SURGEON AT WORK

The Associating Liver Partition and Portal Vein

Ligation for Staged Hepatectomy Approach Using
Only Segments I and IV as Future Liver Remnant
Martin de Santibañes, MD, Fernando A Alvarez, MD, Fanny Rodriguez Santos, MD, Victoria Ardiles, MD,
Eduardo de Santibañes, MD, PhD, FACS

Liver resection, with or without chemotherapy, remains the SURGICAL TECHNIQUE

only treatment with the potential for curing malignant liver
tumors.1-3 Frequently, major liver resections are mandatory
to achieve tumor-free surgical margins.4 One of the most
severe complications associated with extended resections
is posthepatectomy liver failure (PHLF). The best candi-
dates for liver resection with curative intention are those
who have enough parenchymal reserve, which should be
at least 20% of the total liver volume in the case of a healthy
future liver remnant (FLR),5,6 and between 30% and 40%
in patients with chemotherapy-related liver injury, fibrosis
orsteatosis.7,8 Portal vein occlusion has become the gold
standard strategy to regenerate the FLR with a low
morbidity, allowing up to 20% to 35% hypertrophy in
45 days.9-11 However, up to 40% of patients treated with
this approach are finally not candidates for resection, either
because of tumor progression during the interval period or
insufficient FLR hypertrophy.12 Recently, associating liver
partition and portal vein ligation for staged hepatectomy
(ALPPS) has been introduced as a strategy for preventing
PHLF by inducing a rapid (1 week) and large FLR volume
increase (21% to 200%).13-15 Briefly, during the first surgi-
cal stage, the complete removal of any tumor in the FLR
must be completed whenever bilateral disease is present.
Then the liver parenchyma is transected and portal vein
ligation of the tumor-bearing side is applied. The second
stage is performed when sufficient hypertrophy of the
FLR is demonstrated, usually as a right hepatectomy or tri-
sectionectomy, leaving the left lateral segments of the liver
(segments II and III) as part of the FLR. Here we describe a
new surgical strategy using the principles of the ALPPS
technique, preserving only segments I and IV as the FLR.
The basic principle of the ALPPS approach is to prevent
PHLF by rapid and effective hypertrophy of the FLR.
The indications for this innovative surgical strategy
include patients with marginally resectable or primarily
nonresectable locally advanced liver tumors of any origin
with an insufficient FLR in either volume or quality.16
With regard to the present surgical variation of the
ALPPS approach, it is indicated in patients with bilateral
disease and a high tumor load in the left lateral segment,
precluding its use as a part of the FLR (Fig. 1). Preoper-
ative volumetric analysis of the predicted FLR with multi-
detector CT or MR is a crucial element of surgical
planning (Fig. 2).
Stage 1
The procedure begins with a bilateral subcostal incision
with midline extension. The entire abdominal cavity is
explored to rule out intra- or extrahepatic disease that
might preclude resectability. Intraoperative Doppler
ultrasound (IOUS) of the liver allows a correct evaluation
of the vasculobiliary anatomy and its relationship with

Disclosure Information: Nothing to disclose.

Received November 12, 2013; Revised January 29, 2014; Accepted January
29, 2014.
From the Hepato-Pancreato-Biliary and Liver Transplant Sections, General
Surgery Service, Hospital Italiano de Buenos Aires, Buenos Aires,
Figure 1. Surgical exploration demonstrating a liver with an exten-
Argentina.
Correspondence address: Martin de Santibañes, MD, Hepato-Pancreato- sive tumor load. Metastatic lesions are presents in all segments of
Biliary and Liver Transplant Sections, General Surgery Service. Hospital the liver. Segment IV clean up is planned to become part of the
Italiano de Buenos Aires, Peron 4190, CP 1181, Buenos Aires, Argentina. future liver remnant (dotted lines). (Drawing by Fanny Rodriguez
email: martin.desantibanes@hiba.org.ar Santos, MD.)

ª 2014 by the American College of Surgeons http://dx.doi.org/10.1016/j.jamcollsurg.2014.01.070

Published by Elsevier Inc. e5 ISSN 1072-7515/14
e6 de Santibañes et al ALPPS to Prevent Posthepatectomy Liver Failure
Abbreviations and Acronyms
ALPPS ¼ associating liver partition and portal vein ligation
for staged hepatectomy
FLR ¼ future liver remnant
IOUS ¼ intraoperative Doppler ultrasound
PHLF ¼ posthepatectomy liver failure
tumor lesions, monitoring the level of resection, the
potential for resectability, and the detection of new
lesions. Once resectability is confirmed, the left liver is
mobilized by taking down the falciform, the left trian-
gular, and the coronary ligaments. The next step is to
mobilize the right lobe, including the right coronary
Figure 2. (A) Preoperative liver volumetric MR in a 77-year-old
patient with multiple bilateral colorectal liver metastases who
received 6 cycles of chemotherapy. (B) The estimated future liver
remnant volume (FLR) including segments I and IV was 305 mL. The
FLR represented only 20% of the total liver volume.
J Am Coll Surg
and triangular ligaments, then isolate and divide all acces-
sory hepatic veins localized in the right and anterior
aspect of the inferior vena cava. The right hepatic vein
is dissected and encircled. Cholecystectomy is performed
and the cystic duct is marked for additional transcystic
manipulation. Subsequently, the attention is directed to-
ward the hepatoduodenal ligament, where a complete
lymphadenectomy is carried out. This surgical maneuver
has an oncologic purpose and is also helpful for the iden-
tification of anatomical variations (Fig. 3). The hepatic
pedicle is encircled for the eventual need for a Pringle
maneuver during liver partition. Then, an aggressive clean
up of the hepatic lesions in the FLR (segments IV and I)
is carried out, putting emphasis on not compromising the
inflow or outflow of these segments (Fig. 4).
Before starting the parenchymal transection, the
vascular inflow and outflow of segments I and IV (which
will represent the FLR) should be assessed with IOUS
after clamping the right portal vein. Once a proper vascu-
larization is certified, the right portal vein is sectioned
(Fig. 5) and liver partition is carried out through the
Cantlie’s line. Cavitron ultrasonic surgical aspirator, in
combination with the harmonic scalpel and cautery, is
used for parenchymal partition. The anterior and poste-
rior right hepatic pedicle branches are isolated and
encircled with silks or vessel loops for better identification
during the second stage (Fig. 6). During this step, it is
important to prevent right hepatic artery injuries because
it is the only vascular inflow of this hemi-liver. Careful
Figure 3. Portal pedicle lymphadenectomy during the first stage of
associating liver partition and portal vein ligation for staged hepa-
tectomy. A black silk is around the portal triad. The left portal vein is
encircled with a blue vessel loop, the right hepatic artery with a red
vessel loop, and the left hepatic artery with a white vessel loop. Bile
duct is pointed with an asterisk and the cystic duct with a black
arrow.
Vol. 219, No. 2, August 2014 de Santibañes et al
Figure 4. Atypical resections (clean up) of metastatic lesions in
segments IVa and IVb.
control of hemostasis is performed with Argon beam,
sutures, and hemostatic agents.
Once it is certified that the ALPPS is technically
feasible, the resection of the left lateral segment due to
high tumor load can be carried out (Fig. 7). The paren-
chymal transection line is marked 1 cm to the left of the
falciform ligament to preserve segment IV vascular and
biliary pedicles. The left lateral segment pedicle is
dissected and ligated inside the umbilical plate. The liga-
ment of Arantius is subsequently divided, and the conflu-
ence of the middle and left hepatic veins isolated. Finally,
the left hepatic vein is sutured, isolating the left lateral
segment from segment IV. At this point, an IOUS is per-
formed to ensure adequate inflow and outflow of the FLR.
To detect biliary fistulas, a transcystic hydraulic test
and cholangiography are routinely performed. To
Figure 5. The right portal vein is divided between clamps and
sutured in a running fashion.
ALPPS to Prevent Posthepatectomy Liver Failure e7
Figure 6. Liver partition at the level of the Cantlie’s line using the
hanging maneuver. The right hepatic vein (white arrowhead) as well
as the anterior and posterior right hepatic pedicles are encircled
with light blue ties.
simplify the second stage, a plastic sheath is placed bet-
ween the cut surfaces. Two drains are situated in the tran-
section line and the right subphrenic space.
Stage 2
During postoperative day 6, a volumetric multidetector
CT or MR of the FLR (segments IV and I) is performed
to confirm liver hypertrophy and a tumor-free FLR. If the
patient is in good condition and volumetric analyses
showed a sufficient FLR hypertrophy, the completion
surgery is scheduled for the next day.
The previous incision is used to enter the abdominal cav-
ity. After releasing lax adhesions, the plastic sheath is
removed and sent for microbiologic analyses. An IOUS is
Figure 7. Left lateral resection due to extensive metastatic
compromise. (Drawing by Fanny Rodriguez Santos, MD.)
e8 de Santibañes et al ALPPS to Prevent Posthepatectomy Liver Failure
Figure 8. Intraoperative photo during the second stage of associ-
ating liver partition and portal vein ligation for staged hepatectomy.
A 152% hypertrophy was demonstrated on preoperative volumetric
analysis and observed intraoperatively. The hypertrophied liver
remnant (771 mL) is seen after the resection of the diseased hemi-
liver.
performed in the FLR to certify a patent hepatic artery and
portal vein. The anterior and posterior right pedicles that
were encircled during stage 1 are recognized and ligated.
The right hepatic vein is divided and sutured in a running
fashion and the right hepatectomy is completed (Fig. 8). At
the end of the procedure, a hydraulic test and cholangiog-
raphy, whenever possible, are recommended to certify the
absence of bile leaks.
DISCUSSION
Major liver resections continue to be associated with sub-
stantial morbidity and mortality, particularly related with
PHLF. Portal vein occlusion remains the gold standard
technique to guarantee a sufficient FLR. However,
patients with diabetes or severe sinusoidal injury (a com-
mon situation in this population of patients) can be asso-
ciated with impaired initial growth of the FLR.17 Up to
40% of patients are not candidates for surgical resection,
because of either tumor progression or insufficient FLR
hypertrophy. Embolization of segment IV portal branches
carries a considerable risk of accidental thrombosis or
injury to the left portal vein, which vascularizes the
FLR.18 The ALPPS approach has emerged as a new surgi-
cal strategy to increase resectability in patients with locally
advanced oncologic disease by rapid FLR hypertrophy.
Schnitzbauer and colleagues13 described the initial multi-
centric German experience with the ALPPS technique in
25 patients with primary or metastatic liver tumors using
the left lateral segments as part of the FLR. However,
only patients with a tumor-free left lateral segment were
included in the study. In our experience, we have included
J Am Coll Surg
patients with multiple bilobar disease, in whom we per-
formed the resection (clean up) of those lesions in the
left lateral segment or the right posterior segments
(VI and VII) as part of the FLR.16
Recently, Gauzolino and colleagues19 presented
different technical variations of the ALPPS approach,
including the “left ALPPS,” the “right ALPPS,” and the
so-called “rescue ALPPS” in patients with failed portal
vein embolization. However, there are no reports about
the complete resection of segments II and III as an extreme
clean up of the FLR when performing a right hepatectomy
during ALPPS. In this situation, only segments I and IV
constitute the FLR.
In this article, we highlighted the technical aspects that
we believe are important to safely perform this original
variation of the ALPPS approach. For the particular tech-
nical aspect of using a plastic sheath to minimize adhe-
sions, the main disadvantage is that the patient might
still require a reoperation to remove this foreign body if
the second stage cannot be performed. With this in
mind, other authors have reported on the use of absorb-
able material with favorable results.20 To date, we have
treated 29 patients with the ALPPS approach and, in 2
patients, we used the technique described here. Both of
those patients had colorectal liver metastases, were male,
and were 69 and 77 years old. During the postoperative
period, both experienced a mild elevation of the bilirubin
levels that recovered before 72 hours after the second
stage. Neither patient had PHLF, but pleural effusion,
acute renal insufficiency, and inguinal hematoma devel-
oped in 1 patient due to a dialysis catheter, which pro-
longed the hospital stay. Both patients were discharged
fully recovered at 15 and 43 days after the first-stage pro-
cedure. At follow-up, 1 patient is disease-free 7 months
after surgery and the other patient died from brain metas-
tases 5 months after the procedure.
Given the fact that the ALPPS approach is a very com-
plex and challenging 2-stage procedure, it should be per-
formed only by hepatobiliary specialists at high-volume
centers.
Author Contributions
Study conception and design: M de Santibañes, Alvarez,
E de Santibañes
Acquisition of data: M de Santibañes, Alvarez, Rodriguez
Santos, Ardiles, E de Santibañes
Analysis and interpretation of data: M de Santibañes,
Alvarez, Rodriguez Santos, Ardiles, E de Santibañes
Drafting of manuscript: M de Santibañes, Alvarez, E de
Santibañes
Critical revision: M de Santibañes, Alvarez, Rodriguez
Santos, Ardiles, E de Santibañes
Vol. 219, No. 2, August 2014 de Santibañes et al
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