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Malerba et al. Hepatoma Res 2021;7:19 I http://dx.doi.org/10.20517/2394-5079.2020.131 Page 7 of 9

An important aspect of our case is the total laparoscopic approach used in both operations. Laparoscopic
liver surgery has been gaining popularity, thanks to many studies confirming its safety and oncological
[22]
efficacy [31-34] , and this has also been proven even when 2-stage hepatectomies are performed . In fact,
laparoscopic two-stage hepatectomy was considered safe and feasible and without detrimental effects on
[35]
long-term outcomes in the Southampton guidelines .

A recent systematic review comparing available literature on minimally invasive and open ALPPS suggests
better short-term outcomes for the minimally invasive approach , highlighting, however, that minimally
[33]
invasive ALPPS requires advanced surgical skills, and as such, it is difficult to reproduce.

In conclusion, this report highlights the importance of the MDT in guiding decision-making and in
opening the possibility of integrating different strategies. In addition, this case is a clear call for attempting
every possible strategy to enable a radical treatment even in extreme cases. In fact, the multidisciplinary
approach for cancer management has been one of the greatest developments in patient’s care in the last 2
decades.

Fully laparoscopic ALPPS is a technically challenging procedure; however, it is feasible and safe when
performed in centers with advanced experience in laparoscopic liver surgery and may help in reducing the
surgical stress both after the first stage ALPPS operation, thus allowing patients to approach the second
procedure in a better shape, and after the second stage of ALPPS, enhancing functional postoperative
recovery.

DECLARATIONS
Authors’ contributions
Conceived designed the study: Abu Hilal M
Wrote the manuscript: Malerba V, Zimmitti G
Analyzed the data: Malerba V, Benedetti Cacciaguerra A, Zimmitti G
Edited the video: Benedetti Cacciaguerra A
Mprovided data and critically revised the manuscript: Manzoni A, Sallemi C, Monfardini L, Graffeo M, Bnà
C, Natalini G, Zaniboni A, Montresor MC, Codignola C, Garatti M, Abu Hilal M

Availability of data and materials
Not Applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not Applicable.

Consent for publication
Consent form of video and images were taken after patients consent for publication.

Copyright
© The Author(s) 2021.