Totally Laparoscopic Associating Liver Tourniquet and Portal Ligation for Staged Hepatectomy Using The Anterior Approach Techniquefor Hepatocellular Carcinoma with Hepatitis B Cirrhosis_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

 ZHANGYu , CHENYun-fei , LUTao , ZHUShi-kai , XUJun ,  YANGHong-ji

Department of Hepatobiliary Surgery and Center of Transplantation, Sichuan Academy of Medical Sciences(Sichuan Provincial People's Hospital), Chengdu 610072, China;

Corresponding author：

YANGHong-ji, Email: 68532815@qq.com

Keywords：

Liver neoplasms; Liver cirrhosis; Laparoscopy; Associating liver tourniquet and portal ligation for staged hepatectomy; Anterior approach technique

DOI：

10.7507/1007-9424.20150017

Video：

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Objective To investigate the application value of totally laparoscopic associating liver tourniquet and portal ligation for staged hepatectomy (ALTPS) using the anterior approach technique for hepatocellular carcinoma (HCC) with hepatitis B cirrhosis. Methods In September, 2014, a patient suffered cirrhotic hepatocellular carcinoma in the right liver scheduled for two-stage liver resection, in whom the future liver remnant (FLR) was considered too small (FLR/standard liver volume:29.1%, FLR/body wight:0.49%). In the first stage, using totally laparoscopic technique, a tourniquet was placed around the parenchymal transection line on the Cantlie's line via an anterior approach through retrohepatic tunnel for staged right hepatectomy, and the right portal vein was ligated. In the second stage, totally laparoscopic right hemihepatectomy was carried out on 10 days after the first-stage operation that achieved sufficient hypertrophy of the FLR. Results The FLR on postoperative day 4 of the first stage increased from 301.48 to 496.45 mL (FLR/standard liver volume:47.9%, FLR/body wight:0.81%), with a 64.67% hypertrophy. And the FLR on postoperative day 8 of the first stage increased to 510.96 mL (FLR/standard liver volume:49.3%, FLR/body wight:0.84%), with a 69.48% hypertrophy. The remnant liver volume on postoperative day 5 of the second stage increased to 704.53 mL. The duration of the first stage was 180 min, intraoperative blood loss was 50 mL, and patient did not received a blood transfusion. The duration of the second stage was 220 min, intraoperative blood loss was 400 mL, and patient did not required a blood transfusion. No serious complications happened. The patient was discharged on 7 days after the second stage. Conclusions As a effective, safe, simple, and "non-touch" technique which provided a less aggressive modification of the ALPPS procedureto achieve oncological efficacy, the totally laparoscopic ALTPS using the anterior approach technique also could achieve sufficient hypertrophy of the FLR in several days. A proper expansion of the indications for the procedure is safe and feasible in HCC patients with cirrhosis.

Citation： ZHANGYu, CHENYun-fei, LUTao, ZHUShi-kai, XUJun, YANGHong-ji. Totally Laparoscopic Associating Liver Tourniquet and Portal Ligation for Staged Hepatectomy Using The Anterior Approach Techniquefor Hepatocellular Carcinoma with Hepatitis B Cirrhosis. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2015, 22(1): 70-75. doi: 10.7507/1007-9424.20150017 Copy

1.	Schnitzbauer AA, Lang SA, Goessmann H, et al. Right portalvein ligation combined with in situ splitting induces rapid leftlateral liver lobe hypertrophy enabling 2-staged extended righthepatic resection in small-for-size settings. Ann Surg, 2012, 255(3):405-414.
2.	de Santibañes E, Clavien PA. Playing Play-Doh to preventpostoperative liver failure:the "ALPPS" approach. Ann Surg, 2012, 255(3):415-417.
3.	de Santibañes E, Alvarez FA, Ardiles V. How to avoid postoperativeliver failure:a novel method. World J Surg, 2012, 36(1):125-128.
4.	Cavaness KM, Doyle MB, Lin Y, et al. Using ALPPS to induce rapid liver hypertrophy in a patient with hepatic fibrosis and portal vein thrombosis. J Gastrointest Surg, 2013, 17(1):207-212.
5.	Alvarez FA, Ardiles V, Sanchez Claria R, et al. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS):tips and tricks. J Gastrointest Surg, 2013, 17(4):814-821.
6.	Li J, Girotti P, Königsrainer I, et al. ALPPS in right trisectionectomy:a safe procedure to avoid postoperative liver failure? J Gastrointest Surg, 2013, 17(5):956-961.
7.	Machado MA, Makdissi FF, Surjan RC. ALPPS procedure with the use of pneumoperitoneum. Ann SurgOncol, 2013, 20(5):1491-1493.
8.	Torres OJ, Fernandes Ede S, Oliveira CV, et al. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS):the Brazilian experience. Arq Bras Cir Dig, 2013, 26(1):40-43.
9.	Sala S, Ardiles V, Ulla M, et al. Our initial experience with ALPPS technique:encouraging results. Updates Surg, 2012, 6(3):167-172.
10.	Adam R, Laurent A, Azoulay D, et al. Two-stage hepatectomy:a planned strategy to treat irresectable liver tumors. Ann Surg, 2000, 232(6):777-785.
11.	Alvarez FA, Iniesta J, Lastiri J, et al. New method ofhepatic regeneration. Cir Esp, 2011, 89(10):645-649.
12.	周俭, 王征, 孙健, 等.联合肝脏离断和门静脉结扎的二步肝切除术.中华消化外科杂志, 2013, 12(7):485-489.
13.	刘允怡, 刘晓欣.对"联合肝脏离断和门静脉结扎的二步肝切除术"的述评.中华消化外科杂志, 2013, 12(7):481-484.
14.	Torres OJ, Moraes-Junior JM, Lima e Lima NC, et al. Associating liver partition and portal vein ligation forstaged hepatectomy (ALPPS):a new approach in liverresections. Arq Bras Cir Dig, 2012, 25(4):290-292.
15.	Dokmak S, Belghiti J. Which limits to the 'ALPPS'approach? Ann Surg, 2012; 256(3):e6.
16.	Robles R, Parrilla P, López-Conesa A, et al. Tourniquet modification of the associating liver partitionand portal ligation for staged hepatectomy procedure.Br J Surg, 2014, 101(9):1129-1134.
17.	Belli G, Fantini C, D'Agostino A, et al. Laparoscopic versus open liver resection for hepatocellular carcinoma in patients with histologically proven cirrhosis:shortand middle-term results. Surg Endosc, 2007, 2l(11):2004-2011.
18.	Ai JH, Li JW, Chen J, et a1. Feasibility and safety of laparoscopic liver resection for hepatocellular carcinoma with a tumor size of 5-10 cm. PLoS One, 2013, 8(8):e72328.
19.	Machado MA, Makdissi FF, Suran RC. Totally laparoscopic ALPPS is feasible and may be worthwhile. Ann Surg, 2012, 256(3):e13.
20.	Li FG, Yan LN, Li B, et al. Estimation of standard liver volume in Chinese adult living donors. Transplant Proc, 2009, 41(10):4052-4056.
21.	Clavien PA, Petrowsky H, DeOliveira ML, et al. Strategies for safer liver surgery and partial liver transplantation. N Engl J Med, 2007, 356(15):1545-1559.
22.	Earl TM, Chapman WC. Conventional surgical treatment of hepatocellular carcinoma. Clin Liver Dis, 2011, 15(2):353-370, vii-x.
23.	Makuuchi M, Thai BL, Takayasu K, et al. Preoperative portalembolization to increase safety of major hepatectomy for hilar bileduct carcinoma:a preliminary report. Surgery, 1990, 107(5):521-527.
24.	Elias D, De Baere T, Roche A, et al. During liver regenerationfollowing right portal embolization the growth rate ofliver metastases is more rapid than that of the liver parenchyma. Br J Surg, 1999, 86(6):784-788.
25.	Kokudo N, Tada K, Seki M, et al. Proliferative activity ofintrahepatic colorectal metastases after preoperative hemihepaticportal vein embolization. Hepatology, 2001, 34(2):267-272.
26.	Mueller L, Hillert C, Möller L, et al. Major hepatectomy forcolorectal metastases:is preoperative portal occlusion an oncologicalrisk factor? Ann Surg Oncol, 2008, 15(7):1908-1917.
27.	Adam R, Laurent A, Azoulay D, et al. Two-stage hepatectomy:a planned strategy to treat irresectable liver tumors. Ann Surg, 2000, 232(6):777-785.
28.	Sotiropoulos GC, Kouraklis G. The ALPPS procedure for extendedindications in liver surgery:an old finding applied in surgicaloncology. Ann Surg, 2013, 257(6):e26.
29.	Cavaness KM, Doyle MB, Lin Y, et al. Using ALPPS to inducerapid liver hypertrophy in a patient with hepatic fibrosis and portalvein thrombosis. J Gastrointest Surg, 2013, 17(1):207-212.
30.	Vennarecci G, Laurenzi A, Levi Sandri GB, et al. The ALPPSprocedure for hepatocellular carcinoma. Eur J Surg Oncol, 2014, 40(8):982-988.
31.	Andriani OC. Long-term results with associating liver partition andportal vein ligation for staged hepatectomy (ALPPS). Ann Surg, 2012, 256(3):e5.
32.	郑树国, 李建伟, 肖乐, 等.全腹腔镜联合肝脏离断和门静脉结扎的二步肝切除术治疗肝硬化肝癌.中华消化外科杂志, 2014, 7(13):502-507.
33.	Li J, Kantas A, Ittrich H, et al. Avoid "all-touch" by hybrid ALPPS to achieve oncological efficacy. Ann Surg, 2014, 2014 Jul 28.[Epub ahead of print].
34.	Neuhaus P, Thelen A, Jonas S, et al. Oncologicalsuperiority of hilar en bloc resection for the treatmentof hilarcholangiocarcinoma. Ann Surg Oncol, 2012, 19(5):1602-1608.
35.	Liu CL, Fan ST, Cheung ST, et al. Anterior approach versus conventional approach right hepatic resection for large hepatocellular carcinoma:a prospective randomized controlled study. Ann Surg, 2006, 244(2):194-203.

1. Schnitzbauer AA, Lang SA, Goessmann H, et al. Right portalvein ligation combined with in situ splitting induces rapid leftlateral liver lobe hypertrophy enabling 2-staged extended righthepatic resection in small-for-size settings. Ann Surg, 2012, 255(3):405-414.
2. de Santibañes E, Clavien PA. Playing Play-Doh to preventpostoperative liver failure:the "ALPPS" approach. Ann Surg, 2012, 255(3):415-417.
3. de Santibañes E, Alvarez FA, Ardiles V. How to avoid postoperativeliver failure:a novel method. World J Surg, 2012, 36(1):125-128.
4. Cavaness KM, Doyle MB, Lin Y, et al. Using ALPPS to induce rapid liver hypertrophy in a patient with hepatic fibrosis and portal vein thrombosis. J Gastrointest Surg, 2013, 17(1):207-212.
5. Alvarez FA, Ardiles V, Sanchez Claria R, et al. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS):tips and tricks. J Gastrointest Surg, 2013, 17(4):814-821.
6. Li J, Girotti P, Königsrainer I, et al. ALPPS in right trisectionectomy:a safe procedure to avoid postoperative liver failure? J Gastrointest Surg, 2013, 17(5):956-961.
7. Machado MA, Makdissi FF, Surjan RC. ALPPS procedure with the use of pneumoperitoneum. Ann SurgOncol, 2013, 20(5):1491-1493.
8. Torres OJ, Fernandes Ede S, Oliveira CV, et al. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS):the Brazilian experience. Arq Bras Cir Dig, 2013, 26(1):40-43.
9. Sala S, Ardiles V, Ulla M, et al. Our initial experience with ALPPS technique:encouraging results. Updates Surg, 2012, 6(3):167-172.
10. Adam R, Laurent A, Azoulay D, et al. Two-stage hepatectomy:a planned strategy to treat irresectable liver tumors. Ann Surg, 2000, 232(6):777-785.
11. Alvarez FA, Iniesta J, Lastiri J, et al. New method ofhepatic regeneration. Cir Esp, 2011, 89(10):645-649.
12. 周俭, 王征, 孙健, 等.联合肝脏离断和门静脉结扎的二步肝切除术.中华消化外科杂志, 2013, 12(7):485-489.
13. 刘允怡, 刘晓欣.对"联合肝脏离断和门静脉结扎的二步肝切除术"的述评.中华消化外科杂志, 2013, 12(7):481-484.
14. Torres OJ, Moraes-Junior JM, Lima e Lima NC, et al. Associating liver partition and portal vein ligation forstaged hepatectomy (ALPPS):a new approach in liverresections. Arq Bras Cir Dig, 2012, 25(4):290-292.
15. Dokmak S, Belghiti J. Which limits to the 'ALPPS'approach? Ann Surg, 2012; 256(3):e6.
16. Robles R, Parrilla P, López-Conesa A, et al. Tourniquet modification of the associating liver partitionand portal ligation for staged hepatectomy procedure.Br J Surg, 2014, 101(9):1129-1134.
17. Belli G, Fantini C, D'Agostino A, et al. Laparoscopic versus open liver resection for hepatocellular carcinoma in patients with histologically proven cirrhosis:shortand middle-term results. Surg Endosc, 2007, 2l(11):2004-2011.
18. Ai JH, Li JW, Chen J, et a1. Feasibility and safety of laparoscopic liver resection for hepatocellular carcinoma with a tumor size of 5-10 cm. PLoS One, 2013, 8(8):e72328.
19. Machado MA, Makdissi FF, Suran RC. Totally laparoscopic ALPPS is feasible and may be worthwhile. Ann Surg, 2012, 256(3):e13.
20. Li FG, Yan LN, Li B, et al. Estimation of standard liver volume in Chinese adult living donors. Transplant Proc, 2009, 41(10):4052-4056.
21. Clavien PA, Petrowsky H, DeOliveira ML, et al. Strategies for safer liver surgery and partial liver transplantation. N Engl J Med, 2007, 356(15):1545-1559.
22. Earl TM, Chapman WC. Conventional surgical treatment of hepatocellular carcinoma. Clin Liver Dis, 2011, 15(2):353-370, vii-x.
23. Makuuchi M, Thai BL, Takayasu K, et al. Preoperative portalembolization to increase safety of major hepatectomy for hilar bileduct carcinoma:a preliminary report. Surgery, 1990, 107(5):521-527.
24. Elias D, De Baere T, Roche A, et al. During liver regenerationfollowing right portal embolization the growth rate ofliver metastases is more rapid than that of the liver parenchyma. Br J Surg, 1999, 86(6):784-788.
25. Kokudo N, Tada K, Seki M, et al. Proliferative activity ofintrahepatic colorectal metastases after preoperative hemihepaticportal vein embolization. Hepatology, 2001, 34(2):267-272.
26. Mueller L, Hillert C, Möller L, et al. Major hepatectomy forcolorectal metastases:is preoperative portal occlusion an oncologicalrisk factor? Ann Surg Oncol, 2008, 15(7):1908-1917.
27. Adam R, Laurent A, Azoulay D, et al. Two-stage hepatectomy:a planned strategy to treat irresectable liver tumors. Ann Surg, 2000, 232(6):777-785.
28. Sotiropoulos GC, Kouraklis G. The ALPPS procedure for extendedindications in liver surgery:an old finding applied in surgicaloncology. Ann Surg, 2013, 257(6):e26.
29. Cavaness KM, Doyle MB, Lin Y, et al. Using ALPPS to inducerapid liver hypertrophy in a patient with hepatic fibrosis and portalvein thrombosis. J Gastrointest Surg, 2013, 17(1):207-212.
30. Vennarecci G, Laurenzi A, Levi Sandri GB, et al. The ALPPSprocedure for hepatocellular carcinoma. Eur J Surg Oncol, 2014, 40(8):982-988.
31. Andriani OC. Long-term results with associating liver partition andportal vein ligation for staged hepatectomy (ALPPS). Ann Surg, 2012, 256(3):e5.
32. 郑树国, 李建伟, 肖乐, 等.全腹腔镜联合肝脏离断和门静脉结扎的二步肝切除术治疗肝硬化肝癌.中华消化外科杂志, 2014, 7(13):502-507.
33. Li J, Kantas A, Ittrich H, et al. Avoid "all-touch" by hybrid ALPPS to achieve oncological efficacy. Ann Surg, 2014, 2014 Jul 28.[Epub ahead of print].
34. Neuhaus P, Thelen A, Jonas S, et al. Oncologicalsuperiority of hilar en bloc resection for the treatmentof hilarcholangiocarcinoma. Ann Surg Oncol, 2012, 19(5):1602-1608.
35. Liu CL, Fan ST, Cheung ST, et al. Anterior approach versus conventional approach right hepatic resection for large hepatocellular carcinoma:a prospective randomized controlled study. Ann Surg, 2006, 244(2):194-203.

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CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Totally Laparoscopic Associating Liver Tourniquet and Portal Ligation for Staged Hepatectomy Using The Anterior Approach Techniquefor Hepatocellular Carcinoma with Hepatitis B Cirrhosis

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