completed TSH but without the non-negligible 40% rate of dropout, which mainly affected cumulative survival in TSH group in an intention to treat perspective [40]. On the other hand, a more recent multicenter case-match analysis sug­gests that ALPPS and E-OSH may achieve comparable long­term results in patients affected by bilobar CLM, despite a higher mortality and morbidity rate after ALPPS [41]. A safer clinical outcome after major tissue deprivation in a parenchyma sparing vessel guided fashion compared to that following major resections through conventional vessels amputation should deserve some consideration. On the other hand, ALPPS has shown to be associated with an increment in liver volume which does not translate one to one with liver function [42]. PSVGH keeping the architecture of the organ with its major vessels even in presence of high amount of liver tissue removed as it happens in case of multiple com­plex resection for bilobar CLM has shown a low risk and in particular a low rate of liver failure: milder regeneration of the liver after PSVGH compared to that evident after major amputation of the organ should be considered as a possibility to be investigated. Through IOUS and vessel guidance, PSS has entered the complexity, and entering the complexity has arrived to a different way of large tissue deprivation: the parenchymal sparing major hepatectomies could be a mean­ingful and promising paradox.