ALPPS Procedure with the Use of Pneumoperitoneum

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A new method for liver hypertrophy was recently introduced, the so-called associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure. We present a video of an ALPPS procedure with the use of pneumoperitoneum.


A 29-year-old woman with colon cancer and synchronous liver metastasis underwent a two-stage liver resection by the ALPPS technique because of an extremely small future liver remnant.


The first operation began with 30 min pneumoperitoneum. Anatomical resection of segment 2 was performed, followed by multiple enucleations on the left liver. The right portal vein was ligated and the liver partitioned. The abdominal cavity was partially closed, and a 10 mm trocar was left to create a pneumoperitoneum for additional 30 min. The patient had an adequate future liver remnant volume after 7 days, but she was not clinically fit for the second stage of therapy, so it was postponed. She was discharged on day 7 after surgery. The second stage took place 3 weeks later and consisted of an en-bloc right trisectionectomy extended to segment 1. The patient recovered and was discharged 9 days after second-stage surgery. Postoperative CT scan revealed an enlarged remnant liver.


The ALPPS procedure is a new revolutionary technique that permits R0 resection even in patients with massive liver metastasis. The use of pneumoperitoneum during the first stage is an easy tool that may prevent hard adhesions, allowing an easier second stage. This video may help oncological surgeons to perform and standardize this challenging procedure.

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Drs. Machado, Surjan and Makdissi have no conflicts of interest or financial ties to disclose.

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Correspondence to Marcel Autran Machado MD.

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Machado, M.A., Makdissi, F.F. & Surjan, R.C. ALPPS Procedure with the Use of Pneumoperitoneum. Ann Surg Oncol 20, 1491–1493 (2013).

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  • Laparoscopic Liver Resection
  • Future Liver Remnant
  • Middle Hepatic Vein
  • Synchronous Liver Metastasis
  • Portal Vein Ligation