Fully Robotic ALPPS and Simultaneous Left Colectomy for Synchronous Colorectal Liver Metastases

Case presentation

A 61-year-old woman presented with vague abdominal pain. Abdominal ultrasonography revealed multiple solid liver lesions. Contrast-enhanced computed tomography (CT) of the chest and abdomen showed four lesions (Sg4–5, Sg5, Sg6, and Sg7) in the right liver lobe, with the largest being 9 cm in size (Fig. 1a). CT revealed thickening of the left colon wall. Subsequent colonoscopy detected a 4-cm ulcerated lesion in the sigmoid colon, and biopsy confirmed the lesion to be invasive adenocarcinoma. Molecular analysis revealed a KRAS exon 2 mutation and wild-type NRAS and BRAF.

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FIG. 1.

Contrast-enhanced CT scan showing CLMs in the right lobe before (a) and after (b) chemotherapy (eight cycles of FOLFOX plus bevacizumab). Meaningful tumor response is visible. The largest lesion was located in the Sg7 (arrow). Note a small lesion straddling Sg5 and Sg4 that disappears after chemotherapy (encircled) and a large lesion in the Sg5 that lies in contact with the gallbladder (asterisk). CLMs, colorectal liver metastases; CT, computed tomography.

After multidisciplinary tumor board evaluation, first-line chemotherapy comprising 5-fluorouracil, oxaliplatin, and bevacizumab was initiated. A significant tumor response was detected on CT after chemotherapy completion (Fig. 1b). Liver-specific contrast-enhanced magnetic resonance imaging confirmed the number and location of liver lesions; accordingly, the patient was referred to our department of surgery.

According to our policy, combined resection of the primary tumor and CLMs in a single procedure was considered; however, given the small FLR volume (Fig. 2a), liver resection with p-ALPPS combined with left colectomy was planned. Given our background in laparoscopic colorectal and liver resections (Table 1) and the recent implementation of robotic surgery at our department, the procedure was attempted using the Da Vinci “Xi” Surgical System platform (Intuitive Surgical, Sunnyvale, CA).

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FIG. 2.

CT liver volumetry. (a) Before surgery the FLR (i.e., Sg1+Sg2+Sg3+Sg4) volume was 325 mL, with a TLV of 1195 mL and a BW of 61 kg. Thus, the FLR/TLV and the FLR/BW ratio were 27% and 0.53%, respectively. (b) After the first step of p-ALPPS hypertrophy of the FLR has been obtained (557 mL) with an FLR/TLV of 47% and an FLR/BW ratio of 0.9%. BW, body weight; CT, computed tomography; FLR, future liver remnant; p-ALPPS, partial-associating liver partition and portal vein ligation for staged hepatectomy; TLV, total liver volume.

Stage 1: robotic left colectomy combined with simultaneous first-stage p-ALPPS

The patient was placed in the supine position with legs apart. The operating table was adjusted to the 20° Trendelenburg position and rotated 20° toward the right. After pneumoperitoneum was established using a Veress needle, an optical trocar was introduced in the right flank and attached to a high-pressure continuous-flow insufflation system for assistance (AirSeal IFS system; SurgiQuest, Milford, CT).

Left colectomy was performed first (Supplementary Video S1). Four robotic ports were positioned along an oblique line from the left costal margin to the right anterior superior iliac spine (Fig. 3a). Standard left colectomy with intracorporeal vascular control and central lymph node dissection was performed. After dividing the rectum just above the peritoneal reflection using an articulated stapling device, the transection site at the level of the descending colon was identified using indocyanine green angiography. Then, the large bowel was exteriorized through a wound protector through suprapubic minilaparotomy and transected. Intracorporeal colorectal anastomosis was completed using transanal double-stapling technique.

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FIG. 3.

Schematic of the port placement. (a) left colectomy (black) and first stage of p-ALPPS (gray). The right flank port for the first stage of p-ALPPS was placed at the site of the previous air seal device. (b) Second stage of p-ALPPS. Port position for the first and second stage of p-ALPPS was the same. p-ALPPS, partial-associating liver partition and portal vein ligation for staged hepatectomy.

Subsequently, liver resection was performed as planned (Supplementary Video S2). For performing the first step of p-ALPPS, redocking was necessary. Two additional robotic ports were introduced along the transverse umbilical line, and the assistant port was shifted to the site of the previous suprapubic minilaparotomy (Fig. 3a). The patient was placed in the 15° reverse Trendelenburg position and rotated 10° toward the left. Intraoperative ultrasound (IOUS) confirmed the number and sites of liver lesions. Cholecystectomy was not performed during the first stage of liver resection because IOUS revealed that the metastasis in Sg5 had infiltrated the gallbladder. A vessel loop was passed around the hepatic pedicle to facilitate the Pringle maneuver. Hilar dissection was performed using monopolar scissors. The right hepatic artery was looped, and the portal plate was exposed. The patient had portal trifurcation; therefore, the right posterior and anterior branches of the portal vein were individually isolated and encircled. After selective clamping of the right hepatic artery and both portal vein branches, discoloration on the Glissonian surface was marked using electrocautery. Next, the portal branches were ligated and the liver parenchyma was partially transected along the Cantlie line using an ultrasonic scalpel. On completion of the procedure, a nonsuction drain was placed along the transection groove.

Operation time was 361 min, and blood loss was 350 mL. The postoperative course was uneventful. After postoperative day 10, CT and hepatobiliary scintigraphy were performed to evaluate FLR hypertrophy (Fig. 2b) and liver function, respectively. The estimated FLR volume was considered adequate, and after 1 week the second stage of p-ALPPS was performed (Supplementary Video S3).

Stage 2: second-stage robotic p-ALPPS

Patient position and trocars placement were the same as those used in first-stage p-ALPPS (Fig. 3b). After cholecystectomy, the right branch of the hepatic artery was reisolated and divided with clips. The previously isolated right portal branches were identified, encircled, and individually divided in the same manner. The right hepatic duct was incised. After obtaining control over the vascular inflow, parenchymal transection was completed under IOUS guidance using an ultrasonic scalpel and bipolar forceps. The Glissonian pedicles and right branches of the middle hepatic vein were individually divided with clips. A major branch of the middle hepatic vein and the right hepatic vein were divided intraparenchymally using an articulating vascular stapler. Finally, the stump of the right hepatic duct was closed with a running suture. A specimen was extracted through suprapubic minilaparotomy, and a nonsuction drain was placed near the surface of the parenchymal transection.

Operation time was 327 min, and blood loss was 400 mL. The patient was treated for a surgical site infection at the site of suprapubic minilaparotomy on postoperative day 5 and was discharged 8 days after the second operation.

Complications

The most worrisome intraoperative complication of this procedure is massive bleeding secondary to hepatic vessels injury. Gentle dissection and adequate vascular exposure may prevent this complication. Once hemorrhage occurs, definitive primary repair through direct suture (e.g., lateral venorrhaphy) may be attempted. In this phase, the key concept is rapid achievement of vascular control, because an excessive delay may lead to fatal outcome. If minimally invasive management fails to control bleeding, conversion to open surgery is mandatory. Contrary to popular belief, the robotic platform does not significantly interfere with the conversion since robotic arms can be removed quickly from the operating field.

Additional complications include bile leakage, abdominal abscess, anastomotic leakage, and liver failure.