Fig. 4.

Patient not suitable for ‘!’ 2-stage hepatectomy (TSH), with synchronous colorectal liver metastases after neoadjuvant/conversion chemotherapy. a Contrast-enhanced computed tomography (CT) scan showing bilateral large colorectal liver metastases prior to chemotherapy. b Contrast-enhanced CT scan after 4 months of chemotherapy showing excellent response of the liver metastases, prior to the first surgery. c Intraoperative view at the end of the first surgery after resection of 5 metastases from the left (including segment IV) and the right portal vein division, in preparation for later removal of metastases on the right side by right hepatectomy. Preoperatively, ‘!’ liver resection/ALPPS had been planned; due to a larger than expected number of metastases in the left lobe (detected by intraoperative contrast-enhanced ultrasound), the strategy was changed intraoperatively. d Contrast-enhanced CT scan 8 weeks after primary surgery showing increase in volume of the left liver (including segments IV and I), prior to the second surgery following TSH/portal vein ligation. e Contrast-enhanced CT scan 5 weeks after the second surgery (right hepatectomy with minor parts of segment IVa).