The World Health Organization [
10] defined cHCC-CC as a rare tumor containing unequivocal elements of intimately admixed HCC and CC. This tumor is distinguished from separate HCC and CC arising within the same liver. Patients with cHCC-CC and HCC are clinicopathologically similar in average age at the time of diagnosis (i.e., 50-60 years old), with a male predominance, viral hepatitis, elevated α-fetoprotein, and liver cirrhosis [
3,
4,
11], and clinicopathological features in our case were similar to the above data. It is difficult to make a differential diagnosis of cHCC-CC or HCC; however, therapeutic options for patients with these tumors are almost the same, and liver resection leads to improved survival for both tumors [
2‐
7].
Because a liver tumor located in segment 2 with PVTT in P2 is thought to readily metastasize through the portal venous flow to segments 3 and 4, left hepatectomy is the first choice of treatment. Left lateral sectionectomy is the second choice because the tumor was close to the left hepatic vein. However, in patients with liver cirrhosis, the left lateral section hypertrophies, and left hepatectomy or left lateral sectionectomy are sometimes not feasible because of decreased liver functional reserve and the relatively large volume of the left hemiliver or left lateral section [
12]. In our case, the left hemiliver and left lateral section became large (45% and 41% of the total liver, respectively) and the ICG-R15 level was relatively high (24%). And we judged preoperatively that we can exfoliate the tumor from the left hepatic vein. Therefore, anatomical liver segmentectomy 2 rather than left hepatectomy or left lateral sectionectomy was selected because it optimizes the balance between oncological requirements and the need to spare functioning liver parenchyma. Although preoperative surgical planning was evaluated by two-dimensional CT in our case, we think that three-dimensional CT computer-assisted preoperative surgical planning may be helpful for anatomical liver segmentectomy 2 [
13]. In anatomical segmentectomy 2, transection of the glissonean pedicle that feeds segment 2 [
12] and intraoperative ultrasound-guided blunt compression of the segment 2 portal branch [
14] have been reported; however, these techniques are not suitable in liver cancer patients with PVTT in the root of P2, including our patient. In such cases, complete removal of PVTT is extremely important to prevent early tumor recurrence; therefore, after A2, A3, P2, and umbilical and transverse portions of the left portal vein were separated, the liver was dissected, and PVTT was removed under direct vision. It is easy to ligate and divide the origin of P2 before liver transection; however, we think that it is safer and more certain to incise the origin of P2 and suture the stump of P2 after liver transection than before liver transection. This separation method could be adapted for segmentectomy 3 and segmentectomy 3 and 4 [
15]. Although several reports [
16,
17] have demonstrated the feasibility and safety of laparoscopic anatomic resection based on three-dimensional CT images recently, we performed anatomical liver segmentectomy 2 by open surgery because laparoscopic approach to hepatic tumors remains a challenge, and the patient in present report underwent upper abdominal surgeries (splenectomy, partial gastrectomy, and cholecystectomy). Left hemihepatic vascular occlusion, limited to 30 min followed by 5 min of perfusion, is useful to prevent blood loss originating from hepatic inflow [
9]; however, it is difficult to control retrograde bleeding from the left hepatic vein using this maneuver. Selective hepatic vascular exclusion (SHVE), which combines inflow vascular occlusion (Pringle maneuver) with extrahepatic control of the major hepatic veins, overcomes the drawbacks of backflow bleeding of the Pringle maneuver [
18]. In segmentectomy 2 or 3, modified selective hepatic vascular exclusion (m-SHVE), which combines extrahepatic control of the middle and left hepatic veins with left hemihepatic inflow occlusion, is sufficient to reduce both backflow and inflow bleeding. In our case, this m-SHVE procedure contributed to reduce bleeding during liver dissection and was not associated with hemodynamic changes. SHVE has been used in major liver resections to control intraoperative bleeding [
19,
20]; however, this technique has not been reported and studied in anatomical liver segmentectomy 2, to our knowledge. Furthermore, although it is reported in previous publications that SHVE entails Pringle maneuver and extrahepaic clamping of major hepatic veins [
19,
20], m-SHVE which entails not Pringle maneuver but hemihepatic inflow occlusion has not been reported. Therefore, anatomical liver segmentectomy 2 with m-SHVE is the novel technique. We think that this m-SHVE is the effective technique in anatomical liver segmentectomy 2 and can be adapted also for anatomical liver segmentectomy 3. Intraabdominal adhesion resulting from previous surgery was very severe, and then, about 120 min were required and blood loss was about 400 ml during exfoliation of this adhesion. Therefore, we think that the operative time (419 min) and the amount of blood loss (939 ml) in our case seem in the tolerance. The liver transection time was relatively longer because of the hard texture of liver parenchyma resulting from liver cirrhosis. Because postoperative liver function was adequate in our case, anatomical segmentectomy 2 is feasible to preserve remnant liver function in selected patients with liver cirrhosis.
Survival of patients with cHCC-CC was significantly poorer than that of HCC or CC patients [
3‐
5], and the PVTT was found to be significant predictor of poor outcome [
3,
5]. In our case, the patient is alive 9 months after surgery with lymph nodes metastasis. Although limited hepatectomy was performed, the patient has no recurrence in the remnant liver. Therefore, in selected patients with liver cirrhosis, limited hepetectomy including anatomical segmentectomy 2 may be an appropriate operation even if patients have the PVTT.