Two-stage Hepatectomy Research Articles

Liver regeneration and liver metastasis.

Surgical resection for primary and secondary hepatic neoplasms provides the best chance of cure. Advanced surgical techniques such as portal vein embolisation, two-staged hepatectomy and associated liver partition and portal vein ligation for staged-hepatectomy (ALPPS) have facilitated hepatic resection in patients with previously unresectable, bi-lobar disease. These techniques are frequently employed to ensure favourable clinical outcomes and avoid potentially fatal post-operative complications such as small for size syndrome and post-hepatectomy liver failure. However, they rely on the innate ability of the liver to regenerate. As our knowledge of liver organogenesis, liver regeneration and hepatocarcinogenesis has expanded in recent decades it has come to light that liver regeneration may also drive tumour recurrence. Clinical studies in patients undergoing portal vein embolisation indicate that tumours may progress following the procedure in concordance with liver regeneration and hypertrophy, however overall survival in these patients has not been shown to be worse. In this article, we delve into the mechanisms underlying liver regeneration to better understand the complex ways in which this may affect tumour behaviour and ultimately inform clinical decisions.

Current status of laparoscopic liver resection for the management of colorectal liver metastases.

Colorectal cancer (CRC) is one of the most prevalent malignancies worldwide. The commonest site of spread is the liver, with up to 40% of patients developing colorectal liver metastasis (CLRM) during the course of their lifetime. Significant advances in surgical techniques, as well as breakthroughs in chemotherapy and biologic agents, have resulted in dramatic improvements in prognosis. A multimodal approach comprising of liver resection coupled with systemic therapy offers these patients the best chance of cure. The arrival of laparoscopic liver resection (LLR) within the last 3 decades has added a whole new dimension to the management of this condition. Today, CLRM is one of the most frequent indications for LLR globally. Meta-analyses of retrospective studies and two randomized trials have demonstrated superior short-term outcomes following LLR, with no differences in mortality rates. Oncologically, R0 resection rates are comparable to the open approach, while overall and disease-free survival rates are also similar. As surgeons gain confidence, boundaries are pushed even further. High-volume centers have published their early experiences with complex LLR of recurrent CLRM as well as totally laparoscopic synchronous resection of CRC and liver metastases, with very encouraging results. In the presence of extensive bilobar CLRM, two-stage hepatectomy (TSH) and associating liver partition with portal vein ligation (ALPPS) may be adopted to augment an inadequate future liver remnant to facilitate metastasectomy. Interestingly, the adoption of LLR for these techniques also seem to confer additional benefits. Despite the plethora of advantages, LLR comes with its own unique set of limitations such as a steep learning curve and high cost. The surgical world eagerly awaits the results of prospective trials currently underway in order to further advance the management of this disease.

Sequential Portal Vein Embolization: a Technical Option for Hepatic Metastasis Resection

We present the clinical case of a patient who, having been referred for surgery on two-stage hepatectomy, could not have a conventional portal embolization performed as an intermediate step in order to be able to resection the whole of the hepatic illness she was suffering. During right portal embolization (PE), the portography revealed minimal flow in the left portal vein, without thrombosis or stenosis. Given the risk of serious hepatic insufficiency, the embolization procedure was ruled out. Our option was to perform a portal embolization in two stages: initial PE of the right posterior branch, and subsequently, right anterior branch PE. After that, the liver resection could be completed.

Surgical technique and clinical results of one- or two-stage laparoscopic right hemihepatectomy after portal vein embolization in patients with initially unresectable colorectal liver metastases: A case series.

The use of the laparoscopic approach in one-stage or second-step of two-stage right hemihepatectomy (RHH) after portal vein embolization (PVE) in patients with initially unresectable colorectal liver metastases (CRLMs) is technically demanding. Currently, there is limited published data regarding the technique and results required to better understand its safety and feasibility. This paper reports our experience, results, techniques and variety of tips and tricks (highlighted in the attached video), to facilitate this resection. A prospectively maintained database of laparoscopic liver surgery within our unit at a tertiary referral centre between August 2003 and March 2019 was reviewed. Patients with initially unresectable CRLMs who underwent laparoscopic RHH or extended RHH after PVE in the context of a one or two-stage procedure were included. Between August 2003 and March 2019, 19 patients with initially unresectable CRLMs underwent laparoscopic RHH after PVE. Twelve patients (63.2%) had RHH in the context of a two-stage hepatectomy and 7 as a one-stage procedure. Median time interval between PVE and surgery was 42.5 days (IQR, 34.5-60.0 days). Mean operating time was 351.8±80.5 minutes. Median blood loss was 850 mL (IQR, 475-1350 mL). Conversion to open surgery occurred in 2 of 19 cases (10.5%). Severe postoperative morbidity occurred in 2 patients. The mortality rate was 5.3%. Median postoperative hospital stay was 5 days (IQR, 4-7 days). Radical resection was obtained in eighteen patients (94.7%). Laparoscopic RHH after PVE in the context of a one- or two-stage resection in patients with initially unresectable CRLMs is a safe and feasible procedure with favourable oncological outcomes.

Evolution of Surgical Management of Colorectal Liver Metastasis

AbstractThe treatment of colorectal liver metastasis (CRLM) has progressed markedly in the past decades. Main contributions stem from improvement in surgical approach and applications of chemotherapy. The availability of several perioperative and surgical techniques, including portal vein embolization, ablation techniques, and two-stage hepatectomies, has expanded surgical indications. In addition, preoperative imaging methods have contributed to these advances.In patients with high oncological risk of recurrence, or initially unresectable CRLM, highly individualized treatment regimens are becoming more widely utilized. These patients should be evaluated for surgical resection after several cycles of chemotherapy given the survival benefit afforded by liver resection for CRLM. Several biomarkers, including RAS mutation, BRAF mutation, and microsatellite stability, have become essential in guiding therapy. Immunotherapy has recently been highlighted, especially for cases of microsatellite instability. Looking forward, biomarkers will likely to continue to guide individualized treatment patterns.Liver transplantation as an option for patients with unresectable CRLM may boast comparable outcomes to patients with primary liver tumors, but it remains controversial considering the limited supply of donor livers.Management of CRLM requires the complex decision making process common to contemporary tumor board discussions, and a multidisciplinary approach likely figures into future directions of management for CRLM.

Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Registry: What Have We Learned?

In 2007, the first associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure was performed in Regensburg, Germany. ALPPS is a variation of two-stage hepatectomy to induce rapid liver hypertrophy allowing the removal of large tumors otherwise considered irresectable due to a too small future liver remnant. In 2012, the international ALPPS registry was created, and it now contains more than 1,000 cases. During the past years, improved patient selection and refinements in operative techniques, in particular, less invasive approaches such as Partial ALPPS, Tourniquet ALPPS, Ablation-assisted ALPPS, Hybrid ALPPS or Laparoscopic or Robotic approaches, have resulted in significant improvements in safety. The most frequent indication for ALPPS is colorectal liver metastases. In the first randomized controlled study, ALPPS provided a higher resectability rate than conventional two-stage hepatectomy, with similar complication rates. Long-term outcome data are still missing. The initial results of ALPPS for hepatocellular carcinoma and for perihilar cholangiocarcinoma were devastating, but with progress in surgical technic and better patient selection, ALPPS could serve as a treatment alternative in carefully selected cases, even for these tumors. ALPPS has enlarged the armamentarium of hepato-pancreato-biliary surgeons, but there is still discussion regarding how to use this novel technique, which may allow resection of tumors that are otherwise deemed irresectable.

Role of thermal ablation in the management of colorectal liver metastasis.

With a recent randomized prospective trial revealing that thermal ablative therapy as local tumor control improved overall survival (OS) in patients with unresectable colorectal cancer liver metastases (CRLM), thermal ablation continues to remain as an important treatment option in this patient population. Our aim of this article is to review the current role of the ablative therapy in the management of CRLM patients. Main indications for thermal ablation include (I) unresectable liver lesions; (II) in combination with hepatectomy; (III) in patients with significant medical comorbidities or poor performance status (PS); (IV) a small (<3 cm) solitary lesion, which would otherwise necessitate a major liver resection; and (V) patient preference. There are several approaches and modalities for ablative therapy, including open, percutaneous, and laparoscopic approaches, as well as radiofrequency ablation (RFA) and microwave ablation (MWA). Each approach and ablation modality have its own pros and cons. Percutaneous and laparoscopic approaches are preferred due to minimally invasive nature, yet laparoscopic approach has more benefits from thorough intraoperative ultrasound (US) exam as well as complete peritoneal staging with laparoscopy. Similarly, whereas high local tumor failure rate has been a major concern with RFA, MWA or microwave thermosphere ablation (MTA) have demonstrated significantly improved local tumor control due to homogenous tissue heating, ability to reach higher tissue temperatures, and less susceptible to the "heat-sink" effect. Although liver resection is the standard of care for CRLM, there have been some retrospective studies demonstrating similar oncological outcome between ablative therapy and surgical resection in very selected populations with small (<3 cm) solitary CRLM. Lastly, ablative therapy and liver resection should not be mutually exclusive, especially in the management of bilobar liver metastases. Concomitant ablative therapy with hepatectomy may spare the patients from having two-stage hepatectomy with less morbidity. The role of the thermal ablation will continue to evolve in patients with resectable and ablatable lesions owing to newly emerging technology, in addition to new systemic treatment options, including immunotherapy for metastatic colorectal cancer (CRC).

Partial orthotopic liver transplantation in combination with two-stage hepatectomy: A proof-of-concept explained by mathematical modeling

BackgroundResection And Partial Liver Segment 2/3 Transplantation with Delayed total hepatectomy (RAPID) includes total hepatectomy in 2 steps with small graft transplantation at first stage. To avoid graft portal hyperperfusion, portal vein pressure monitoring is required after revascularization and right portal vein clamping. To date, portal flow modulation has not been reported but simulating hemodynamics in RAPID patients would be useful to anticipate these procedures.Our team developed hemodynamic 0D modeling; we aimed to assess if this mathematical model could be accurately used in the RAPID setting. MethodsThe modified 0D model was retrospectively tested on 3 patients. We compared our estimated portal vein pressures and portocaval gradients to those intraoperatively measured, as indication to modulate portal flow relies on these measures. FindingsPortal pressures measured after right portal vein clamping (end of RAPID procedure) in patients 1, 2 and 3 were respectively of 14, 16 and 12 mmHg while the simulated pressures were of 13.1, 14.8 and 11.5 mmHg (p = 0.25).Portocaval gradients measured after right portal vein clamping in the 3 patients were respectively of 10, 11 and 7 mmHg while the simulated gradients were of 9.9, 11.6 and 8.3 mmHg (p = 0.5). InterpretationWe succeeded to predict portal vein pressures and portocaval gradients after RAPID. This promising report demonstrates that 0D simulation could be a useful tool for human decision-making. Moreover, such a patient-specific model could be of importance if we transpose RAPID experience to hepatocellular carcinoma bearing cirrhotics, a population with high probability of portal hypertension after RAPID.

Laparoscopic first stage of ALPPS for hepatoblastoma in an infant

Radical tumor removal remains the key task in hepatoblastoma surgery. Patients who need extended resection and have a risk of posthepatectomy liver failure are particularly difficult. In cases with insufficient future liver volume, the method of choice is a two-staged hepatectomy or liver transplantation. Despite the wide spread of laparoscopic liver surgery in adults, the minimally invasive approach has not been studied in pediatrics, and the literature on this issue is scarce. In current publication a case of successful partial associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) in a child, firstly accomplished pure laparoscopically. Described experience suggests the feasibility of laparoscopic liver resections in children and effectiveness of partial in situ liver splitting to reach appropriate future liver remnant volume and to avoid liver transplantation and its disadvantages.

ALPPS and minialpps. Alternatives between liver hypertrophy techniques. Presentation of two cases in liver disease of non-colorectal origin

Presenter: Fabio Vergara MD | IPS Universidad de Antioquia, Clinica Leon XIII Background: Liver resections are the treatment of choice for most liver tumors. Thanks to liver regeneration, various procedures have appeared to stimulate liver hypertrophy in cases where it is required. Among them is the ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy), which consists of performing a hepatectomy in two stages, achieving faster hypertrophy and in less time. This surgical technique can have high morbidity and mortality rates, so it is very important to properly select patients. In recent years, groups from Chile and Argentina have developed a variant in this technique which they have called Mini-ALPPS, where the hepatic transection is minor, thus reducing the morbidity that this part of the surgery can bring. Methods: We present two cases of ALPPS and Mini-AlPPS in liver disease of non colorectal origin. The first case of a two-stage hepatectomy using ALPPS is a 65-year-old male patient, with MRI of the abdomen shows a giant liver in the right lobe and part of segment IV compatible with probable hepatocarcinoma over non-cirrhotic liver. Hepatic volumetry show insufficient hepatic remnant, it was decided to perform an ALPPS with the aim of obtaining a faster hepatic hypertrophy. The first time was performed by laparoscopic technique, achieving right portal ligation and hepatic transection. At 10 days, a new abdominal tomography was performed to assess hypertrophy. Then proceed to the second time of the ALPPS, with an open approach. Hepatic transection is completed with right hepatic artery ligation, right bile duct control and right hepatic vein section. In the second case we used de Mini-ALLPS strategy. A 52-year-old woman with a history of resected retroperitoneal sarcoma. In the follow-up hepatic recurrence of sarcoma. MRI confirms presence of hepatic bilobar disease in the right lobe and segment IV with a single lesion in the left lateral section. It was decided to perform MiniALPPS with resection of the metastasis of the left lateral section, right portal ligation and hepatic section of 3cms deep in the firs stage. At 10 postoperative days a CT scan of the abdomen shows compensatory hypertrophy of the left lateral section. In the second stage an extended right hepatectomy was performed. Results: In the two cases the procedure was uncomplicated, did not require blood transfusion or vasopressor support, extubation and transfer to the ICU was achieved for surveillance. The ALPPS case had no signs of liver failure, he was discharged after 8 days. The pathology shows a hepatocarcinoma on non-cirrhotic liver. The MiniALPPS case has present type B postoperative liver failure, it required vasopressor support and blood transfusion. The pathology confirmed sarcoma metastases Conclusion: ALPPS and MiniALPPS are an alternative in the treatment of liver tumors where the liver remnant is insufficient. They can use when the cause of its tumor biology and we need a hypertrophy is less time or when the other ways of generating hypertrophy are failed. However, it is a procedure that can have high morbidity and mortality, so it is important to select patients in a multidisciplinary team.

Surgical Treatment of a Primary Tumour and Liver Metastases in a Patient With Intracranial Haemangiopericytoma

Cancers exhibit a spectrum of behaviours ranging from aggressive malignancy to those which progress in an almost benign fashion. An appreciation of this aspect of tumour biology is crucial when planning patient management as non-curative debulking procedures for slower growing tumours often still confer a survival benefit. The present report is a case in point.&#x0D; Haemangiopericytoma is a rare cancer whilst clear indications for an ALPPS procedure are still evolving. Inherent to the patient groups in whom ALPPS is considered is the presence of advanced underlying disease. Many of these patients would previously not be considered for liver resection or have progressed beyond resectability by the time sufficient hypertrophy of their future liver remnant had been achieved using conventional two-stage hepatectomy techniques.&#x0D; ALPPS offers another treatment option for these patients, although at a cost. Early experience reported unacceptably high morbidity and mortality rates following ALPPs resection and suggested that tumour type and patient fitness were key factors in determining outcome. The patient must be fit enough to withstand two major operations 1-2 weeks apart. The slow growing nature of the tumour in the present case combined with the fit, motivated patient meant that, despite developing post-operative liver insufficiency, Mr X still recovered well.&#x0D; As is so often the case in surgery, patient selection is key

Renal Impairment Is Associated with Reduced Outcome After Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy

BackgroundImpaired postoperative renal function is associated with increased morbidity and mortality after liver resection. The role of impaired renal function in the two-stage hepatectomy setting of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is unknown. MethodsAn international multicenter cohort of ALPPS patients captured in the ALPPS Registry was analyzed. Particular attention was drawn to the renal function in the interstage interval to determine outcome after stage 2 surgery. Interstage renal impairment (RI) was defined as an increase of serum creatinine of ≥ 0.3 mg/dl referring to a preoperative value or an increase of serum creatinine of ≥ 1.5× of the preoperative value on the fifth postoperative day after stage 1. ResultsA total of 705 patients were identified of which 7.5% had an interstage RI. Patients developing an interstage RI were significantly older. During stage 1, a longer operation time, higher rate of intraoperative transfusions, and additional procedures were observed in patients that developed interstage RI. After stage 1, interstage RI patients had more major complications and higher interstage mortality (1% vs. 8%, p < 0.001). Furthermore, these patients developed more and severe complications after completion of stage 2. Mortality of patients with interstage RI was 38% vs. 8% without interstage RI. In 41% of patients with interstage RI, the renal function recovered before stage 2; however, the mortality after stage 2 remained 28% in those patients. Risk factors for the development of an interstage RI were age over 67 years, prolonged operative time, and additional procedure during stage 1. ConclusionThis study shows that interstage RI is a predictor for interstage and post-stage 2 morbidity and perioperative mortality. The causality of impaired renal function on outcome, however, remains unknown. Interstage RI may directly cause adverse outcome but may also be a surrogate marker for major complications.

Auxiliary living donor liver transplantation combined with two-stage hepatectomy for unresectable colorectal liver metastases.

To review the role of liver transplantation for unresectable colorectal liver metastases (u-CRLM) and to describe the intial experience with auxiliary living donor liver transplantation combined with two-stage hepatectomy for u-CRLM (i.e. living donor RAPID). Patients affected with u-CRLM have a poor prognosis with 5 years overall survival (OS) rate less than 10% under standard modern chemotherapy.There is an actual international consensus that liver transplantation for u-CRLM represents a viable option in highly selected patients with OS rate at 5 years up to 80% notwithstanding high recurrence rates. Due to the scarcity of whole liver graft from deceased donors, the RAPID procedure (i.e. resection and partial liver segment 2-3 transplantation from deceased donors with delayed total hepatectomy) has been introduced as possible alternative. The RAPID procedure represents the most actual and modern fusion of the two most challenging procedures of modern hepatobiliary and liver transplant surgery: that is auxiliary partial orthotopic liver transplantation and associating liver partition and portal vein ligation for staged hepatectomy. Although the deceased donor-RAPID procedure may show promising results, the basic problem of scarcity of organs from deceased donors and mainly the lack of splittable organs still remains. The living donor RAPID, based on transplantation of left lateral segments from living donor, may represent the way out to this problem. It is feasible and safe (for both donor and recipient), but characterized by a very challenging high-end transplantological procedure.

Two-Stage Hepatectomy with Portal Embolization to Treat Bilateral Hepatic Adenomas

Two-Stage Hepatectomy with Portal Embolization to Treat Bilateral Hepatic Adenomas

Laparoscopic versus open two-stage hepatectomy for bilobar colorectal liver metastases: A bi-institutional, propensity score-matched study

BackgroundThe safety and feasibility of laparoscopic, two-stage hepatectomy for bilobar colorectal liver metastases is poorly evaluated. MethodsWe reviewed retrospectively 86 consecutive patients who underwent complete two-stage hepatectomy (left lobe clearance as the first stage and standard/extended right hepatectomy as the second stage) for bilobar colorectal liver metastases between 2007 and 2017 in 2 tertiary centers. Short- and long-term outcomes were compared between laparoscopic and open two-stage hepatectomy before and after propensity score matching. ResultsLaparoscopic two-stage hepatectomy was performed in 38 patients and open two-stage hepatectomy in 48. After propensity score matching, 25 laparoscopic and 25 open patients showed similar preoperative characteristics. For the first stage, a laparoscopic approach was associated with lesser hospital stays (4 vs 7.5 days; P < .001). For the second stage, a laparoscopic approach was associated with less blood loss (250 vs 500 mL; P = .040), less postoperative complications (32% vs 60%; P = .047), lesser hospital stays (9 vs 16 days; P = .013), and earlier administration of chemotherapy (1.6 vs 2 months; P = .039). Overall survival, recurrence-free survival, and liver-recurrence-free survival were comparable between the groups (3-year overall survival: 80% vs 54%; P = .154; 2-year recurrence-free survival: 20% vs 18%; P = .200; 2-year liver-recurrence-free survival: 39% vs 33%; P = .269). Although both groups had comparable recurrence patterns, repeat hepatectomies for recurrence were performed more frequently in the laparoscopic two-stage hepatectomy group (56% vs 0%; P = .006). ConclusionLaparoscopic two-stage hepatectomy for bilobar colorectal liver metastases is safe and feasible with favorable surgical and oncologic outcomes compared to open two-stage hepatectomy.

Futility and utility of two-stage hepatectomy

Futility and utility of two-stage hepatectomy

Outcomes of staged hepatectomies for liver malignancy.

Liver malignancies are the fifth most common cause of death worldwide. Surgical intervention with curative intent is the treatment of choice for liver tumors as it provides long-term survival. However, only 20% of patients with metastatic liver lesions can be managed by curative liver resection. In most of the cases, hepatectomy is not feasible because of insufficient future liver remnant (FLR). Two-stage hepatectomy is advocated to achieve liver resection in a patient who is considered to not be a candidate for resection. Procedures of staged hepatectomy include conventional two-stage hepatectomy, portal vein embolization, and associating liver partition and portal vein ligation for a staged hepatectomy. Technical success is high for each of these procedures but variable between them. All the procedures have been reported as being effective in achieving a satisfactory FLR and completing the second-stage resection. Moreover, the overall survival and disease-free survival rates have improved significantly for patients who were otherwise considered nonresectable; yet, an increase in the morbidity and mortality rates has been observed. We suggest that this type of procedure should be carried out in high-flow centers and through a multidisciplinary approach. An experienced surgeon is key to the success of those interventions.

The incidence and severity of post-hepatectomy bile leaks is affected by surgical indications, preoperative chemotherapy, and surgical procedures.

Bile leaks are one of the most common complications after liver resection. The International Study Group of Liver Surgery (ISGLS) established a uniform bile leak definition including a severity grading. However, a risk factor assessment according to ISGLS grading as well as the clinical implications has not been studied sufficiently so far. The incidence and grading of bile leaks according to ISGLS were prospectively documented in 501 consecutive liver resections between July 2012 and December 2016. A multivariate regression analysis was performed for risk factor assessment. Association with other surgical complications, 90-day mortality as well as length of hospital stay (LOS) was studied. The total rate of bile leaks in this cohort was 14.0%: 2.8% grade A, 8.0% grade B, and 3.2% grade C bile leaks were observed. Preoperative chemotherapy or biliary intervention, diagnosis of hilar cholangiocarcinoma, colorectal metastasis, central minor liver resection, major hepatectomy, extended hepatectomy or two-stage hepatectomy, were some of the risk factors leading to bile leaks. The multivariate regression analysis revealed that preoperative chemotherapy, major hepatectomy and biliodigestive reconstruction remained significant independent risk factors for bile leaks. Grade C bile leaks were associated not only with surgical site infection, but also with an increased 90-day mortality and prolonged LOS. The preoperative treatment as well as the surgical procedure had significant influence on the incidence and the severity of bile leaks. Grade C bile leaks were clinically most relevant, and led to significant increased LOS, rate of infection, and mortality.

Dealing with an insufficient future liver remnant: Portal vein embolization and two-stage hepatectomy.

Colorectal liver metastases (CLM) are not always resectable at the time of diagnosis. An insufficient future liver remnant is a factor excluding patients from curative intent resection. To deal with this issue, two-stage hepatectomy was introduced approximately 20 years ago. It is a sequential treatment strategy for bilateral CLM, which consists of preoperative chemotherapy, portal vein embolization, and planned first and second liver resections. This study reviews current evidence supporting use of two-stage hepatectomy.

Alpps for the treatment of giant hepatocellular carcinoma

Background: Liver resections are the treatment of choice for most liver tumors. Thanks to hepatic regeneration, various procedures have been emerging to stimulate liver hypertrophy in cases where it is required. Among them is the ALPPS (Associative Liver Partition and Portal Vein Ligation for Staged Hepatectomy). Which consists of performing a hepatectomy in two stages, achieving faster hypertrophies and in less time. This surgical technique can have high rates of morbidity and mortality, which is why it is very important to select patients appropriately. Methods: We present our first case of a two-stage hepatectomy using the ALPPS. Male patient of 65 years, with abdominal ultrasound finding of a mass in right hepatic lobe. Magnetic resonance imaging of the abdomen shows a hepatic giant tumor in the right lobe and part of the IV segment compatible with probable hepatocellular carcinoma in a non-cirrhotic liver. Hepatic volumetry and previous preanesthetic assessment were performed with liver, cardiac and pulmonary function tests. Given the insufficient hepatic remnant, and the large tumor burden that it represented, it was decided to perform an ALPPS in order to obtain a more rapid liver hypertrophy. Results: The first stage was performed by laparoscopic technique, achieving right portal ligation (the anterior and posterior branches separately) and the hepatic transection without the need for Pringle's maneuver. The postoperative evolution was without complications. After 10 days, a new abdominal tomography was performed to assess the hypertrophy. A hepatic remnant of almost 40% is achieved. We proceed then to the second stage of the ALPPS, this time with an open approach. The hepatic transection is completed with ligature of the right hepatic artery, control of the right bile duct and section of the hepatic veinhe procedure was without complications, did not require blood transfusion or vasopressor support, extubation was achieved and transfer to ICU for surveillance where it was 2 days. He had no signs of liver failure, and was discharged at 8 days. The pathology reveals hepatocelluar carcinoma on a non-cirrhotic liver. Conclusion: ALPPS is an alternative in the treatment of liver tumors where the liver remnant is insufficient, and because of its tumor biology a hypertrophy is required in less time or when the other forms of hypertrophy have failed. However, it is a procedure that can have high morbidty and mortality, which is why it is important to select patients in a multidisciplinary team.