Minimally Invasive Approach in the Setting of ALPPS Procedure: a Systematic Review of the Literature

  • Fabio Melandro
  • Francesco Giovanardi
  • Redan Hassan
  • Zoe Larghi Laureiro
  • Flaminia Ferri
  • Massimo Rossi
  • Gianluca Mennini
  • Timothy M. Pawlik
  • Quirino LaiEmail author
Review Article



Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) represents a new surgical technique for the resection of advanced hepatic malignancies with predicted insufficient future liver remnant. In some patients, ALPPS can be associated with an increased risk of poor outcomes. Minimally invasive surgery (MIS) has been proposed in combination with ALPPS with the intent to minimize this risk. We systematically evaluated the outcomes of MIS-ALPPS cases to compare the relative outcomes of open ALPPS versus MIS-ALPPS.


A systematic review was done in accordance with the PRISMA guidelines. Search terms utilized included the following: (“ALPPS”[Title/Abstract] OR “associating liver partition and portal vein ligation for staged hepatectomy”[Title/Abstract] OR “in situ split”[Title/Abstract]) AND (“minimally invasive”[Title/Abstract] OR “laparoscopic”[Title/Abstract] OR “robotic”[Title/Abstract]).


Fifteen articles were identified, with a total of 27 patients reported. Colorectal metastatic disease was the most commonly observed indication for MIS-ALPPS (66.7%), followed by hepatocellular carcinoma (25.9%). Time passed from the first to the second stage ranged 7–30 days. MIS-ALPPS patients did not experience procedure failures between the first and second stages. Only four (15.4%) subjects had a grade IIIb complication. No perioperative mortality after the first or second stage was reported. Compared with open ALPPS, MIS-ALPPS demonstrated better results. Hospital stay duration ranged 8–33 days with a follow-up ranging 1–20 months.


MIS-ALPPS appears to be safe, with potentially lower morbidities and mortalities relative to open patients. The present results should be considered with caution. A limited number of articles exist on this topic. Furthermore, selection biases exist when comparing open versus MIS-ALPPS data. Registry studies are needed to better define the outcomes of patients undergoing MIS-ALPPS.


Minimally invasive Laparoscopic Robotic ALPPS 



Associating liver partition and portal vein ligation for staged hepatectomy


Colorectal liver metastases


Hepatocellular carcinoma


Hilar cholangiocellular cancer


Minimally invasive surgery


Newcastle-Ottawa Quality Assessment Scale


Preferred Reporting Items for Systemic Reviews and Meta-Analyses


Radiofrequency-assisted liver partitions with portal vein embolization for staged hepatectomy


Standardized future liver remnant



FM, FG, QL, and TMP designed the research; FM, FG, QL, and TMP collected and interpreted the data; FM, FG, QL, and TMP wrote the paper; RH, ZLL, FF, MR, and GM critically revised the paper; all the authors gave final approval of the article to be published.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.


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Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  • Fabio Melandro
    • 1
  • Francesco Giovanardi
    • 1
  • Redan Hassan
    • 1
  • Zoe Larghi Laureiro
    • 1
  • Flaminia Ferri
    • 2
  • Massimo Rossi
    • 1
  • Gianluca Mennini
    • 1
  • Timothy M. Pawlik
    • 3
  • Quirino Lai
    • 1
    • 4
    Email author
  1. 1.Hepato-bilio-pancreatic and Liver Transplant Unit, Department of General Surgery and Organ Transplantation, Umberto I Policlinic of RomeSapienza University of RomeRomeItaly
  2. 2.Division of Gastroenterology, Department of Clinical Medicine, Umberto I Policlinic of RomeSapienza University of RomeRomeItaly
  3. 3.The Ohio State University Wexner Medical CenterColumbusUSA
  4. 4.Department of General Surgery and Organ Transplantation, Umberto I Policlinic of RomeSapienza University of RomeRomeItaly

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