Page 40 - Read Online

Ciria et al. Mini-invasive Surg 2024;8:10 https://dx.doi.org/10.20517/2574-1225.2023.126 Page 7 of 9

Second stage
Similarly to classic ALPPS, a CT scan on days 10-14 after the first procedure to check volumetric status is
performed. If adequate remnant volume is achieved, the procedure is finalized by a laparoscopic right
hepatectomy or right trisectionectomy. In case of insufficient liver hypertrophy, the embolization of right
hepatic vein or both middle and right hepatic vein to obtain a complete Liver venous deprivation (or
“double vein embolization”) may be performed to increase FLR. In case of insufficient liver hypertrophy or
disease progression, the tourniquet should ideally be removed by a minimally invasive approach. Blunt
dissection and the use of saline irrigation may facilitate removal of adhesions during tourniquet removal.
However, this procedure should not be underestimated as iatrogenic injury may occur during surgery. In
our experience, we only had to remove one tourniquet and there were no incidences.

The positioning and access trocars are the same as those used in the first stage. In the liver surface, the tape
and the knot will be observed. By releasing the knot, an ischemic line is observed and transection in this
area becomes easier. The tape is employed to perform a hanging maneuver that facilitates the transection
plane. By pulling up the tape, access to the transection plane is easily gained towards the anterior surface of
the inferior vena cava (IVC). However, it should noted that the tape may cause tight adhesions in the
anterior surface of IVC that might be dissected with caution. The last step includes hepatic veins and
Glissonean pedicles section using endostaplers.

CONCLUSION
MI-ALPPS is a technique with a high degree of complexity and must be performed by surgeons with
expertise in MILS. The preliminary evidence suggests that it may be safe with a lower morbidity and
mortality rate relative to open series. However, the number of series is limited, and caution should be taken
to get powerful conclusions regarding the application of this technique.

DECLARATIONS
Authors’ contributions
Conception and design of the study: Ciria R
Data review: Durán M, Calleja R, Pérez-de-Villar JM
Draft manuscript preparation: Durán M, Calleja R, Pérez-de-Villar JM
Critical review: Ciria R, Briceño J
All authors reviewed the results and approved the final version of the manuscript.

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
As this is a technical review article and no patient data is presented, it did not need to be submitted to an
ethics committee. Informed consent was obtained from the patient for the publication of the images.

Consent for publication
Not applicable.