Robotic Complete ALPPS (rALPPS)-First German Experiences

Abstract

Background: ALPPS leads to fast and effective liver hypertrophy. This enables the resection of extended tumors. Conventional ALPPS is associated with high morbidity and mortality. MILS reduces morbidity and the robot adds technical features that make complex procedures safe.

Material and methods: The MD-MILS was screened for patients who underwent rALPPS. Demographic and perioperative data were evaluated retrospectively. Ninety days postoperative morbidity was scored according to the CD classification. The findings were compared with the literature.

Results: Since November 2021, five patients have been identified. The mean age and BMI of the patients were 50.0 years and 22.7 kg/m². In four cases, patients suffered from colorectal liver metastases and, in one case, intrahepatic cholangiocarcinoma. Prior to the first operation, the mean liver volume of the residual left liver was 380.9 mL with a FLR-BWR of 0.677%. Prior to the second operation, the mean volume of the residual liver was 529.8 mL with a FLR-BWR of 0.947%. This was an increase of 41.9% of the residual liver volume. The first and second operations were carried out within 17.8 days. The mean time of the first and second operations was 341.2 min and 440.6 min. The mean hospital stay was 27.2 days. Histopathology showed the largest tumor size of 39 mm in diameter with a mean amount of 4.7 tumors. The mean tumor-free margin was 12.3 mm. One complication CD > 3a occurred. No patient died during the 90-day follow up.

Conclusion: In the first German series, we demonstrated that rALPPS can be carried out safely with reduced morbidity and mortality in selected patients.

Keywords: ALPPS; hepatectomy; liver surgery; minimally invasive liver surgery; robotic.

Figure 1

(A) The divided liver between liver segments II/III and IV after the first step of full robotic liver partition and portal vein ligation (rALPPS). (B) The remaining liver segments II/III after hypertrophy and completion of rALPPS after the second operation.

Figure 2

Postoperative liver enzymes (all cases, mean, d1-d5 postoperativ) (A) GLDH (nmol/sl); (B) ALAT/ASAT (µmol/sl) after the first (1) and second steps (2) of complete robotic associated liver partition and portal vein ligation (rALPPS).

Figure 3

Magnet resonance imaging (MRI) of patients who underwent complete robotic-associated liver partition and portal vein ligation (rALPPS), (a,c,e): before rALPPS, (b,d,f): hypertrophy of the liver remnant after complete rALPPS.