PMC5994687_01
(A) Preoperative CT image with metastasiin segments 7 and 8. Intra-operative ultrasound however, identified two additional metastases in segments 8 and 3 necessitating extension of the planned resection. (B) Transverse CT -image after the first stage of ALPPS procedure showing the in situ partial transection of the liver according to the planned, extended right hemihepatectomy. The right portal vein has been ligated while the right hepatic artery and right hepatic vein are preserved together with the right bile ducts. (C) Coronal, reconstructed CT image after the first stage of ALPPS demonstrating the split liver. The deportalized right liver lobe shows atrophy while the FRL has markedly hypertrophied. (D) CT image at follow-up after stage-2 demonstrating the completed right hemihepatectomy with the hypertrophied remnant liver.
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At staging (Contast enhanced computer tomography and magnetic resonance imaging), two liver metastasis in segments 7 and 8 were identified which led to radiological tumor staging of cT3cN2M1 (Fig. 2).
Operative images during stage-1 of the ALPPS procedure. The left panel shows the in situ split of the liver. The right panel illustrates the application of Hemopatch on both the transection surfaces in order to provide haemostasis and prevent adhesions between the two liver lobes.
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To secure haemostasis and at the same time prevent adhesions between the liver transection surfaces, Hemopatch was applied to both cut-surfaces after completion of the in-situ split (Fig. 3).
Operative images during stage-2 of the ALPPS procedure. In the left panel the right hemi-liver has been removed. The image illustrates the partially absorbed Hemopatch applied at the first stage and the new, posterior parenchymal transection surface at completion of transection. The right panel shows the application of Hemopatch on the fresh surface of the last part of the transection.
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The procedure was uncomplicated with 800 cc blood loss (Fig. 4).