Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy.
PhD School in Experimental Medicine, University of Pavia, Pavia, Italy.
Ann Surg Oncol. 2021 Oct;28(11):6826-6827. doi: 10.1245/s10434-021-09711-7. Epub 2021 Feb 24.
The range of procedures with documented feasibility by laparoscopic approach is widening in the setting of liver resections. Many technical limits have been overcome in the attempt to reduce the biological impact of major procedures [1-8]. Similarly, associated liver partition and portal vein ligation for staged hepatectomy (ALPPS)-which could be assumed as the paradigm of maxi-invasiveness-has recently been proposed in a minimally invasive fashion to reduce the impact of this procedure [9-12]. Technical insights to perform laparoscopic ALPPS are provided.
Perioperative and intraoperative tips for laparoscopic ALPPS are provided within a SMART (Strategy to Minimize ALPPS Risks by Targeting invasiveness) protocol. Stage 1: After volumetric and functional assessment, partial liver transection is performed, keeping intact both the hilum and the caval plane (to prevent adhesions), therefore avoiding portal ligation. No inert material is left inside the abdominal cavity at the end of procedure to keep the liver surfaces apart. Radiologic portography with portal vein embolization is scheduled on postoperative day (POD) 1. Liver volume (pre-PVE: 29%; post-PVE: 52%) and liver function measured through a Technetium-99 hepatobiliary scintigraphy [13] (pre-PVE: 2.15%/min/sqm; post-PVE: 3.67%/min/sqm) of the future remnant liver are reassessed within 10 days to verify whether size and function are adequate. Stage 2: After 2 weeks from the first stage, laparoscopic right hepatectomy is performed following an anterior approach.
No conversion to open was required. Operative time was 100 and 300 minutes for stage 1 and 2, respectively. Intraoperative blood loss was 50 and 300 ml for the two procedures. Postoperative course was uneventful; patient was discharged on POD 6 of the second operation.
The implementation of a perioperative protocol to prevent the risk of liver failure by both assessing volume and function of FLR and targeting the invasiveness of the surgical procedure may allow to minimize and control risks of a maximally invasive procedure, such as ALPPS.
腹腔镜技术在肝切除术中的应用范围不断扩大，许多技术限制已被克服，以减少主要手术的生物学影响[1-8]。同样，针对分阶段肝切除术（ALPPS）的相关肝分割和门静脉结扎术-可以被认为是最大限度侵袭性的范例-最近也被提出采用微创方式，以降低该手术的影响[9-12]。本文提供了腹腔镜 ALPPS 的技术要点。
提供了 SMART（通过靶向侵袭性最小化 ALPPS 风险的策略）方案中腹腔镜 ALPPS 的围手术期和术中技巧。第 1 阶段：在进行容量和功能评估后，进行部分肝切除术，保持肝门和腔静脉平面完整（以防止粘连），因此避免门静脉结扎。手术结束时，腹腔内不留任何惰性材料，以保持肝脏表面分开。术后第 1 天（POD）计划进行放射性门静脉造影伴门静脉栓塞术。肝体积（术前 PVE：29%；术后 PVE：52%）和肝功能通过锝-99 肝胆闪烁显像术[13]（术前 PVE：2.15%/min/sqm；术后 PVE：3.67%/min/sqm）进行评估，以确认剩余肝脏的大小和功能是否足够。第 2 阶段：第 1 阶段后 2 周，采用前入路进行腹腔镜右肝切除术。
无中转开腹。第 1 阶段和第 2 阶段的手术时间分别为 100 分钟和 300 分钟。两阶段的术中出血量分别为 50ml 和 300ml。术后恢复顺利；患者于第 2 次手术的第 6 天出院。
通过评估 FLR 的体积和功能以及靶向手术侵袭性来实施围手术期方案，以预防肝衰竭风险，可能有助于最大限度地减少和控制如 ALPPS 等最大限度侵袭性手术的风险。
