Sequential Portal Vein Ligation and Robotic-Assisted Hepatectomy Following Conversion Therapy for Initially Unresectable Hepatocellular Carcinoma

Summary

This protocol aims to demonstrate a multimodal treatment strategy for initially unresectable hepatocellular carcinoma by combining portal vein ligation with targeted and immune-based conversion therapy, followed by robotic-assisted right hepatectomy. The goal is to enable safe resection, optimize future liver remnant volume, and achieve favorable oncological outcomes.

Abstract

The goal of this protocol is to present a comprehensive multimodal approach for treating hepatocellular carcinoma (HCC) that is initially considered unresectable due to insufficient future liver remnant or advanced tumor burden. The strategy integrates oncological conversion therapy with functional liver regeneration techniques, followed by minimally invasive robotic resection. First, targeted therapy, immunotherapy, and interventional vascular treatment are applied to control tumor progression and enhance resectability. Subsequently, laparoscopic right portal vein ligation is performed to induce hypertrophy of the contralateral liver, ensuring adequate functional reserve. After reassessment, patients meeting surgical criteria undergo Da Vinci robot-assisted anatomical right hepatectomy using an anterior approach, which allows precise vascular dissection, reduced blood loss, and improved surgical safety. This protocol highlights the feasibility and advantages of combining systemic therapy, interventional procedures, and advanced robotic techniques to expand surgical eligibility, optimize perioperative outcomes, and achieve favorable oncological control in patients with complex or advanced HCC.

Introduction

Hepatocellular carcinoma (HCC) is one of the malignant tumors that severely impacts the health of Chinese citizens. According to the latest data from the National Cancer Center, the incidence of HCC ranks fourth among newly diagnosed cancers in China, while its annual mortality and mortality rate both rank second. Approximately 64% of Chinese HCC patients are already in the intermediate or advanced stages at initial diagnosis¹. Conversion therapy refers to interventions that enable initially unresectable HCC patients to become eligible for surgical resection. These interventions primarily include functional future liver remnant (FLR) conversion....

Protocol

The research was performed in compliance with the institutional guidelines of the human research ethics committee at Shenzhen People's Hospital. The reagents and the equipment used are listed in the Table of Materials.

1. Confirming the treatment indication

1. Identify the solid space-occupying lesion in the right lobe of the liver.
   NOTE: In this case, the basic clinical characteristics include: 61-year-old male; Chief complaint: Incidental finding of a liver mass on abdominal imaging 1 week ago; Past Medical history: HBV infection for 10 years, maintained on entecavir antiviral therapy;....

Results

In the context of the described technique, the representative results demonstrate that robotic hepatectomy, when combined with conversion therapy and L-PVL, achieves both functional liver regeneration and oncologic downstaging. As shown in Table 1, baseline liver volumetric parameters prior to any intervention included an SRLVR of 35.1% and a total liver volume (TLV) of 2450.58 mL. After conversion therapy (D-TACE, targeted therapy, immunotherapy), ICG-R15 rose slightly to 5.5% while SRLVR reached 37.6%,.......

Discussion

A critical step in this protocol is the integration of oncological and functional conversion strategies prior to surgical resection. The timing and sequence of targeted therapy, immunotherapy, and interventional treatment are essential to downstage the tumor while maintaining liver function⁹. Similarly, laparoscopic portal vein ligation plays a decisive role in stimulating hypertrophy of the FLR, and accurate reassessment of liver volume is required before proceeding to hepatectomy

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Absorbable hemostatic dressing	Ethicon	2082	Surgical  hemostasis
Bipolar coagulating.	YOUSHI	101.017A.3	Electrosurgical hemostasis
Cadiere forceps	INTUITIVE	470049	Disposable Non Destructive Grasping Forceps in Da Vinci Xi
Continuous Firing Clip Applier and Stapling Clips	Johnson &Johnson	LT200	Vessel Ligation
Disposable Urethral Catheter Tray	STAR	20162141618	Pringle's maneuvor
Drainage tube	BAINUS MEDICAL	SY-Fr22-C	Abdominal fluid drainage
ENDOPATH XCEL Trocars	Johnson &Johnson	2CB12LT/2CB5LT	Laparoscopic port access
Endoscopic linear cutting stapler cartridges	Ethicon	GST60W	Vascular stapler cartridge
Endoscopic linear cutting stapler cartridges	Ethicon	GCFLGB	Hepatic pedicle stapler cartridge
Endoscopic retrieval bag	HUANKANG	20162220561	Specimen retrieval
Fenstrated Bipolar Forceps	INTUITIVE	471205	Disposable Bipolar coagulating in Da Vinci Xi
Harmonic ACE curved shears	INTUITIVE	480275	Disposable Ultrasonic shears in Da Vinci Xi
Indocyanine Green for Injection	Yi Chuang	H20055881	intraoperative fluorescence imaging
Intraoperative ultrasound	HITACHI	ALOKA-UST5418	Vessel/tumor localization
Laparoscopic suction irrigation	KANGJI	101.149	Fluid evacuation/blunt dissection
Ligating Clip	Wedu MedicaL	WD-JZ 3S	Vessel ligation
PDS synthetic absorbable surgical sutures	Johnson &Johnson	W9109H	Bile duct closure
Peng's multiple operative dissector, PMOD	SHUYOU SURGICAL	SY-IIIA (N)-1	Tissue dissection/hemostasis
Powered Plus Articulating Endocscopic Linear Cutter	Ethicon	PSEE60A	Laparoscopic stapler
Prolene Polypropylene non-absorbable sutures	Johnson &Johnson	W8761/W8710/W8706	Vessel closure
Retrieval basket	Cook Medical	NTSE-045065-UDH	Bile duct stone extraction
Surgical Endoscopic Instrument Control System	INTUITIVE	Da Vinci Xi (SK3164)	Surgical control system