Ann Hepatobiliary Pancreat Surg.  2017 Nov;21(4):217-222. 10.14701/ahbps.2017.21.4.217.

Totally laparoscopic associating liver partition and portal vein ligation for staged hepatectomy using anterior approach in HCC patient with Type II portal vein anomaly: a case report

  • 1Department of Surgery, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea.


Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has gradually developed because of rapid hypertrophy of the future liver remnant volume (FLR) in spite of high morbidity. To minimize the patient's postoperative pain and morbidity including wound complication caused by two consecutive major abdominal operations, we adopted a totally laparoscopic approach and used a composite mesh graft. Also, to maximize the oncologic efficacy, we adopted the "anterior approach" technique. A 44-year-old woman with large hepatitis B-related hepatocellular carcinoma (HCC) in her right lobe was transferred to our hospital for surgical treatment. Preoperatively predicted FLR by a CT scan was 21% and type II portal vein anomaly was detected. A totally laparoscopic approach was planned. During the first stage operation, right anterior and posterior portal veins were meticulously dissected and tied. After parenchymal transection by the "anterior approach" technique, two glissonian pedicles of the right liver were individually isolated. A composite mesh graft was used to prevent severe adhesion on both liver partition surfaces. During the second-stage operation, 9 days after the first stage operation, the two isolated glissonian pedicles were initially transected. After full mobilization of the right lobe, the right hepatic vein was also transected. The right lobe was removed through the Pfannenstiel incision. She was discharged 7 days after the second stage operation. Her postoperative course was uneventful and there was no HCC recurrence for 15 months after hepatectomy. A totally laparoscopic ALPPS procedure can be a feasible technique that ensures patient safety and oncologic superiority, even in patients with complicated anatomical variation.


Associating liver partition and portal vein ligation for staged hepatectomy; Hepatocellular carcinoma; Portal vein anomaly; Liver cirrhosis; Future liver remnant; Anterior approach

MeSH Terms

Carcinoma, Hepatocellular
Hepatic Veins
Liver Cirrhosis
Pain, Postoperative
Patient Safety
Portal Vein*
Tomography, X-Ray Computed
Wounds and Injuries


  • Fig. 1 Preoperative computed tomography scan shows a large mass abutting the right hepatic vein (yellow arrow) and the right posterior portal vein (blue arrow) (A) and type II portal vein (red arrow) anomaly (B).

  • Fig. 2 The first stage operation findings. The right posterior portal vein and the right anterior portal vein were meticulously dissected and preservation of the right anterior and posterior hepatic arteries was also identified (A). After liver parenchymal transection using the anterior approach technique, the right anterior and posterior glissonian pedicles were separately isolated (B). A composite mesh graft was used to minimize adhesions between both transected cut surfaces (C). (Blue arrow, right posterior portal vein and hepatic artery; Yellow arrow, right anterior portal vein and hepatic artery).

  • Fig. 3 Computed tomography scans 7 days after the first stage operation show intact right anterior and posterior hepatic arteries (red arrow), an adequately ligated right portal vein and a patent left portal vein (blue arrow), and a well-preserved middle hepatic vein (yellow arrow).

  • Fig. 4 The second stage operation findings. The right anterior glissonian pedicle (A) and the posterior glissonian pedicle (B) were sequentially transected with laparoscopic staplers (A). Finally, the right hepatic vein (C) was transected.

  • Fig. 5 Postoperative liver function.


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