent restoration of hepatic synthetic function during postoperative recovery [16, 18].

A marked decline in AFP levels was observed after surgery. Although this finding may reflect successful tumor removal and a favorable short-term biological response, AFP should be interpreted cautiously. AFP is a surrogate biomarker rather than a definitive measure of oncological success, and not all HCCs are AFP-secreting tumors. Therefore, normalization of AFP cannot be considered equivalent to oncological clearance or long-term disease control. Previous studies have suggested that AFP kinetics may provide prognostic information when interpreted together with imaging findings, pathological characteristics, and long-term follow-up data [19, 20]. The oncological implications of the present findings should therefore be interpreted with caution. Although laparoscopic hepatectomy was associated with favorable perioperative outcomes and substantial reductions in AFP levels, long-term oncological outcomes such as recurrence rates, recurrence-free survival, and overall survival were not evaluated. Consequently, the present study provides evidence supporting the short-term feasibility and safety of laparoscopic hepatectomy rather than definitive evidence of oncological effectiveness. Future prospective multicenter studies with larger sample sizes and longer follow-up are required to evaluate long-term oncological outcomes and further define the role of laparoscopic hepatectomy in the management of hepatocellular carcinoma.

Furthermore, no significant change in body weight was observed during the follow-up period, suggesting relative preservation of nutritional status. While this may reflect the benefits of minimally invasive surgery, including reduced surgical stress and faster recovery, it should be interpreted with caution. Body weight alone is an insensitive indicator of nutritional status, particularly in patients with chronic liver disease, where factors such as fluid retention, sarcopenia, and metabolic alterations may confound assessment. The absence of more specific nutritional parameters, such as skeletal muscle mass or validated nutritional scores, limits the ability to draw firm conclusions regarding postoperative nutritional recovery [7, 21, 22].

This study has several limitations that should be acknowledged. First, the retrospective design may introduce selection bias and limits the ability to establish causal relationships. In addition, the predominance of Child-Pugh A patients suggests a highly selected study population, which may limit the generalizability of the findings to patients with more advanced liver dysfunction. Second, because this study was restricted to patients who underwent laparoscopic hepatectomy, the findings reflect outcomes in a selected surgical population rather than the entire spectrum of patients with hepatocellular carcinoma. Consequently, selection bias cannot be excluded, and the results may not be generalizable to patients undergoing open hepatectomy or non-surgical treatment. Third, the study focused primarily on perioperative and short-term postoperative outcomes, and long-term oncological outcomes, including recurrence rates, recurrence-free survival, and overall survival, were not available. Fourth, the absence of a control group limits the ability to directly compare laparoscopic hepatectomy with conventional surgical approaches. Some important clinicopathological variables, including detailed tumor staging and pathological prognostic factors, were not comprehensively evaluated, which may affect the interpretation of oncological outcomes. Finally, although postoperative AFP levels decreased substantially, AFP is a surrogate biomarker and cannot replace established oncological endpoints. Therefore, the observed biochemical improvement should be interpreted as a favorable short-term treatment response rather than definitive evidence of oncological effectiveness. Future prospective multicenter studies with larger sample sizes, more comprehensive pathological assessments, and longer follow-up are needed to validate these findings and clarify long-term oncological outcomes.

Conclusions

Laparoscopic hepatectomy appears to be a safe and feasible treatment option for selected patients with HCC, particularly those with preserved liver function and early-stage disease. In this study, the procedure was associated with acceptable operative parameters, a relatively short hospital stay, and a low rate of postoperative complications. However, given the retrospective design, absence of a control group, and limited follow-up duration, the findings should be interpreted with caution. Further prospective studies with larger sample sizes and longer follow-up are needed to evaluate long-term oncological outcomes, including recurrence-free survival and overall survival.

Acknowledgements

The authors thank the study participants and our colleagues for completing the survey for this study.

Disclosures

This research received no external funding.

The study protocol was approved by the Institutional Review Board of Hanoi Medical University (approval number 1056/GCN-HMUIRB, January 19, 2024) and conducted in accordance with the ethical principles of the Declaration of Helsinki. This was a retrospective study based on medical record review; therefore, the requirement for written informed consent was waived by the Institutional Review Board. All patient data were anonymized and de-identified prior to analysis to ensure confidentiality. The study did not affect patient management or clinical care in any way.

The authors declare no conflict of interest.

References