Wang Jiaguo, Xu Jie, Liu Zuojin
Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Ann Surg Oncol. 2023 Nov;30(12):7360-7361. doi: 10.1245/s10434-023-13946-x. Epub 2023 Jul 27.
Despite the ALPPS technique remains a controversy, various ALPPS techniques have made many attempts. This video discusses the technical tips for L-ALPPS after conversion therapy.
A 56-year-old, HCC patient who performed the abdominal CT showed a 6.0*5.7-cm-sized mass with intrahepatic metastasis. After four cycles of conversion therapy, the patient achieved a radiologic complete response. However, the standardized, remnant liver volume ratio (SRLVR) was only 34%. Thus, L-ALPPS was contemplated.
After full mobilization, intraoperative ultrasonography marked the main trunk of MHV. The concept of "Laennec membrane anatomy" was introduced. The anterior pedicle (AP) and the posterior pedicle (PP) were elastically suspended along the Laennec membrane. The conventional hilar dissection approach was used to isolate and suspend RHA and the right portal vein (RPV). Then, IRHV and short hepatic vein were clipped and cut. The Pringle maneuver was used intermittently during the parenchymal transection. Hepatic resection was performed from the caudal to the cranial side along MHV after RPV was ligated. The RHV was elastically suspended after hepatic resection. The omentum was used to cover the resection surface. Stage 2, preoperative SRLVR increased to 68.3%. The adhesion of the right hemiliver was bluntly separated. AP, PP, and RHV were divided by the stapler respectively. Operation time and bleeding volume for stage-1 surgery and stage-2 surgery were 240 min and 80 min, 200 ml and 250 ml, respectively. The postoperative recovery was uneventful.
L-ALPPS as a surgical option seems to be feasible and safe for intermediate-advanced HCC after conversion therapy.
尽管ALPPS技术仍存在争议，但各种ALPPS技术已进行了多次尝试。本视频讨论了转化治疗后L-ALPPS的技术要点。
一名56岁的肝癌患者进行腹部CT检查，显示有一个6.0×5.7厘米大小的肿块并伴有肝内转移。经过四个周期的转化治疗，患者达到了影像学完全缓解。然而，标准化的残余肝体积比（SRLVR）仅为34%。因此，考虑进行L-ALPPS。
充分游离后，术中超声标记了肝中静脉主干。引入了“兰氏膜解剖”的概念。前蒂（AP）和后蒂（PP）沿兰氏膜弹性悬吊。采用传统的肝门解剖方法分离并悬吊肝右动脉（RHA）和右门静脉（RPV）。然后，夹闭并切断肝右后静脉（IRHV）和肝短静脉。在实质离断过程中间歇性使用Pringle手法。在结扎RPV后，沿肝中静脉从尾侧向头侧进行肝切除。肝切除后弹性悬吊肝右静脉。使用网膜覆盖切除面。二期手术前，SRLVR增加到68.3%。钝性分离右半肝的粘连。分别用吻合器切断AP、PP和RHV。一期手术和二期手术的手术时间分别为240分钟和80分钟，出血量分别为200毫升和250毫升。术后恢复顺利。
对于转化治疗后的中晚期肝癌，L-ALPPS作为一种手术选择似乎是可行且安全的。
