Salvage robotic associating liver partition and portal vein ligation for staged hepatectomy for advanced hepatocellular carcinoma with insufficient future liver remnant after conversion therapy

Many cases of hepatocellular carcinoma (HCC) are initially considered unresectable. Advances in conversion therapy have enabled some of these patients to subsequently undergo curative resection. However, an insufficient future liver remnant (FLR) prevents patients with HCC undergoing conversion therapy from obtaining the opportunity for surgical resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been shown to be effective in promoting FLR hypertrophy in patients with HCC. Nevertheless, the safety and feasibility of ALPPS in patients with HCC who have an insufficient FLR after conversion therapy have rarely been reported. Here, we report the first case in which salvage robotic ALPPS enabled a patient with HCC and insufficient FLR after conversion therapy to undergo radical resection. This 56-year-old man was diagnosed with initially unresectable HCC and received five cycles of lenvatinib plus pembrolizumab. Although a partial response was achieved on oncological evaluation, the patient was not eligible for surgical resection because the FLR remained insufficient at 35.5% of the standard liver volume. To promote FLR hypertrophy and achieve radical resection, we performed a two-stage robotic ALPPS after the fifth cycle of systemic therapy. The FLR increased from 35.5% to 49.4% one month after the first stage of ALPPS (robotic cholecystectomy, right portal vein ligation, and liver partition), and subsequent robotic right hemihepatectomy was successfully performed. The patient recovered uneventfully after the two-stage procedure, and no recurrence was observed at the 3-month postoperative follow-up. This case demonstrates that total robotic ALPPS is a feasible bridge to curative resection for selected patients with insufficient FLR after successful conversion therapy. Building upon the concept of salvage ALPPS, this report further highlights the technical advantages of a total robotic platform in facilitating precise, minimally invasive staged hepatectomy.