Two-Stage Completely Laparoscopic Hemihepatectomy: Completely Laparoscopic ALPPS Using Round-the-Liver Ligation

Abstract

The safety of liver resection mainly depends on the function of the future liver remnant (FLR). Inadequate volume of FLR is associated with a significant increase in postoperative liver failure, especially in patients with liver cirrhosis. Even though laparoscopic hepatectomy could decrease the surgical trauma, it still could not solve the problem of inadequate volume of FLR. In clinical practice, surgical indications for patients with small volumes of FLR are always difficult to make because of the conflict between safety and oncological radicality. Two effective methods for increasing volume of FLR are adopted. One is portal vein ligation or percutaneous portal vein embolization, and the other is a two-stage surgery. However, these methods require several weeks for liver regeneration before the resection of liver malignancy. The risk of tumor progression during the waiting time is of concern by surgeons (Hayashi et al. 2007; Kokudo et al. 2001). Recently, a new “two-stage” operation which was named as “associating liver partition with portal vein ligation for staged hepatectomy (ALPPS)” by de Santibanes and Clavien (2012) has drawn the attention of surgeons. This method enables the rapid growth of FLR. However, the complication of bile leakage increased. In Schnitzbauer’s report (Schnitzbauer et al. 2012), bile leakage was observed in 24 % of the patients and the mortality was 12 %. The safety of the ALPPS was questioned by some surgeons (Kokudo and Shindoh 2013). The procedure of the in situ splitting of the liver was supposed to the major cause of the high occurrence rate of biliary leakage. This procedure was modified by Robles Campos et al. (2013). A round-the-liver ligation was executed to replace liver splitting to avoid the complication of biliary leakage and simplify the procedure as well (Fig. 8.1).