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Pegoraro et al. Hepatoma Res 2021;7:24 Hepatoma Research
DOI: 10.20517/2394-5079.2020.142

Case Report Open Access

Laparoscopic ICG-guided RALPPS procedure for

HCC on cirrhosis with 3D reconstruction
implementation: a case report

1
1
1
2
Francesca Pegoraro , Roberto Montalti , Gianluca Rompianesi , Mariano Cesare Giglio , Roberto Ivan
Troisi 1
1
Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University,
Naples 80131, Italy.
2
Department of Public Health, Federico II University, Naples 80131, Italy.
Correspondence to: Prof. Roberto Ivan Troisi, Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical
Medicine and Surgery, Federico II University, Via Pansini 5, Naples 80131, Italy. E-mail: roberto.troisi@unina.it
How to cite this article: Pegoraro F, Montalti R, Rompianesi G, Giglio MC, Troisi RI. Laparoscopic ICG-guided RALPPS procedure
for HCC on cirrhosis with 3D reconstruction implementation: a case report. Hepatoma Res 2021;7:24.
https://dx.doi.org/10.20517/2394-5079.2020.142

Received: 5 Nov 2020 First Decision: 11 Jan 2021 Revised: 18 Jan 2021 Accepted: 26 Jan 2021 Available online: 8 Apr 2021
Academic Editor: Allan Tsung Copy Editor: Yue-Yue Zhang Production Editor: Yue-Yue Zhang

Abstract
We present a fully laparoscopic partial RALPPS (radiofrequency-assisted liver partition with portal vein ligation for
staged hepatectomy) on a cirrhotic 71-year-old man with a bifocal hepatocellular carcinoma. The patient’s liver
was preoperatively studied through a CT-guided 3D-reconstruction. During stage-1, the right portal vein was
ligated and injected with alcohol distally; the vascular limit between the right and left anterior sectors was defined
through the systemic infusion of indocyanine green for a negative staining. Hence, laparoscopic ablations, guided
by luminescence and checked with intraoperative ultrasounds, were performed. After 55 days, the future liver
remnant increased from 28.6% to 46.3%, allowing a laparoscopic RALPPS stage-2. Fully laparoscopic RALPPS
technique shows several advantages compared to the original procedure, especially in patients with cirrhosis. The
avoidance of liver transection during stage-1 reduced blood loss and intraabdominal adhesions, and it eliminated
the risk of biliary fistulae and allowed an easier liver transection during stage-2.

Keywords: Liver resection, 3D reconstruction, fluorescence, HCC, ICG, laparoscopy, LiMON test, RALPPS

INTRODUCTION
Hepatocellular carcinoma (HCC) is the fourth most common cause of cancer-related death worldwide and

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