Intraoperative iatrogenic rupture of hepatocellular carcinoma (HCC), which can occur during hepatic resection when large tumors are being mobilized, may adversely affect the operative outcome. Little information is available in the literature on this serious intraoperative complication. The aim of the present study is to document iatrogenic rupture of HCC as a serious complication during hepatic resection and its effects on the operative and long-term outcomes of patients with this complication. A retrospective study was performed on all patients with intraoperative iatrogenic rupture of HCC during hepatic resection from 1989 to 1997, and the operative and long-term survival outcomes were compared with those of patients without the complication. Among 194 patients who underwent hepatic resection for a large HCC (> or =5 cm) during the study period, 8 (4.1%) had intraoperative iatrogenic rupture of the tumor. When compared with 186 patients with similar clinical parameters but without intraoperative rupture, patients with intraoperative rupture had significantly more intraoperative blood loss (median 5.7 vs. 2.0 L;p = 0.01) and blood transfusion requirement (median 3.1 vs 0.9 L; p = 0.02). On follow-up, patients in the intraoperative rupture group had a significantly higher intraperitoneal extrahepatic recurrence rate (33.3% vs. 2.9%; p =0.02) and significantly shorter survival (median 11.5 vs. 37.9 months,p = 0.04) when compared with patients without the complication. Intraoperative iatrogenic rupture is a serious complication of hepatic resection for HCC because it is associated with increased intraoperative blood loss, increased incidence of intraperitoneal extrahepatic recurrence, and short survival. Extreme care should be taken during mobilization of the tumor, and an alternative operative approach in the presence of a difficult hepatic resection of a large HCC may be required to avoid the complication.