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Page 2 of 9 Ciria et al. Mini-invasive Surg 2024;8:10 https://dx.doi.org/10.20517/2574-1225.2023.126

[3]
expected insufficient future liver remnant (FLR) . In patients with colorectal liver metastases (CRLM) with
extensive bilobar disease not amenable to curative one-stage resection due to insufficient FLR, neoadjuvant
[4-6]
chemotherapy followed by two-stage hepatectomy (TSH) was described as a potential curative option . In
2012, Schnitzbauer et al. first introduced the procedure of associating liver partition and portal vein ligation
for staged hepatectomy (ALPPS) as an alternative for FLR augmentation .
[7]
ALPPS is a two-stage procedure that first combines portal vein occlusion with (partial/complete)
parenchymal transection to induce rapid growth of the FLR; in the second stage, usually within 7-14 days
after the first stage, and when adequate FLR hypertrophy has been obtained, hepatectomy is completed . It
[7]
was introduced as the potential surgical response to the high dropout rates seen in other bridging
[8]
strategies . Most of the accumulated experience with ALPPS is described in bilobar colorectal metastases;
however, some other series have shown its potential in less frequent hepatic tumors or even in hepatitis-
related hepatocellular carcinoma (HCC) [9-11] .

ALPPS has been described as a high-risk operation due to the high interstage morbidity, including bile leak,
septicaemia and liver failure [12-14] . Initial series of ALPPS reported mortality rates of up to 25% . These
[15]
initial problems were the main pitfall of a technique that, conversely, eliminates the main reason for the
failure of two-stage classical hepatectomies, which is disease progression during the waiting period of FLR
hypertrophy. Compared to other staged approaches, ALPPS induces rapid liver hypertrophy that reduces
[16]
stage intervals. In addition, it may also be an effective alternative as a rescue after PVE failure . Outcomes
of ALPPS have significantly improved over recent years due to meticulous patient selection, procedure
technical refinements and introduction of several modifications, such as partial-ALPPS, hybrid-ALPPS,
mini-ALPPS, ablation-assisted ALPPS, tourniquet-ALPPS and/or minimally invasive approaches [17-24] . More
recent analyses have demonstrated that continual research, improved understanding of the physiopathology
of the procedure, and technical refinements have resulted in evident benefits, with a drop in 90-day
mortality from 17% to 4% and major interstage complications from 10% to 3% . The achievement of
[25]
satisfactory long-term results relies on a careful patient selection and attempt to reduce perioperative
complications. However, in the context of ALPPS, achieving this balance can be challenging. In this regard,
[26]
a prediction model identifying predisposing risk factors to futile outcomes in ALPPS has been reported .

MINIMALLY INVASIVE ALPPS
Minimally invasive liver surgery (MILS) is one of the most important advances in liver surgery in recent
years. The first laparoscopic liver resections (LLRs) were reported 30 years ago [27,28] . Since the first Louisville
Consensus, laparoscopic liver surgery has been recognized as a safe and effective approach to perform liver
resections by trained surgeons. Large meta-analyses reported better results in both short- and long-term
outcomes for laparoscopic and robotic approaches [29,30-34] . The progressive dissemination of MILS has led
liver surgeons to perform complex liver resections with adequate results . In this regard, ALPPS is not an
[35]
exception. In addition to the inherent advantages of MILS, such as reduced blood loss, faster recovery and
shorter hospital stay, there are specific benefits, including a diminished formation of adhesions between
stages, thereby facilitating the subsequent stage of the procedure. Nonetheless, it is essential to acknowledge
that this approach involves technical complexity and a challenging learning curve, and may lead to longer
[36]
operative times .
Table 1 summarizes the outcomes from the most relevant series related to minimally invasive ALPPS (MI-
ALPPS), excluding case reports. Only two of these series included robotic approaches [39,40] , and only one
[39]
included a minimally invasive surgery (MIS) approach in both stages . Two important observations should
be noted from these studies: (a) Morbidity rate reported is heterogeneous, ranging between 0%-24% for