Abstract
Background
A new method for liver hypertrophy was recently introduced, the so-called associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure. We present a video of an ALPPS procedure with the use of pneumoperitoneum.
Methods
A 29-year-old woman with colon cancer and synchronous liver metastasis underwent a two-stage liver resection by the ALPPS technique because of an extremely small future liver remnant.
Results
The first operation began with 30 min pneumoperitoneum. Anatomical resection of segment 2 was performed, followed by multiple enucleations on the left liver. The right portal vein was ligated and the liver partitioned. The abdominal cavity was partially closed, and a 10 mm trocar was left to create a pneumoperitoneum for additional 30 min. The patient had an adequate future liver remnant volume after 7 days, but she was not clinically fit for the second stage of therapy, so it was postponed. She was discharged on day 7 after surgery. The second stage took place 3 weeks later and consisted of an en-bloc right trisectionectomy extended to segment 1. The patient recovered and was discharged 9 days after second-stage surgery. Postoperative CT scan revealed an enlarged remnant liver.
Conclusions
The ALPPS procedure is a new revolutionary technique that permits R0 resection even in patients with massive liver metastasis. The use of pneumoperitoneum during the first stage is an easy tool that may prevent hard adhesions, allowing an easier second stage. This video may help oncological surgeons to perform and standardize this challenging procedure.
Similar content being viewed by others
References
Adam R, Laurent A, Azoulay D, Castaing D, Bismuth H. Two-stage hepatectomy: a planned strategy to treat irresectable liver tumors. Ann Surg. 2000;232:777–85.
Jaeck D, Oussoultzoglou E, Rosso E, Greget M, Weber JC, Bachellier P. A two-stage hepatectomy procedure combined with portal vein embolization to achieve curative resection for initially unresectable multiple and bilobar colorectal liver metastases. Ann Surg. 2004;240:1037–51.
Wicherts DA, Miller R, de Haas RJ, et al. Long-term results of two-stage hepatectomy for irresectable colorectal cancer liver metastases. Ann Surg. 2008;248:994–1005.
Baumgart J, Lang S, Lang H. A new method for induction of liver hypertrophy prior to right trisectionectomy: a report of three cases. HPB. 2011;13:1–145.
Schnitzbauer AA, Lang SA, Goessmann H, et al. Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings. Ann Surg. 2012;255:405–14.
de Santibañes E, Alvarez FA, Ardiles V. How to avoid postoperative liver failure: a novel method. World J Surg. 2012;36:125–8.
de Santibañes E, Clavien PA. Playing Play-Doh to prevent postoperative liver failure: the “ALPPS” approach. Ann Surg. 2012;255:415–7.
Sala S, Ardiles V, Ulla M, Alvarez F, Pekolj J, de Santibañes E. Our initial experience with ALPPS technique: encouraging results. Updates Surg. 2012;64:167–72.
Campos RR, Paricio PP, Conesa AL, Hernandez CM, Perez RG, Quiñonero MF. A new surgical strategy for multiple multiple bilobular liver metastases: right portal occlusion and tourniquet in the parenchyma section line. Cir Esp. 2012;90:191–6.
Gutt CN, Oniu T, Schemmer P, et al. Fewer adhesions induced by laparoscopic surgery? Surg Endosc. 2004;18:898–906.
Chen MD, Teigen GA, Reynolds HT, Johnson PR, Fowler JM. Laparoscopy versus laparotomy: an evaluation of adhesion formation after pelvic and paraaortic lymphadenectomy in a porcine model. Am J Obstet Gynecol. 1998;178:499–503.
Machado MA, Makdissi FF, Surjan RC. Totally laparoscopic ALPPS is feasible and may be worthwhile. Ann Surg. 2012;256:e13.
Machado MA, Makdissi FF, Surjan RC, Kappaz GT, Yamaguchi N. Two-stage laparoscopic liver resection for bilateral colorectal liver metastasis. J Laparoendosc Adv Surg Tech A. 2010;20:141–2.
Machado MC, Coelho AM, Martins JO, et al. CO2 abdominal insufflation decreases local and systemic inflammatory response in experimental acute pancreatitis. Pancreas. 2010;39:175–81.
Machado MA, Herman P, Machado MC. A standardized technique for right segmental liver resections. Arch Surg. 2003;138:918–20.
Dokmak S, Belghiti J. Which limits to the “ALPPS” approach? Ann Surg. 2012;256:e6.
Schnitzbauer AA, Lang SA, Lang H, Schlitt HJ. ALPPS: response to letter to the editor. Ann Surg. 2012;256:e16–7.
Disclosure
Drs. Machado, Surjan and Makdissi have no conflicts of interest or financial ties to disclose.
Author information
Authors and Affiliations
Corresponding author
Electronic supplementary material
Below is the link to the electronic supplementary material.
Supplementary material 1 (WMV 95265 kb)
Rights and permissions
About this article
Cite this article
Machado, M.A., Makdissi, F.F. & Surjan, R.C. ALPPS Procedure with the Use of Pneumoperitoneum. Ann Surg Oncol 20, 1491–1493 (2013). https://doi.org/10.1245/s10434-013-2920-y
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-013-2920-y