Laparoscopic unroofing for hepatic cysts compressing the left portal vein, partial TIPE ALPPS, and hepatic vein deprivation to overcome a small future liver remnant before right hemihepatectomy

Momose H, Kudo S, Miyauchi R, Hasui N, Matsuki R, Kogure M, Onozawa S, Sakamoto Y

Preoperative portal vein embolization (PVE) is widely used to induce hypertrophy of the future liver remnant (FLR) before major hepatectomy. However, in cases of impaired portal flow in the FLR, conventional preoperative PVE may fail to achieve sufficient hypertrophy. A 76-year-old woman presented with intrahepatic cholangiocarcinoma involving the right Glissonean sheath. The FLR volume was 21.9% of the total liver volume, indicating the need for preoperative liver regeneration before right hemihepatectomy. However, the left portal vein (LPV) was narrowed by hepatic cysts in the Spiegel lobe; thus, sufficient left liver regeneration could not be expected after conventional PVE. Laparoscopic unroofing of hepatic cysts, partial liver partitioning, and transileocecal PVE were therefore performed as the first stage of partial transileocecal portal vein embolization with associated liver partition and portal vein ligation for staged hepatectomy (partial TIPE ALPPS). The pressure gradient between the main portal trunk and LPV was 1.5 cm. Two and four weeks after the first stage, the FLR volume increased to 39.0% and 41.5%, respectively; however, the indocyanine green (ICG) retention rate at 15 min and ICG clearance of remnant liver values were 17.8% and 0.047 (lower than the safe criterion [≥ 0.05]), respectively. To overcome the slightly insufficient FLR volume, right hemihepatectomy was performed after additional right hepatic vein deprivation (HVD) without any signs of posthepatectomy liver failure. This case illustrates a novel strategy that combines laparoscopic unroofing, partial TIPE ALPPS, and right HVD to achieve functional liver regeneration in cases of LPV stenosis.

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