Laparoscopy in ALPPS Procedure: When We Can Do It?

PABLO BARROS SCHELOTTO; GABRIEL GONDOLESI

ANNALS OF SURGERY

LIPPINCOTT WILLIAMS & WILKINS

Lugar: Philadelphia; Año: 2015

0003-4932

We would like to acknowledge the e-Letter to the Editor, written byMachado MA, describing totally laparoscopic ALPPS procedure performed on apatient with bilateral colorectal liver metastases as well as to contribute to hisproposal with a new concept to accomplish these cases.1 The goal of thisprocedure is to avoid adhesions in the first surgery and to facilitate the secondstage hepatectomy. Therefore, a less invasive surgical procedure can beoffered in these cases, aiming to reduce the number and severity ofpostoperative complications. Laparoscopy ALPPS can be planned beforesurgery, for a patient with a small future liver remnant.However, there are several situations in which we have to decide theALPPS procedure while an open liver resection is being performed. For thesecases, we thought to propose the alternative of performing the second stagelaparoscopically.To support this letter and proposal, we would like to report the procedurethat was successfully performed, on a 37 year-old male patient who had apreoperative diagnosis of multiple epithelioid hemangioendotheliomas. Theinitial proposal was to perform a combined segment II and right posteriorhepatectomy. But during the intraoperative ultrasound, more lesions wereidentified confined to the right lobe and a new surgical master plan decided.The future liver remnant was not adequate to proceed with a formal segment IIplus right hepatectomy. Therefore, we decided to proceed with ALPPSprocedure and the anatomical resection of segment II.Manuscript (including references and Figure legends)Click here to download Manuscript (including references and Figure legends): carta annals .docThe right portal vein was identified, tied and transected. The right hepaticartery, bile duct and hepatic vein were isolated and tagged with a polypropyleneto facilitate identification during the second stage. Parenchymal transectionbetween right-left hemi-livers was done following the demarcation line.Postoperative course was uneventful. After a week, the new liver volumetryshowed a 120 % increase on the future liver remnant. The second stage wasperformed laparoscopically on POD 7. Pneumoperitoneum was used to releaseadhesions between the liver and the diaphragm. The right artery and bile ductwere transected with endoscopic linear staples. After this, the right liver wasmobilized, the right hepatic vein transected with the same device and finallyremoved through a partial opening of the previous midline incision. Patient wasdischarged 3 days later without complications.Perhaps, high morbidity is the major criticism received by the ALPPSprocedure.2 It has been demonstrated that laparoscopic hepatectomy hasseveral advantages over open surgery, reducing the rate of complication andhospitalization time.3,4 There is scarce literature demonstrating the use oflaparoscopic surgery in the treatment of complications after an open surgery.Laparoscopic or hand assisted ALLPS have started to be proposed as avalid option to improve outcomes.5,6 In the case here reported we proved thefeasibility of accomplishing a second stage laparoscopically. No intraoperativeor postoperative complications were diagnosed. Neither did previous or recentincisions impact on pneumoperitoneum while complications associated to thesecond stage did not evolve. Largest series will define if the second stageperformed laparoscopically would potentially decrease the complication rates inALPPS but we consider that it could become part of the surgicalarmamentarium for HPB surgeons.References