{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T17:57:13Z","timestamp":1781719033332,"version":"3.54.5"},"reference-count":20,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2023,3,13]],"date-time":"2023-03-13T00:00:00Z","timestamp":1678665600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Current Oncology"],"abstract":"<jats:p>In-situ splitting of the liver before extended resection has gained broad attention. This two-step procedure requires several measures to make an effective and safe procedure. Although the procedure is performed in many institutions, there is no consensus on a uniform technique. The two steps can be divided into different parts and a standardized technique may render the procedure safer and the results will be easier to evaluate. In this paper, we describe a detailed approach to in-situ splitting that allows making both procedures safe, avoids liver necrosis, and is easily reproducible. In the first procedure the portal branches to segments I and IV to VIII are divided, the arterial branches and bile ducts to these segments are preserved and encircled and the parenchyma between segments II\/III and IVa\/b is divided. This avoids necrosis and bile leaks of segments I and IV and avoids urgent completion operations. In particular, the handling of vital structures close to the dissection line seems important to us. Complete splitting and securing the right and middle hepatic vein will make the second step of this procedure a minimal-risk procedure at a stage where the patient is still recovering from the more demanding first step.<\/jats:p>","DOI":"10.3390\/curroncol30030249","type":"journal-article","created":{"date-parts":[[2023,3,13]],"date-time":"2023-03-13T07:28:15Z","timestamp":1678692495000},"page":"3277-3288","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Optimizing Growth of the Future Liver Remnant and Making In-Situ Liver Transsection Safe\u2014A Standardized Approach to ISLT or ALPPS"],"prefix":"10.3390","volume":"30","author":[{"given":"Andrea","family":"Alexander","sequence":"first","affiliation":[{"name":"Departments of Surgery, Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7663-9618","authenticated-orcid":false,"given":"Nadja","family":"Lehwald-Tywuschik","sequence":"additional","affiliation":[{"name":"Departments of Surgery, Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander","family":"Rehders","sequence":"additional","affiliation":[{"name":"Departments of Surgery, Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Levent","family":"Dizdar","sequence":"additional","affiliation":[{"name":"Departments of Surgery, Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9322-1659","authenticated-orcid":false,"given":"Georg","family":"Fluegen","sequence":"additional","affiliation":[{"name":"Departments of Surgery, Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9874-9225","authenticated-orcid":false,"given":"Sami","family":"Safi","sequence":"additional","affiliation":[{"name":"Departments of Surgery, Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wolfram","family":"Knoefel","sequence":"additional","affiliation":[{"name":"Departments of Surgery, Heinrich-Heine-University, University Hospital Duesseldorf, 40225 Duesseldorf, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,3,13]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"463","DOI":"10.1634\/stemcells.2004-0283","article-title":"Portal application of autologous CD133+ bone marrow cells to the liver: A novel concept to support hepatic regeneration","volume":"23","author":"Knoefel","year":"2005","journal-title":"Stem Cells"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1097\/SLA.0b013e31823d7d08","article-title":"Infusion of CD133+ bone marrow-derived stem cells after selective portal vein embolization enhances functional hepatic reserves after extended right hepatectomy: A retrospective single-center study","volume":"255","author":"Schmelzle","year":"2012","journal-title":"Ann. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1036","DOI":"10.1016\/S0016-5085(11)64302-3","article-title":"Increasing Safety of Liver Resection in Cirrhotic Livers. An Initial Experience Combining Autologous CD 133+ Stem Cell Application With in-Situ Splitting and Two Stage Hemihepatectomy","volume":"140","author":"Alexander","year":"2011","journal-title":"Gastroenterology"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"405","DOI":"10.1097\/SLA.0b013e31824856f5","article-title":"Right Portal Vein Ligation Combined With In Situ Splitting Induces Rapid Left Lateral Liver Lobe Hypertrophy Enabling 2-Staged Extended Right Hepatic Resection in Small-for-Size Settings","volume":"255","author":"Schnitzbauer","year":"2012","journal-title":"Ann. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"388","DOI":"10.1002\/bjs.8955","article-title":"In situ liver transection with portal vein ligation for rapid growth of the future liver remnant in two-stage liver resection","volume":"100","author":"Knoefel","year":"2013","journal-title":"Br. J. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1148\/radiol.2271012010","article-title":"Portal Vein Embolization with Polyvinyl Alcohol Particles and Coils in Preparation for Major Liver Resection for Hepatobiliary Malignancy: Safety and Effectiveness\u2014Study in 26 Patients","volume":"227","author":"Madoff","year":"2003","journal-title":"Radiology"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"126","DOI":"10.1016\/j.jamcollsurg.2013.03.004","article-title":"Analysis of the Efficacy of Portal Vein Embolization for Patients with Extensive Liver Malignancy and Very Low Future Liver Remnant Volume, Including a Comparison with the Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy Approach","volume":"217","author":"Shindoh","year":"2013","journal-title":"J. Am. Coll. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"956","DOI":"10.1007\/s11605-012-2132-y","article-title":"ALPPS in right trisectionectomy: A safe procedure to avoid postoperative liver failure?","volume":"17","author":"Li","year":"2013","journal-title":"J. Gastrointest. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1016\/j.hpb.2020.04.009","article-title":"Variation in complications and mortality following ALPPS at early-adopting centers","volume":"23","author":"Wanis","year":"2021","journal-title":"HPB"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Wu, X., Rao, J., Zhou, X., Deng, R., and Ma, Y. (2019). Partial ALPPS versus complete ALPPS for staged hepatectomy. BMC Gastroenterol., 19.","DOI":"10.1186\/s12876-019-1090-1"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1058","DOI":"10.1016\/j.surg.2015.11.013","article-title":"Variations and adaptations of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS): Many routes to the summit","volume":"159","author":"Edmondson","year":"2016","journal-title":"Surgery"},{"key":"ref_12","first-page":"1","article-title":"A single center comparative retrospective study of in situ split plus portal vein ligation versus conventional two-stage hepatectomy for cholangiocellular carcinoma","volume":"2022","author":"Vaghiri","year":"2022","journal-title":"Acta Chir. Belg."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Lehwald-Tywuschik, N., Vaghiri, S., Esch, J.S.A., Alaghmand, S., Klosterkemper, Y., Schimm\u00f6ller, L., Lachenmayer, A., Ashmawy, H., Krieg, A., and Topp, S.A. (2020). In situ split plus portal vein ligation (ISLT)\u2014A salvage procedure following inefficient portal vein embolization to gain adequate future liver remnant volume prior to extended liver resection. BMC Surg., 20.","DOI":"10.1186\/s12893-020-00721-y"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"978","DOI":"10.1001\/archsurg.143.10.978","article-title":"Portal Vein Ligation as an Efficient Method of Increasing the Future Liver Remnant Volume in the Surgical Treatment of Colorectal Metastases","volume":"143","author":"Capussotti","year":"2008","journal-title":"Arch. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"686","DOI":"10.1016\/j.amjsurg.2008.04.022","article-title":"Present status and future perspectives of preoperative portal vein embolization","volume":"197","author":"Liu","year":"2009","journal-title":"Am. J. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1372","DOI":"10.1245\/s10434-019-08192-z","article-title":"ALPPS for Locally Advanced Intrahepatic Cholangiocarcinoma: Did Aggressive Surgery Lead to the Oncological Benefit? An International Multi-center Study","volume":"27","author":"Li","year":"2020","journal-title":"Ann. Surg. Oncol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"825","DOI":"10.1097\/SLA.0b013e31816a9d7c","article-title":"Comparative Study of Portal Vein Embolization Versus Portal Vein Ligation for Induction of Hypertrophy of the Future Liver Remnant Using a Mini-Pig Model","volume":"247","author":"Wilms","year":"2008","journal-title":"Ann. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1007\/s11605-017-3512-0","article-title":"Rapid Liver Hypertrophy After Portal Vein Occlusion Correlates with the Degree of Collateralization Between Lobes\u2014A Study in Pigs","volume":"22","author":"Deal","year":"2018","journal-title":"J. Gastrointest. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"717","DOI":"10.1016\/j.jamcollsurg.2015.05.017","article-title":"Impact of Neoadjuvant Chemotherapy on Hypertrophy of the Future Liver Remnant after Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy","volume":"221","author":"Kremer","year":"2015","journal-title":"J. Am. Coll. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1159\/000520695","article-title":"Rescue Partial ALPPS for Left Hemihepatectomy with Reconstruction of the Middle Hepatic Vein","volume":"38","author":"Kogure","year":"2021","journal-title":"Dig. 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