The SMART-ALPPS Protocol: Strategy to Minimize ALPPS Risks by Targeting Invasiveness.

Area of Science:

• Hepatobiliary Surgery
• Minimally Invasive Surgery
• Surgical Oncology

Background:

• Laparoscopic liver resections are expanding, overcoming technical challenges.
• Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) is highly invasive but can be performed laparoscopically.
• Minimally invasive approaches reduce the biological impact of major liver procedures.

Purpose of the Study:

• To provide technical insights for performing laparoscopic ALPPS.
• To present a protocol (SMART) for minimizing risks associated with ALPPS.
• To detail a two-stage approach for laparoscopic ALPPS.

Main Methods:

• Stage 1 involves partial liver transection, avoiding portal ligation and adhesions, followed by embolization.
• Post-embolization assessment of future remnant liver (FRL) volume and function using imaging and scintigraphy.
• Stage 2 is a laparoscopic right hepatectomy performed after FRL assessment.

Main Results:

• Laparoscopic ALPPS was completed without conversion to open surgery.
• Stage 1 operative time was 100 minutes with 50 ml blood loss; Stage 2 was 300 minutes with 300 ml blood loss.
• The patient had an uneventful recovery and was discharged on postoperative day 6.

Conclusions:

• A perioperative protocol assessing FRL volume and function is crucial.
• Targeting invasiveness in ALPPS minimizes risks of liver failure.
• Laparoscopic ALPPS can be safely performed with careful risk management.