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The management of colorectal liver metastases has evolved over the past decades, with more patients now being offered surgery. The use of modern chemotherapeutic and adjunct techniques to surgery has contributed greatly to improve resectability rates and outcomes. As a consequence, patients with advanced CLM are living longer than they did previously due to these major advances in treatment. The surgical strategy should be tailored according to the existence of both patient and liver-related operative risks. From a technical perspective, the availability of state-of-the-art abdominal imaging is crucial to define resectability and to plan the optimal surgical procedure. Associating an acceptable patient risk with a safe technical proposal and a reasonable oncological indication should be the goal of liver surgeons when selecting candidates for surgery. Patient treatment should be routinely discussed by a multidisciplinary tumor board including colorectal surgeons, liver surgeons, oncologists, radiation oncologists, radiologists, and pathologists. Such a multidisciplinary approach has been demonstrated to offer better patient care and survival outcomes, as well as improved consistency, continuity, coordination, and cost-effectiveness of treatment.

In the last 2 decades, the results of hepatic resections (HR) have significantly improved. This improvement was possible because of the development of new anesthetic techniques, better postoperative care, better patient selection, the development of new technological devices and the specialization of hepatobiliary surgery units. The low mortality in referral centers has extended indication for HRs, allowing surgeons to perform extreme procedures in patients considered unresectable 20 years ago. These extreme procedures include associated vascular resections and reconstruction, ex vivo surgeries and the simultaneous resection of adjacent organs. The incidence of complications and perioperative mortality varies in the literature, between 15–45% and 0–25% respectively. The different criteria used to define morbidity as well as the inclusion (or not) of mild complications (Dindo-Clavien’s Grade 1 and 2) explains in part the variability of morbidity rates in the literature. Different factors have been associated with the development of postoperative complications: blood loss, number of resected segments, preoperative hypoalbuminemia, renal insufficiency, associated biliary procedures, associated vascular procedures, male gender and associated patients comorbidities. In addition, the experience of the surgical team, type of tumor, the moment of indication (elective, urgency, emergency resection), extent of resection, parenchymal quality of the liver (steatosis, steatohepatitis, fibrosis, cirrhosis, post-chemotherapy changes) and patient selection are also key aspects. Reoperations to solve postoperative complications vary between 3 and 19%. The most frequent cause of reoperations is postoperative bleeding and intra-abdominal collections. In this chapter, local specific postoperative complications related to HR are described along with their specific management and prevention.

At diagnosis, 15–25% of patients with stage IV colon cancer have synchronous detected liver metastases. About 30% of patients are not initially resectable due to the extent of hepatic disease or a small future liver remnant (FLR). When size of FLR is regarded to be not sufficient to sustain liver function in the postoperative course, techniques of portal vein occlusion (PVO) such as portal vein embolization (PVE) or portal vein ligation (PVL) can be used in the context of a classic two-stage hepatectomy (TSH) to get increase of the residual liver. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel two-stage technique which combines PVO and parenchymal transection, followed by hepatectomy in a shorter period of time than classical TSH. However, many concerns have been addressed to the safety of this procedure. Further refinements of the original technique have been explored to improve its results. We report herein the case of a 44-year-old female patient with an obstructive cancer of the sigmoid colon and synchronous bilateral colorectal liver metastases, treated with the so-called “mini-ALPPS” approach.