Page 118 - Read Online

Pegoraro et al. Hepatoma Res 2021;7:24 https://dx.doi.org/10.20517/2394-5079.2020.142 Page 9 of 12

During the first stage of a laparoscopic RALPPS a Pringle maneuver is not necessary, as no transection and
liver mobilization are performed. Some reports link the use of hilar clamping to an inferior FLR’s
hypertrophy, due to ischemia-reperfusion damage caused by the intracellular expression of cytokines and
TNFα [34,35] .

Since no transection plane was created, the apposition of foreign material between the two shears was not
needed. The combination of these foresights produced only mild hilar fibrin formation and weak adhesions
in correspondence of the ablation passages, allowing a safe and effective laparoscopic stage-2 completion.

The use of alcohol to achieve portal vein embolization has been previously described as a part of
multimodal treatment before liver transplantation during percutaneous ethanol injections and during
[36]
[37]
PVE . This treatment is associated with significant periportal fibrosis and necrosis, leading to immediate
[38]
blood coagulation and favoring liver hypertrophy . The most common complications include pain,
transient fever, decrease of platelet count, emesis, bile leak, intra/abdominal collections, liver failure, and
[37]
anecdotal alcoholism and general thrombosis . Our patient showed none of these complications and, on
the contrary, benefited from the known hypertrophic potential of pure alcohol injection, which moreover
enhanced the effect of right portal vein closure, and contributed to ablating any collateral circulation
between FLR and treated liver. To our knowledge, this is the first report that describes a portal vein
alcoholization during a RALPPS procedure.

After RALPPS completion, the most common complications are pleural effusion (which could cause
pulmonary infection), impaired liver function, kidney failure, and ileus and abdominal collection [15,39] . The
case reported herein presented a mild pleural effusion only, which was apparently not well tolerated by the
patient and resulted in labored thoracic dynamics and low blood oxygen levels. The fever outbreak observed
on POD5 was probably due to the development of a small subdiaphragmatic fluid collection on the
resection margin. The absence of sepsis was confirmed by the blood cultures, and no further fever outbreaks
were recorded after the initiation of an empiric antibiotic therapy.

At our institution we routinely use a 3D reconstruction software for surgical use (Synapse 3D), which
®
allows use to create a virtual model of a patient’s liver and surrounding organs based on triphasic CT scan
images. The purpose is to evaluate complex cases and postulate different virtual resection hypotheses taking
into consideration anatomic variants, challenging lesion positions and assess possible advantages and
drawbacks whenever multiple approaches are possible. In our experience, this tool application becomes
even more valuable when a staged procedure is planned. The software allows us to accurately evaluate the
disease burden and calculates the precise volume of each structure examined. When an optimal triphasic
CT scan of 1- to 2-mm slice thickness is available, it is possible to compute each vessel’s area of perfusion or
drainage thanks to an automatic tool extraction. Moreover, it allows the performance of multiple virtual
hepatectomies thanks to the manual resection tool, computing volumetries of each defined area accordingly.
In our case, the virtual hepatectomy allowed us to better plan the right hepatectomy, considering the FLR
and the relationship between the lesion and the MHV.

ALPPS and similar techniques should be applied carefully, and selection criteria must be evaluated
[8]
thoroughly to avoid high morbidity and mortality as evidenced in the first ALPPS series . As shown in the
present report, the observance of these premises results in good outcomes and widens the limits of
resectability. However, there is currently no literature available on the comparison between open and
laparoscopic RALPPS.