Comparison of Anatomical and Non‐Anatomical Resection in Low Microvascular Invasion Risk Solitary Hepatocellular Carcinoma ≤ 5 cm

ABSTRACT Background The role of anatomical resection (AR) in hepatocellular carcinoma (HCC) remains controversial, particularly for tumors ≤ 5 cm without vascular invasion. We aimed to evaluate the long‐term outcomes of AR versus non‐anatomical resection (NAR) in solitary HCC presumed negative for microvascular invasion (MVI) and intrahepatic metastasis (IM). Methods We retrospectively analyzed 303 patients with solitary HCC who underwent hepatectomy between 2002 and 2019. Predictive factors for MVI and IM were identified, and 214 patients with solitary HCC ≤ 5 cm and predicted absence of MVI and IM were further analyzed. We compared the perioperative and oncological outcomes between the AR ( n = 94) and NAR ( n = 120) groups. Subsequently, we conducted propensity score matching ( n = 41 per group) and performed subgroup analyses based on tumor size. Results Des‐γ‐carboxy prothrombin > 150 mAU/mL was identified as an independent predictor for MVI and IM. Compared with the NAR group, the AR group had a significantly longer operative time, greater blood loss, and higher rate of complications, but showed no significant differences in recurrence‐free survival and overall survival. Recurrence‐free survival and overall survival remained comparable between the two groups after propensity score matching. Subgroup analyses by tumor size (0–2.0 and 2.1–5.0 cm) showed no prognostic advantage for AR over NAR. Conclusions For solitary HCC ≤ 5 cm without predicted MVI and IM, NAR and AR result in comparable long‐term outcomes. The resection strategy should prioritize remnant liver function over anatomical extent.