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Page 2 of 12 Pegoraro et al. Hepatoma Res 2021;7:24 https://dx.doi.org/10.20517/2394-5079.2020.142

[1]
the most common hepatic primary tumor . When detected at an early stage, surgery is the best curative
therapy available, and the increasing understanding of liver anatomy and physiology has allowed to push
[2]
the limit of resectability further over time . This has been possible also thanks to the development of new
technologies that assist the surgeons both preoperatively and intraoperatively.

Preoperative study implementation with CT-guided 3D reconstruction of the patient’s liver has been
[3]
documented in the last 20 years . This approach is aimed at improving the preoperative understanding of
the patient’s anatomy and location of lesions, allowing the performance of an unlimited number of
resection simulations to select the safest and most oncologically radical option. This technique is extremely
useful in complex cases, particularly for the future liver remnant (FLR) assessment to plan radical
[4]
operations while minimizing the risk of postoperative liver failure (PHLF) . However, despite these
advantages, 3D modeling applied to this setting has only been studied by few authors .
[5-7]
Recently, portal vein ligation for staged hepatectomy (ALPPS) has been described as a valid technique to
reduce the risk of PHLF in case of limited FLR . In fact, this technique offers a rapid and consistent FLR
[8]
growth, compared to portal vein embolization (PVE) [9-11] and could also represent a salvage option in case of
failed PVE. Some ALPPS variants have been developed, such as partial-ALPPS (involving a partial liver
splitting), tourniquet-guided procedure (ALTPS), hybrid ALPPS and RALPPS (radiofrequency-assisted liver
[12]
partition with portal vein ligation for staged hepatectomy) . The RALPPS procedure, described for the first
time in 2015 by Gall et al. , has most of the advantages of the original ALPPS technique, while reducing
[13]
some of its main drawbacks, such as the significant risks of high blood loss and biliary fistula [14,15] .

Several procedures have been developed to perform a safe liver splitting without deviating from a safe plane
or causing poor FLR vascularization, such as ischemic marking of the liver surface, intraoperative
ultrasound (IOUS), and indocyanine green fluorescence (ICG) [16,17] .

We describe a laparoscopic RALPPS procedure combined with 3D reconstruction and intraoperative ICG
fluorescence.

CASE REPORT
Herein, we present the case of a 71-year-old man diagnosed with hepatitis B in the 1970s, treated with
interferon. His comorbidities included reflux from hiatal hernia, chronic gastritis and benign prostatic
hyperplasia, and thus, the patient took no regular medications. The preoperative blood chemistry analysis
showed normal range values and did not detect HCVAb, HBsAg, HBeAb or HBsAb; HBcAb was positive
and HAV IgG > 83 IU/mL. Tumor markers were all within normal range (AFP 3.76 ng/mL, CEA 1.6 ng/mL,
and CA 19.9 17.5 ng/mL) and the liver status was CHILD A5, MELD 7, Na-MELD 8.

During his HBV follow-up, he underwent an abdominal US that showed a hyperechoic lesion at the
confluence of right and middle hepatic vein (MHV), adjacent to the inferior vena cava, of 22 mm × 26 mm,
in Sg8-Sg4a in the context of mild to moderate steatosis. A thoraco-abdominal CT scan [Figure 1A] found
two lesions with HCC characteristics, one of 45 mm in Sg8 and another one in Sg6 of 52 mm with evidence
of a hyperechoic thrombosis in a peripheral portal vein branch of Sg6. A bone scintigraphy was negative for
metastatic lesions.

Given the challenging position of the lesion involving the origin of the MHV and right hepatic vein (RHV),
and the presence of another lesion in Sg6, complete disease eradication could have been achieved with a
right hepatectomy. To better understand the lesions’ position and to calculate the FLR, a virtual