title: Totally laparoscopic ALPPS in the treatment of cirrhotic hepatocellular carcinoma.
abstract: BACKGROUND
  Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a breakthrough in the field of hepatobiliary surgery [1], resulting in the growth of remnant liver volume by 74-87.2% in 9-13 days [2, 3]. However, patients required to undergo two open operations in a short period of time [2-5]. To our knowledge, this video is the first description of the technical aspects of totally laparoscopic ALPPS for the treatment of cirrhotic hepatocellular carcinoma (HCC).
  
  
  METHODS
  A patient with 6-cm cirrhotic HCC in the right liver was referred for surgical treatment. Preoperative examination confirmed that the remnant liver volume to standard liver volume ratio was 27%. Therefore, a totally laparoscopic ALPPS was planned. In the first stage of the operation, the right portal vein was ligated after laparoscopic cholecystectomy. A tape was passed along the retrohepatic avascular space and the liver was suspended during parenchymal transection, resulting in the successful completion of liver partition using the anterior approach, which conformed to the "No Touch" principle. Thirteen days after the first stage, the ratio had reached 40.6%. The second stage involved the transections of the right hepatic pedicle and the right hepatic vein.
  
  
  RESULTS
  The operative times were 255 min for the first stage and 210 min for the second stage. Pathology confirmed the diagnosis of HCC. A complication, pleural effusion, occurred after the second stage. Following pleural puncture drainage, the patient was discharged 9 days postoperatively. Follow-up 4 months after surgery was uneventful. Comparing with our open ALPPS results in two patients, the laparoscopic approach reduced the rate of postoperative complications and peritoneal adhesions, which often complicate the second stage of the operation, thus contributing to more rapid recovery.
  
  
  CONCLUSIONS
  Totally laparoscopic ALPPS is feasible, with satisfactory short-term efficacy, conforming to the "No Touch" principle. ALPPS may be safe for the treatment of HCC in cirrhotic patients, but the interval between the two stages may be extended.
authors.affiliation: Institute of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China, xiaole007@sina.com.
authors.forename: Le
authors.initials: L
authors.lastname: Xiao
authors.forename: Jian-Wei
authors.initials: JW
authors.lastname: Li
authors.forename: Shu-Guo
authors.initials: SG
authors.lastname: Zheng
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000601:surgery*; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008026:Ligation / Q000379:methods; D008113:Liver Neoplasms / Q000601:surgery*; D011169:Portal Vein / Q000601:surgery*