Laparoscopic Liver Partition and Portal Vein Ligation for Staged Hepatectomy

Juan Pekolj, MD, PhD, Fernando A. Alvarez, MD, Victoria Ardiles, MD, Pablo Huespe, MD, Virginia Cano Busnelli, MD, Eduardo de Santibañes, MD, PhD

Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, General Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina (all authors).

ABSTRACT

Introduction: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been introduced as a feasible strategy that allows complete resection with curative intention in selected patients with otherwise locally unresectable disease due to an insufficient future liver remnant. Minimally invasive surgery has shown several benefits over the open approach in different surgical areas, including liver resections, over the past 2 decades. We report a case of a pure laparoscopic ALPPS.

Case Description: A 73-year-old woman with a single hepatic metastasis from breast cancer was referred to our unit. She had been treated with radical left and right mastectomy 30 and 15 years before referral. Magnetic resonance imaging and positron emission tomographic computed tomography demonstrated a single hypermetabolic 68-mm tumor mass located in the right liver lobe without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled, but due to unexpected tumor extension during surgical exploration and the need for a larger than planned liver resection, a pure laparoscopic ALPPS approach was performed. After a 41% future liver remnant hypertrophy, the patient underwent a laparoscopic completion surgery without any complications. She had a favorable recovery and was discharged on postoperative day 3. The histopathological analysis indicated multiple metastatic breast cancer with negative resection margins.

Discussion and Conclusions: Pure laparoscopic ALPPS is feasible and may be performed safely in experienced hands. Minimally invasive access may represent a good alternative to reduce the surgical impact of the ALPPS approach in terms of postoperative recovery in selected patients.

Key Words: ALPPS, Laparoscopic liver surgery, Laparoscopy, Liver malignancy, Minimally invasive surgery.