Totally laparoscopic ALPPS for multiple and bilobar colorectal metastases (with video)

Marcel Autran Machado, MD, FACS, Rodrigo C. Surjan, MD, Tiago Basseres, MD, Fabio F. Makdissi

2017 Jan 31. pii: S1878-7886(16)30192-8. doi: 10.1016/j.jviscsurg.2016.11.004.



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The ALPPS procedure, which stands for Associating Liver Partition and Portal vein ligation for Staged hepatectomy, has become a new strategy for patients with otherwise nonresectable liver tumors [1,2]. On the basis of our previous experience with laparoscopic extended hepatectomies and staged laparoscopic hepatectomies using portal vein ligation, we safely performed and reported a totally laparoscopic ALPPS procedure in 2012 [3]. This video shows a totally laparoscopic ALPPS procedure in a patient with multiple and bilateral colorectal metastases. Both stages were totally performed using laparoscopy. We present in this video the case of a 66-year-old woman with colorectal liver metastases in all liver segments, except S1 and S4. She was evaluated as unresectable. She underwent chemotherapy with objective response and multidisciplinary board decided for ALPPS procedure. The plan was to perform resection of segment 2, enucleation in segment 3, followed by right portal ligature and in situ liver partitioning as stage 1, followed by right hemihepatectomy as stage 2. Future liver remnant was estimated in 197 mL. The patient is placed in a supine position with the surgeon standing between patient’s legs. At laparoscopy, we can see signs of blue liver but no peritoneal implants are detected. Intraoperative ultrasound showed no new lesions. Segment 4 was clear. A large metastasis is found in segment 2, with close contact with left hepatic vein. Liver is carefully dissected with identification of the left hepatic vein and its branches from segment 2 and 3. Branch from segment 2 is divided, segment 2 is removed with preservation of left hepatic vein. Next step is to dissect ¬†and ligate the right portal vein. In this case an early bifurcation of anterior and posterior branches of right portal vein is found and ligated separately. Liver is then partitioned along main fissure. Patient is discharged between stages. CT scan before second stage showed a good regeneration with adequate hypertrophy of the future liver remnant. Second stage took place three weeks after first stage. At laparoscopy there were some loose adhesions that were easily divided. Area of liver partition was separated with blunt maneuver. Intrahepatic approach is performed and right Glissonian pedicle is divided with stapler, followed by division of right hepatic vein with stapler. Surgical specimen is removed through suprapubic incision. In conclusion, laparoscopic ALPPS is feasible and may be useful to decrease morbidity. This video shows the different steps [Fig.1] necessary to perform this complex operation.