Are We Ready to Perform Fully Minimally Invasive ALPPS?

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To the Editor:
We read with keen interest the Letter to the Editor titled “Laparoscopy in ALPPS Procedure: When We Can Do It?” written by Schelotto and Gondolesi.1 The authors described their experience relating to one case of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure in which the second stage of the intervention was achieved laparoscopically.
In this regard, they commented on the previous article by Machado et al,2 who described a fully laparoscopic ALPPS operation. At first laparoscopy, the procedure featured 3 steps: resection of the tumor on the left lateral sector, full mobilization of the right liver, ligature of the right portal vein, and in situ split. The authors reported to have benefited greatly from the presence of only few avascular adhesions at the formal hepatectomy stage.
In the above-mentioned article, Schelotto and Gondolesi1 rightly noted that laparoscopic hepatectomy is associated with several advantages over open surgery, essentially due to reduced complication rates and shortened hospitalization time. We agree with the authors’ proposal to opt for a laparoscopic approach in selected patients. However, although the authors suggest to perform only the second passage of the ALPPS procedure by laparoscopy, we do believe that in this rapidly maturing field, increasingly solid evidence suggests to push over the limits.1–3 In this regard, several aspects should be taken into consideration.
Two parts of the first ALPPS step (wedge left liver resection and right portal vein ligation) have been previously described in laparoscopy for 2-stage resections.4
The ALPPS procedure using the anterior approach make the splitting of the 2 hemilivers easier and facilitates exposure and control of intraparenchimal hepatic veins and bile ducts.5 Totally laparoscopic right hepatectomy carried out by initial hilar dissection and ligation of vascular inflow followed by division of the hepatic parenchyma using an anterior approach has been successfully described in over 60 patients.6
Further, because the commercialization of robotics systems, robot-assisted surgery is now being used for even the most complex minimally invasive surgeries.7–9 Several issues unique to conventional laparoscopic techniques have been partially addressed by the robot that permits 3D imaging and optimal intraoperative ultrasound assessment,10 increases the range of motion within the abdomen, and enhances surgical dexterity, affording excellent control of fine dissection maneuvers such as those required to perform complex hilar dissections, or bilioenteric reconstructions.7
To conclude, we are convinced that robotics represents a valuable option to widen the application of minimally invasive surgery even to highly demanding surgeries, such as the ALPPS procedure. The available data from the literature now suggest that robotic-system can be safely employed to carry out the resection of the tumor on the left lateral sector, the right portal vein ligation, and in situ split in a minimally invasive manner.1–3,6 Completion of surgery can be next achieved by robot-assisted or conventional laparoscopy, as suggested by Schelotto and Gondolesi.1 Actually, the use of a fully minimally invasive procedure would potentially result in decreased complication rates,1 thus shortening postoperative recovery after each stage of the procedure. Accordingly, it can also be of help in respecting the optimal timing to perform the second step of the procedure.
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