First two-stage robotic ALPPS in HCC patients with hepatic vein invasion: a step-by-step procedure from a clinical case

Abstract

Background: The associating liver partitioning and portal vein occlusion for staged hepatectomy (ALPPS) procedure is gaining interest because it brings hope to patients who cannot undergo radical surgical resection due to insufficient remnant liver volume. However, the indications and technical aspects of this procedure are still under debate. This report demonstrates the technical aspects of the first two-stage robotic ALPPS for HCC.

Case presentation: A 55-year-old man with type II portal vein variation was diagnosed with hepatocellular carcinoma. Preoperative 3D reconstruction of the liver based on CT showed a future liver remnant/standard liver volume (FLR/SLV) of 24.45%. The ALPPS procedure was performed using the da Vinci Si system. At the first stage of the operation, we removed the gallbladder and ligated the right anterior branch of the portal vein and the right posterior branch. Following blocking of the hepatic hilum, the liver parenchyma was removed 1 cm away from the right side of the falciform ligament in an incision manner from the top to the bottom and from shallow to deep. The second-stage operation was performed on the 12th postoperative day with a FLR/SLV of 45.13%. During this step, the right hemiliver plus left medial section was separated and removed. Postoperative pathology showed a negative margin. The operative times were 195 and 217 min, respectively. Estimated blood loss was 250 and 500 ml, respectively. There was no need for transfusion or hospitalization in intensive care. The patient was discharged on the 6th postoperative day. Recovery was uneventful after both stages, and the patient did not present any sign of liver failure. Elevation of liver enzymes was minimal. The patient had no evidence of the disease 14 months after the procedure.

Conclusions: The two-stage robotic ALPPS procedure is a safe and feasible technique for select patients with HCC.

Keywords: Associating liver partition and portal vein ligation for staged hepatectomy; Future liver remnant; Hepatocellular carcinoma; Portal vein anomaly; Robotic.

Fig. 1

Preoperative MRI shows a tumour in the inferior segment of the right lobe of the liver (a) and another tumour at the border between the left and right lobes of the liver (b). In addition, the tumour thrombus in the right hepatic vein (c)

Fig. 2

Preoperative liver 3D reconstruction shows tumours (a), tumours invading the middle and right hepatic veins (b) and the right anterior branch of the portal vein originating from the left branch of the portal vein (c)

Fig. 3

The first-stage operation findings. The right posterior portal vein (a) and the right anterior portal vein (b) were dissected and ligated. After liver parenchymal transection, the middle hepatic vein was separately isolated (c). A fibrillar absorbable haemosta was used for haemostasis (d)

Fig. 4

The second-stage operation findings. ICG was applied with a successful display of fluorescence in the left lateral section, the right liver and left medial section were not shown (a), the middle hepatic vein was transected (b) and the right hepatic vein (c), in the end, fixed the remaining liver (d)

Fig. 5

The total bilirubin (T-bili), ALT, AST and INR of patients at the perioperative stage

Fig. 6

One month (a), 5 months (b) and 11 months (c) MRI after the operation