PurposeAlthough associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been advocated for treating advanced liver tumors, increased morbidity and mortality remain serious problems. Many modified procedures have been devised to improve patient safety, but some confusion persists as to benefits and risks.MethodsModifications to ALPPS as originally reported were reviewed to clarify their contributions to safety and their clinical relevance.ResultsA variety of modifications are explained and considered. Modifications mainly aim to reduce adhesions, prevent tumor spread, avoid devascularization during liver splitting, and reduce surgical severity. Such changes aiming to increase safety and reduce invasiveness are needed to avoid high morbidity and mortality rates with this innovative procedure. However, these modified procedures still require more meaningful statistical comparisons of outcome.ConclusionsProspective controlled studies are needed to confirm which modified procedures should be adopted in a standardized manner as an alternative to the original ALPPS. Further, we need to further explore mechanisms of liver regeneration, functional recovery, histopathologic changes of hepatocytes, and blood distribution during ALPPS simultaneously to developing and evaluating modifications of the procedure.