Totally Laparoscopic Mini-ALPPS Using a Novel Approach of Laparoscopic-Assisted Transmesenteric Portal Vein Embolization

Introduction

The associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) approach is a surgical innovation that has proven to offer superior resectability rates than conventional two-stage hepatectomies. ¹ As with most new procedures, the initial morbidity and mortality rates were high. However, more recent data from the International Registry show a continuous reduction of early mortality and major morbidity due mainly to a risk adjustment in patient selection and using less invasive techniques in stage-1 surgery. ² During the first ALPPS International Consensus Meeting at Hamburg in February 2015, we first introduced a revolutionary paradigm change for ALPPS, the so-called “Mini-ALPPS.”^3,4 This new approach involved a complete inversion of the classic paradigm, in which an aggressive prolonged first surgical procedure was followed by a shorter and less aggressive second procedure. Conversely, our proposal maximally reduced the aggressiveness and surgical impact of ALPPS first stage, allowing rapid functional future liver remnant (FLR) increase with optimal patient recovery to better overcome the second stage, and facilitating the dissection of the vasculobiliary pedicles during the second stage. The main modifications to the classic ALPPS were as follows: (1) the application of partial as opposed to total parenchymal transection, (2) the strict avoidance of liver mobilization and dissection of the porta hepatis or hemiliver pedicles, and (3) the replacement of right portal vein ligation by intraoperative portal vein embolization (PVE) through the inferior mesenteric vein (IMV). ⁴ In our original report, we stated that this new approach could be accomplished by totally laparoscopic approach in experienced institutes. We herein report, for the first time, the technique of totally laparoscopic Mini-ALPPS, in which we combined a partial liver partition with a novel technique to percutaneously access the IMV and perform intraoperative PVE.

Technical Report

A 61-year-old man was referred to our unit with diagnosis of a 6 cm hepatocellular carcinoma (HCC), compromising the right glissonian pedicle bifurcation in a dysmorphic liver. The Child-Pugh score was A6 and the Model for End-stage Liver Disease (MELD) score was 11. An extended right hepatectomy was deemed necessary to achieve complete tumor resection. Given that the FLR represented only 23% of the total liver volume (TLV) and the FLR to body weight (BW) ratio was 0.5%, a laparoscopic Mini-ALPPS was planned. Under general anesthesia, the patient was positioned in supine decubitus and both surgeons stood at the left side of the patient. The procedure was performed using a 6-port technique. Trocar ports were placed as follows (Fig. 1): umbilicus camera port (12 mm), left flank port at the mild-clavicular line (12 mm), epigastric port (5 mm), left hypochondrium port at the mild-clavicular line (5 mm), and two right flank ports at the level of the anterior axillary line (5 mm) and middle axillary line (5 mm). Laparoscopic exploration ruled out peritoneal tumor extension. After taking down the falciform ligament and resecting the round ligament for a better exposure, a laparoscopic intraoperative ultrasound was performed to corroborate tumor location and resectability. Partial parenchymal transection was then carried out in the proximities of the falciform ligament using harmonic scalpel (Harmonic Ace; Ethicon, Inc., Cincinnati, OH) with a depth not exceeding 5 cm (Fig. 2). Subsequently, intraoperative PVE was performed through the IMV using a laparoscopic-assisted percutaneous cannulation technique. After the ligament of Treitz was mobilized and the IMV exposed from its origin, a 5 Fr introducer sheath was percutaneously inserted in the abdominal cavity through the left flank with the Seldinger technique (Fig. 3). To cannulate the IMV with the introducer sheath, permanent distal occlusion of the IMV was performed using a Hem-o-lok^® and proximal transitory occlusion was performed using traction with a strong silk. Once vascular control of the IMV was assured, a small venotomy was performed and the introducer sheath was inserted inside the vessel progressively releasing the proximal traction, and using the same silk to tie the introducer to the IMV (Fig. 4). After blood reflux in the introducer was certified, the right portal vein and segment four branches were identified with a portogram and then selectively embolized with a mixture of cyanoacrylate and lipiodol^® ultra-fluid under fluoroscopic digital subtraction by experienced interventional radiologists (Fig. 5). Finally, the last step was to remove the catheter and introducer from the IMV and permanently occlude its proximal end (Fig. 6).

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FIG. 1.

Trocar disposition in the abdomen and vascular introducer sheath in left flank (arrow).

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FIG. 2.

Operative photo of partial parenchymal transection.

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FIG. 3.

(a) Exposure of the IMV. (b) Percutaneous insertion of the introducer sheath in the left flank (white arrow head). A percutaneous traction tie to separate the fat around the IMV is seen in the back (black arrow head). IMV, inferior mesenteric vein.

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FIG. 4.

(a) IMV cannulation with the introducer sheath after permanent distal occlusion with Hem-o-lok^® (white arrow) and proximal transitory occlusion with a strong silk (black arrow). (b) The introducer sheath is secured inside the vessel with a knot around it.

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FIG. 5.

A control portogram is performed after PVE to demonstrate the patency of the left lateral segment portal vein branches and certify the devascularization of the right portal vein (black arrow). PVE, portal vein embolization.

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FIG. 6.

After embolization, the introducer is removed and permanent proximal IMV occlusion with Hem-o-lok is performed (white arrow head).

The operative time of the first stage was 150 minutes and no blood transfusions were required (Fig. 7). The patient had an uneventful course and was discharged 3 days after first stage. A CT scan performed 8 days after surgery showed 59% FLR hypertrophy, with an FLR/TLV ratio of 37% and a FLR/BW ratio of 0.9% (Fig. 8). A scintigraphy performed 10 days after the first step demonstrated a Hospital Italiano de Buenos Aires (HIBA) index of 32%. ⁵ Given that the patient was in good condition and with normal liver function tests, he was readmitted for completion surgery. After releasing few lax adhesions, elective conversion to open surgery was decided due to technical difficulties in mobilizing the fibrotic right lobe. An extended right hepatectomy was uneventfully completed using Cavitron ultrasonic surgical aspirator and vascular staplers. The operative time was 300 minutes and 1 U of packed red blood cells was transfused. The patient had a favorable recovery without any complications and was discharged 5 days after surgery. The histopathological analysis indicated advanced liver fibrosis (METAVIR F4) and a well-differentiated HCC with negative resection margins.

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FIG. 7.

Summary of the technique for the first stage of laparoscopic Mini-ALPPS. The scheme shows partial parenchymal transection combined with percutaneous intraoperative PVE through the IMV.

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FIG. 8.

Volumetric CT scan shows future liver remnant hypertrophy, partial liver partition groove (white arrow head), and embolization of right portal branches (asterisk).

Discussion

Laparoscopic liver surgery has become a safe approach in trained surgeons' hands, with non-inferior oncological outcomes compared to open surgery.^6–8 The use of a laparoscopy during ALPPS, even if performed only in the first stage, as in the patient presented herein, offers the many known benefits of the minimally invasive approach: less abdominal pain, less postoperative ascites, reduction in fluid and temperature shifts, shorter hospital stays, less transfusion requirements, faster recovery, and fewer adhesions.^6–8 Recently, Machado et al. published his own series comparing open and laparoscopic ALPPS, highlighting the benefits of the minimally invasive approach over the open access. ⁹ At the Hospital Italiano de Buenos Aires, we have already performed 41 ALPPS procedures, and in 5 of them, a totally laparoscopic approach was performed in the first stage, the second stage, or both stages. In the last 2 patients of our series, a totally laparoscopic first-stage Mini-ALPPS with the technique presented has been successfully applied. The transmesenteric access to the portal vein is traditionally performed by open manner, in general, using a small McBurney incision for the ileocolic approach or a mid-line laparotomy for IMV approach. Besides being one of the most revolutionary innovations in modern liver surgery, the ALPPS approach has additionally generated an extraordinary phenomenon known as “the domino effect of innovation,” a sequence of innovations in which each produces the circumstances necessary for the initiation of the next. Our technique for laparoscopic transmesenteric PVE represents a paradigmatic example of such phenomenon. This new alternative may result of great utility in any of the following scenarios: (1) when there is high risk of harming the FLR (i.e., bleeding, hematoma, and arterial or portal thrombosis) during percutaneous PVE, (2) when the percutaneous approach is not possible or has failed, and there is need of transmesenteric access, and (3) in patients needing laparoscopic staging before PVE or after laparoscopic FLR clean-up, when for oncological or technical reasons, it is desirable to avoid dissection of the portal pedicle (i.e., gallbladder cancer, hilar cholangiocarcinoma). In addition, this innovative technique can have potential uses in other scenarios, for example, to guide laparoscopic anatomic liver resections, where intraportal balloon occlusion or selective die/fluorescent injection could easily demarcate precise anatomical liver territories. Laparoscopic Mini-ALPPS should be attempted only by an experienced team of liver surgeons and interventional radiologists. In addition, this technique requires either a last generation mobile C-Arm fluoroscopic X-ray machine in a regular operating theatre or an interventional radiology suite prepared for any major abdominal surgery, including laparoscopy (hybrid operating room).

Conclusions

In conclusion, laparoscopic Mini-ALPPS is feasible and may be performed safely in experienced hands, minimizing the surgical impact of ALPPS first stage. To the best of our knowledge, this is the first report describing the successful laparoscopic-assisted percutaneous cannulation of the IMV for transmesenteric PVE, a technical innovation that allows avoiding a laparotomy to access the mesenteric venous territory and the risks of injuring the FLR during percutaneous transhepatic approach. The ALPPS approach has given birth to many different additional innovations, and in this particular case further footsteps in the trail of safety improvements.