Beyond the liver: curative-intent en bloc resection of port-site hepatocellular carcinoma metastasis to the rectus sheath – a rare case report

Introduction and importance: Hepatocellular carcinoma (HCC) is the most prevalent primary hepatic malignancy and is associated with poor outcomes after extrahepatic dissemination. Isolated abdominal-wall recurrence following laparoscopic hepatic resection is rare, with fewer than 50 cases reported. We report a case of isolated HCC metastasis at a previous laparoscopic port site, managed with curative-intent en bloc resection and complex abdominal-wall reconstruction. Presentation of case: A 71-year-old male with alcohol-related cirrhosis (Child-Pugh A6) and recurrent multifocal HCC, previously treated with hepatic resection, transarterial chemoembolization, and stereotactic body radiotherapy, presented with 4 weeks of progressive left periumbilical pain. Examination revealed a firm, tender left rectus sheath mass, with serum alpha-fetoprotein (AFP) within the normal range. CT identified a 3.8 × 2.5 × 2.6 cm heterogeneous mass at a previous laparoscopic port site, without peritoneal extension or distant metastases. En bloc excision with posterior component separation, left transversus abdominis release, and bioresorbable mesh reinforcement achieved an R0 resection. The postoperative course was uncomplicated. Clinical discussion: Port-site metastasis is an uncommon complication of laparoscopic oncological surgery. Potential mechanisms include direct tumor implantation associated with instrumentation or specimen extraction, and tumor disruption. Retrospective series support aggressive local therapy in selected patients with oligometastatic HCC and preserved hepatic function. Extensive abdominal wall resection may require component separation and mesh reinforcement to achieve tension-free reconstruction. Conclusion: Isolated HCC recurrence should be considered when a new abdominal wall mass develops at a previous laparoscopic port-site, even when serum AFP is within the normal range. In carefully selected patients without other metastatic disease, curative-intent local resection may be considered following a multidisciplinary assessment. The reconstructive approach should be individualized according to the resulting abdominal wall defect.