1. N. Alzerwi, CH David Kwon, et al
Safety & Feasibility Of Laparoscopic Major hepatectomy after Portal Vein Embolization, a Case Series
N. Alzerwi, CH David Kwon, et al 
Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

2. Context
Selective portal vein embolization ( PVE ) is an effective adjunct to increase resectability pool*
However, PVE poses several technical challenges to
laparoscopic approach for major hepatectomy ( LMH ):
a thicker pedicle with surrounding inflammation
difficult and bloody hilar dissection
security and safety of pedicle transection with a stapler on top of
coils?
risk of spread of the remnant embolus or fragments to the
contralateral pedicle!
*Makuuchi M, et al. Surgery. 1990

3. Objective
To demonstrate safety and feasibility of
LMH after PVE.

4. Methodology Between May 2012 and September 2014
15 patients underwent LMH after PVE.
Single surgeon
Volumetry: CT
Future Liver Remnant/Standard Liver Volume (FLR/SLV)
Net increase FLR = (Pre-PVE FLR- Post-PVE FLR )/ SLV

5. PVE technique Contralateral approach
Gelfoam distally, 2nd order branches
Coils proximally, 2nd order branches
Sparing 1st order branches
P4b, P4a sparing

6. Operative Technique
Inflow control: Temporary inflow control of glissonean pedicle “TICGL" technique
Parenchymal transection:
Ultrasonic dissector,
advanced bipolar device,
bipolar electrocautery
No CUSA was used

7. *Ischemic heart disease
Demographics
Diagnosis
Age
Sex
Etiology
Comorbidities
Stage
(AJCC
2010)
Tumor Burden
Extent of
Hepatectomy
10 HCC
1 CCC
2 HCC/CCC
2 CLM 58
(32-79)
13 M
2 F
8 HBV
2 HCV
6 DM
7 HTN
4 TB
1 HIV
1 IHD*
1 PE†
1 DVT
1 COPD
12 early
stage I/II
1 stage IVa
CCC
2 stage IV
CLM
No.
Size
11 LRHH
4 LeRH 1
(1-3 )
5 cm
(1.8 – 8
cm )
*Ischemic heart disease
† Pulmonary embolism

8. Parenchymal Functional Reserve
Variables
CTP
ICG-R15
Albumin
INR
Bilirubin
Ascites
Hepatic
encephalopathy
Variceal
Bleeding
Median
( Range ) A5
(A5-A6 )
12.5%
( %)
3.5
( )
1.13
( )
0.8
( )

9. Parenchymal Volumetrics
Variables
SLV ml
Pre PVE FLR
Post PVE FLR
Net ↑ in FLR
PVE-Surgery
Interval
(days)
Vol mL
Vol %
Median
( range )
1191
( )
282
( )
24%
( 16-28% )
483
( )
42%
( 33-46% )
212
( )
71%
( % ) 21
( )

10. Operative Variables Variables Pringle’s EBL (mL) Op Time (mins)
Stapler Color
Code
Margins
LOS
(days) No
Duration
( mins )
Median
( Range ) 1
(0- 5 ) 30
( 8 – 75 )
100
( )
324
(246 – 803 )
11 tan*
2 tan + purple†
1 white‡
1 blue#
1 cm
(0.1-5 cm ) 9
(5-37 )
* (2-3 mm, Tristaple ) thickness
† ( 3-4 mm, Tristaple ) thickness
‡ (2 mm ) thickness
#( 3.5 mm ) thickness

11. Mortality & Morbidity Profile
Cases
Type of
Complication
( Clavien-Dindo )
Relevant details/
risk factors/
management
Case I
Postoperative
bleeding
( II )
Op time = 803 mins
LeRHH
White cartridge
EBL < 300 ml
Lack of sling maneuver of hilar
structures
LOS = 37
Conservatively
Blood component
therapy
PTBD
ERPD
Bile leak
Grade B,
stricture
( IIIa )
Case II
Upper limb DVT
LOS = 14 days
Anticoagulation
Case III
SSI:
Superficial
incisional
Organ space
(thoracic
empyema )
Combined
Colectomy
Iatrogenic pneumothorax
during trocar insertion
ICD insertion
LOS = 25 days
IV Antibiotics
Bedside
Drainage
IV antibiotics
ICD
Case IV
Post
hepatectomy
Liver
Insufficency
( Iva )
HBV
HCC/CCC
55 y.o.
ICG 70%
Post-PVE FLR= 33%
Net increase 38%
PVE-surgery Interval = 42 days
Pringles 3X ( 45 mins )
RHH
LOS = 20 days
Supportive ICU
care
Case V
Brain air
embolism
( V )
CVL insertion
for TPN
Care
POD 35
Mortality rate = 6.6% ( 1/15 )
Morbidity rate = 33% ( 5/15 )

12. Conclusion LMH after PVE seems relatively safe and
feasible with acceptable morbidity & mortality.
Glissonian pedicle is thick post PVE,
white cartridge ( 2 mm ) should be avoided,
tan ( 2-3 mm, Tristaple ) seems safer.