Laparoscopy in ALPPS Procedure: When We Can Do It?

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To the Editor:
We would like to acknowledge the Letter to the Editor written by Machado et al, describing totally laparoscopic ALPPS procedure performed on a patient with bilateral colorectal liver metastases, and to contribute to his proposal with a new concept to accomplish these cases.1 The goal of this procedure is to avoid adhesions in the first surgery and to facilitate the second-stage hepatectomy. Therefore, a less invasive surgical procedure can be offered in these cases, aiming to reduce the number and severity of postoperative complications. Laparoscopy ALPPS can be planned before surgery for a patient with a small future liver remnant.
However, there are several situations in which we have to decide the ALPPS procedure while an open liver resection is being performed. For these cases, we propose the alternative of performing the second-stage laparoscopically.
To support this letter and proposal, we would like to report the procedure that was successfully performed on a 37-year-old male patient who had a preoperative diagnosis of multiple epithelioid hemangioendotheliomas. The initial proposal was to perform a combined segment II and right posterior hepatectomy. But during the intraoperative ultrasound, more lesions were identified 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 II plus right hepatectomy. Therefore, we decided to proceed with ALPPS procedure and the anatomical resection of segment II.
The right portal vein was identified, tied, and transected. The right hepatic artery, bile duct, and hepatic vein were isolated and tagged with a polypropylene to facilitate identification during the second stage. Parenchymal transection between right-left hemi-livers was done following the demarcation line. Postoperative course was uneventful. After a week, the new liver volumetry showed a 120% increase on the future liver remnant. The second stage was performed laparoscopically on postoperative day 7. Pneumoperitoneum was used to release adhesions between the liver and the diaphragm. The right artery and bile duct were transected with endoscopic linear staples. After this, the right liver was mobilized, the right hepatic vein transected with the same device and finally removed through a partial opening of the previous midline incision. The patient was discharged 3 days later without complications.
Perhaps high morbidity is the major criticism received by the ALPPS procedure.2 It has been demonstrated that laparoscopic hepatectomy has several advantages over open surgery, reducing the rate of complication and hospitalization time.3,4 There is scarce literature demonstrating the use of laparoscopic surgery in the treatment of complications after an open surgery.
Laparoscopic or hand-assisted ALLPS have started to be proposed as a valid option to improve outcomes.5,6 In the case here reported, we proved the feasibility of accomplishing a second stage laparoscopically. No intraoperative or postoperative complications were diagnosed. Neither did previous or recent incisions impact pneumoperitoneum, whereas complications associated with the second stage did not evolve. Larger series will define if the second stage performed laparoscopically would potentially decrease the complication rates in ALPPS but we consider that it could become part of the surgical armamentarium for hepatopancreatobiliary surgeons.

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