Modified Anterior Approach for the ALPPS Procedure: How We Do It

Area of Science:

• Hepatobiliary Surgery
• Surgical Oncology
• Liver Transplantation

Background:

• Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a complex procedure requiring precise vascular and parenchymal dissection.
• Minimizing adhesions and preventing tumor rupture are critical in ALPPS, especially for large tumors.
• The standard anterior approach for right hepatectomy differs from ALPPS as key vessels are typically preserved in Stage I.

Purpose of the Study:

• To present a modified anterior approach for the ALPPS procedure.
• To demonstrate the feasibility of this technique for complete in situ parenchymal splitting.
• To evaluate the safety and efficacy of the modified approach in patients with hepatocellular carcinoma.

Main Methods:

• A prospective review of 13 patients undergoing ALPPS with a modified anterior approach for hepatocellular carcinoma.
• Data collected from October 2013 to October 2014.
• Evaluation of future liver remnant (FLR) hypertrophy and subsequent hepatectomy outcomes.

Main Results:

• The median tumor size was 6.0 cm with a baseline FLR of 286 ml.
• Significant FLR hypertrophy (52.7%) to 482 ml was observed within a median of 8 days post-Stage I.
• All patients successfully underwent Stage II hepatectomy with low morbidity (7.7%) and mortality (7.7%), and minimal adhesions.

Conclusions:

• The modified anterior approach is a safe and feasible technique for achieving complete in situ splitting in ALPPS.
• This approach facilitates efficient FLR regeneration and successful completion of staged hepatectomy.
• The technique offers advantages in managing complex liver resections for malignancy.