'Liver-first' approach with ALPPS: The natural combination of two new concepts in liver surgery

Modern colorectal liver metastasis (CRLM) surgery has undergone a very impressive development over the last ten years due to the evolution of methods, techniques and extension of surgical indications. The main limits of surgical CRLM treatment were extension of liver disease, volume and quality of future liver remnant and foreseeable hypertrophy induced by portal vein embolisation or ligation (PVE/PVL) for a possible two-staged hepatectomy. In 2007 Dr. Schlitt, performing the first associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) [1], unconsciously opened Pandora’s box; leading to intense surgical research into two-staged hepatectomies and allowing a further expansion of the resectable pool of liver tumour patients affected by bilobar tumour load. Now, 9 years after the first ALPPS, and after the recently proposed technical evolution named “monosegment ALPPS” [2], we can affirm that we are about to abandon a dogma of liver surgery: for extended liver resection at least 2 liver segments as future liver remnant are necessary; in fact, now this seems to no longer be true. This recent advancement further enhances the concept of liver hypertrophy and the application of ALPPS after agreements of the first consensus meeting [1]. As