Vessel Identifications Tags for Open or Laparoscopic Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy

Abstract

Figure 1. Intraoperative view at the end of the first step of the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure. (A) Color-coded vessel loops: yellow for Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been proposed as the further evolution of the 2-stage hepatectomy technique (2SHT). The first step consists of left clearance, right portal branch occlusion, and in-situ splitting associated with middle hepatic vein section, and with the deportalized liver left in-situ. During the second step, section of the right branch of the hepatic artery, right portal vein, and right bile duct is followed by completion of the right hepatectomy. Surgical trauma from liver partition associated with portal vein ligation (PVL), with the right liver (segments V, VI, VII, and VIII) left in-situ, seems responsible for faster hypertrophy of the future remnant liver (FRL). Several small series in the literature describe an 80% to 200% increase in FRL volume, allowing 9 to 15 days between the 2 steps. This is far from being a harmless procedure; the morbidity rate was as high as 74% in the original series (52% of which were Clavien-Dindo III to IV), and the morbidity rate was reported to be as high as 90% in other series, with high rates of biliary fistula and procedure-related deaths. In classical 2SHT, the second step is often technically demanding due to fibrous adhesions, pedicular inflammation, and anatomic atrophy or hypertrophy. During the second step of ALPPS, mainly inflammatory adhesions are observed. In such setting, hemorrhagic dissection can make this phase particularly technically demanding. This surgical procedure is still considered to be in an early development phase because surgical indications and technique are not standardized. In 2012, we right biliary duct, red for the right hepatic artery, blue for the right branch of portal vein. (B) Acellular collagen membrane to avoid adhesions.