Laparoscopic partial-ALPPS, stage 1. Initial experience

Abstract

Background: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), continues to evolve into different variations and provoking debate about indications, associated morbidity and oncologic outcomes. Throughout this progression, the benefits of a laparoscopic approach and a partial parenchymal transection on the initial stage are becoming more evident (as opposed to a complete transection) in achieving the desired hypertrophy of the future liver remnant (FLR), while decreasing the overall severity of associated complications and simplifying their management between stages . We present our initial experience with Laparoscopic Partial-ALPPS, focused on the stage 1. Methods: 4 cases reviewed at multidisciplinary HPB tumor board, decided to proceed with extended right hepatectomy via ALPPS. Laparoscopic Partial ALPPS was performed during stage 1. Technical steps: 1-Cholecystectomy; 2-Traction cystic-duct stump exposing Right Hepatic Artery (RHA) and Main Portal Vein (MPV) extending into Right Portal Vein (RPV); 3-Circumferential dissection RHA and RPV; 4-Ligation RPV (tie and/or clips); 5- Partial parenchymal transection 50% preserving Middle Hepatic Vein (MHV) outflow. Postoperative imaging confirmed desired hypertrophy of the remnant liver volume within 9-11 days and the stage 2 ALPPS was carried out 14–16 days after stage 1. Three out of the four stage 2 cases were initiated with laparoscopy and intentionally converted to open extended right hepatectomy following a planned learning curve. Results: Case 1: 74F HCV s/p Harvoni, 6 cm HCC in segment 8, abutting the right hepatic and middle hepatic veins. Advanced liver fibrosis. Total liver volume 950 ml, volume of FLR 253 ml. Stage 1-Lap Partial ALPPS. Discharged POD#4. Repeat imaging POD#11, hypertrophied FLR 501ml. Stage 2-POD#16 Lap converted-to-open right extended hepatectomy. Discharged POD#6. Case 2: 58F PMHx of colon cancer, synchronous metastasis to the liver. FOLFOX+ Avastin. Total liver volume 910 ml. Right lobe 622 ml, 2 lesions occupy 58 ml. Left lobe 288 ml, 1 lesion occupies 23ml. Stage 1-Lap wedge LLS lesion+Lap Partial ALPPS. POD#2 Re-laparoscopy, bleeding-control hemostasis. Stage 2: preop imaging hypertrophied FLR 369 ml. POD#15- Open right hepatectomy + extended right colectomy. Discharged on POD#6. Case 3: 66M HCV s/p Harvoni, 3.5 cm HCC segment 8, abutting right hepatic vein, close to middle hepatic vein. Advanced liver fibrosis. Volume FLR 557 ml. Stage 1-Lap Partial ALPPS. Discharged POD#4. Repeated imaging POD#11, hypertrophied FLR 720 ml. Stage 2- POD#15, Lap converted-to-open right extended hepatectomy. Discharged POD#5. Case 4: 67M HCV s/p Harvoni) with 5 cm HCC segment 7, abutting right hepatic vein, close to middle hepatic vein. Advanced liver fibrosis. Volume FLR 583 ml. TACE followed 3 weeks later by Stage 1-Lap Partial ALPPS. Discharged POD#4. Repeated imaging POD#9. Hypertrophied FLR 976 ml. Stage 2-POD#14 Lap converted-to-open right extended hepatectomy. Complicated postop course, bleeding and infection. Reoperation/washout. Discharged POD#23. Conclusion: Each case is presented with a short video clip highlighting the technical steps of the Laparoscopic Partial-ALPPS during Stage 1, which were overall carried out without intraoperative difficulties and with satisfactory recovery and prompt discharge in all cases, while achieving the FLR hypertrophy within the expected timeframe. An additional video clip presents the laparoscopic findings during stage 2 prior to converting to open procedure, illustrating the amount of inflammation that challenged the laparoscopic completion of Stage 2 during this initial experience.