The safety of liver resection mainly depends on the function of the future liver remnant (FLR). Inadequate volume of FLR is associated with a significant increase in postoperative liver failure, especially in patients with liver cirrhosis. Even though laparoscopic hepatectomy could decrease the surgical trauma, it still could not solve the problem of inadequate volume of FLR. In clinical practice, surgical indications for patients with small volumes of FLR are always difficult to make because of the conflict between safety and oncological radicality. Two effective methods for increasing volume of FLR are adopted. One is portal vein ligation or percutaneous portal vein embolization, and the other is a two-stage surgery. However, these methods require several weeks for liver regeneration before the resection of liver malignancy. The risk of tumor progression during the waiting time is of concern by surgeons (Hayashi et al. 2007; Kokudo et al. 2001). Recently, a new “two-stage” operation which was named as “associating liver partition with portal vein ligation for staged hepatectomy (ALPPS)” by de Santibañes and Clavien (2012) has drawn the attention of surgeons. This method enables the rapid growth of FLR. However, the complication of bile leakage increased. In Schnitzbauer’s report (Schnitzbauer et al. 2012), bile leakage was observed in 24 % of the patients and the mortality was 12 %. The safety of the ALPPS was questioned by some surgeons (Kokudo and Shindoh 2013). The procedure of the in situ splitting of the liver was supposed to the major cause of the high occurrence rate of biliary leakage. This procedure was modified by Robles Campos et al. (2013). A round-the-liver ligation was executed to replace liver splitting to avoid the complication of biliary leakage and simplify the procedure as well (Fig. 8.1).

Totally laparoscopic ALPPS was described by Machado et al. in a letter to the editor in 2012. Differing from his cases, we adopted the execution of the round-the-liver ligation to replace the in situ splitting of the liver that could avoid postoperative bile leakage and might simplify the operation. Laparoscopic meticulous dissection is the point of the first-stage operation. The aspiration tube and 90°-angle forceps are good instruments for blunt dissection which could safely free the branches of portal vein (PV) and hepatic veins. The ligation would become loose after the first-stage operation for the gradual atrophy of the liver parenchyma under the ligature, so it is necessary to tighten the ligation a few days after the first-stage operation.

In 2014, completely laparoscopic ALPPS using round-the-liver ligation was performed on patients with an estimated volume of FLR lower than 40 % to achieve a radical resection of multiple liver malignancies, and a rapid increase of FLR volume was observed. Theoretically, the advantage of minimal invasion of laparoscopic surgery would decrease surgical trauma and lead to a lower occurrence rate of postoperative liver failure. The adoption of round-the-liver which replaced liver splitting could avoid biliary leakage and simplify the first-stage operation and finally could lead to decreases in perioperative morbidity and mortality. However, this procedure is still in the exploration stage. The value of this procedure should be further evaluated.