[Stage 1-Laparoscopy Partial PVE-ALPPS Followed by Step 2-Hand-Assisted Laparoscopic Extended Right Hepatectomy in a Patient with Gallbladder Cancer].

Objective: After recent evaluations of the ALPPS registry, with perioperative results sobering in particular for central bile duct carcinomas, the initial euphoria for this procedure disappeared. It is thus desirable to modify the concept of reducing the invasiveness and high complication rate of the procedure.

Indications: Below we report a 72-year-old female patient with a gallbladder carcinoma locally infiltrating and metastatic to segments 4 b and 5. Due to a too small future liver remnant volume of segments 1 - 3 before planned extended right hemihepatectomy, we planned a laparoscopic partial PVE-ALPPS for hypertrophy induction.

Methods: Following an inconspicuous staging laparoscopy, the superficial parenchymal dissection along the falciform ligament was performed using ultrasonic scissors. Crossing deeper structures to segment 4 were visualized by CUSA and transected between clips. For safety reasons, a parenchymal bridge of about 1 cm between left-lateral and left-medial segments was consciously preserved in the sense of a partial ALPPS. The left pedicle remained in its continuity with all the larger vessels radiating into segment 4; however, being transected. A completing intraoperative portal vein ligation in the sense of a classic, partial ALPPS was omitted with regard to oncological principles before planned hilar exploration in the context of the completing resection. Instead, a portal venous embolization (PVE) of segments 5 - 8 was scheduled for the 1st postoperative day after partial ALPPS. After sufficient hypertrophy of segments 1 - 3, the completion was performed in the sense of a minimally invasive extended right hemihepatectomy (segments 4 - 8) with radical hilar lymphadenectomy in hybrid technique.

Conclusion: The complete removal of a locally infiltrating and metastatic gallbladder carcinoma was confirmed histopathologically - TNM (8th Edition) pT3 pN1 (1/12) G3 R0 L0 V0. The patient was discharged on the 8th postoperative day after extended right hemihepatectomy without major complications. Present gallbladder carcinoma is in our view a contraindication neither with regard to a partial ALPPS nor with regard to minimally invasive partial ALPPS and extended hepatectomy.