Totally Laparoscopic ALPPS Is Feasible and May Be Worthwhile.

Machado MA, Makdissi FF,Surjan RC
Ann Surg 2012; 256:e13




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It is a common knowledge that laparoscopy may reduce adhesions. Our previous experience with two-stage laparoscopic liver resection4 showed that laparoscopic rehepatectomy has been greatly facilitated by the lack of adhesions, and it has been possible to use the same trocar incisions. Therefore, in our last case we decided to perform the ALPPS procedure totally laparoscopic. To complete this task totally by laparoscopy we need 3 steps: resection of tumor on the left lateral sector, ligature of the right portal vein and in-situ split. All this steps, except in-situ split, were previously performed by laparoscopy. Our previous experience with extended liver resections5 stimulated us to perform ALPPS totally laparoscopic based on the advantages that laparoscopy can add to this new approach. This procedure was successfully performed in a 69-year old female with multiple and bilobar liver metastases from colorectal origin. Liver volumetry showed a small-for-size future left liver remnant (0.42% left lobe-body weight ratio). In the first stage of the operation, laparoscopic partial resection of segment 3 was followed by ligature of the right portal vein and in-situ split. The liver transection was carried out using a combination of harmonic scalpel and vascular endoscopic stapler. Full mobilization of the right liver was performed in the first stage. CT scan at 7th postoperative day showed an increase of 88% in future liver remnant (0.8% left lobe-body weight ratio). Second stage was performed on the 9th postoperative day and only few avascular, easily lysed adhesions were found. Completion of surgery was easily done given previous in-situ split and right liver already mobilized. Division of the remaining liver parenchyma, pedicle and right hepatic vein were done with stapler and surgical specimen was removed by previous midline incision. Patient recovery was uneventful. ALPPS represents a revolutionary new two-stage technique and one of the most promising advances in liver surgery over the last decade. In several centers all over the world this technique is now been used and we expect soon a new report with a larger number of patients to address some uncertain points such as optimal selection of patients and impact on tumor biology and long-term survival. However, there still some room for improvement in the technique. We believe that the plastic bag should be replaced by a biologic tissue to minimize adhesions and laparoscopy should be more often used. Totally or partial use of laparoscopy may be an easy solution for adhesions and difficulties that may be encountered during the second stage. With the use of laparoscopy, second stage can be performed at the optimal time (for the patient) and the surgeon does not need to rush to avoid adhesions. Laparoscopic ALPPS is feasible and may be worthwhile is experienced hands.