A new procedure with stomach-lifting techniques to simplify laparoscopy-assisted distal gastrectomy and extraperigastric lymph node dissection for gastric cancer

K-Wire Retractor, a Trocar-Free Liver Retraction Technique in Bariatric Surgery

BACKGROUND

Liver retractor helps in the provision of an adequate operative field in bariatric surgery. Though several retractors have been introduced, an optimal retraction method is yet to be desired. We have developed a K-wire retractor, a simple trocar-free liver retractor used in our bariatric surgery. The efficacy and safety of the K-wire retractor were examined.

METHODS

A retrospective review was performed on patients undergoing laparoscopic bariatric surgery from January 2016 to April 2019. Based on the application of liver retractors during surgery, patients were divided into the K-wire retractor group and the suture-based retractor group for comparative analyses. Patients with severe liver injury or missing data, or treated with other types of retractors were excluded.

RESULTS

A total of 317 patients were included in our study and there was no conversion to open surgery. There were no significant differences in patient demographics (age, gender, BMI) and types of bariatric surgery between the two groups. The time taken for placement of retractor was significantly shorter in the K-wire retractor group, in addition to higher operative view score and lesser ALT/AST elevation compared with the suture-based retractor group. Although the K-wire retractor group was less inclined to require additional retraction techniques, patients with BMI ≥ 50 Kg/m² were associated with higher risk (OR:3.8; 95% CI: 1.2, 12.8) of requiring additional retractors. There were no severe K-wire retractor-related complications observed.

CONCLUSION

The trocar-free K-wire liver retractor is safe, simple, and effective as a standard liver retraction method in bariatric surgery.

Stomach hanging technique using gauze during laparoscopic gastrectomy

INTRODUCTION

Lifting the stomach using laparoscopic instruments during laparoscopic gastrectomy is difficult and increases the risk of crushing the tumor. In this study, we present a stomach hanging technique using gauze pieces that reduces the risk to the tumor.

MATERIALS AND SURGICAL TECHNIQUE

After a partial omentectomy and the opening of the lesser sac, the antrum was wrapped with a 15-20-cm gauze piece. Next, a straight needle with 2-0 monofilament suture material pierced the abdominal cavity through the right subcostal area on the mid-clavicular line, and the gauze was then sutured twice in a figure of eight manner. The needle was removed percutaneously through the right middle quadrant of the abdomen. Another suture was applied to wrap the left side of the stomach. The stomach was easily lifted and positioned by pulling the four suture strings in different directions. After the suture materials were fastened to the abdominal wall using hemostat forceps, the surgical field was sufficiently exposed, facilitating lymph node dissection on the superior surface of the pancreas. This method freed the assistant from holding the stomach and enabled this individual to assist the operation in other ways.

DISCUSSION

This stomach lifting technique using gauze is a good option for exposing the surgical field, enables the assistant to perform other tasks, and reduces the risk of crushing the tumor during laparoscopic gastrectomy.

Efficacy of early use of snake retractor in retroperitoneoscopic nephrectomy or nephroureterectomy

BACKGROUND AND PURPOSE

A snake retractor is generally used to create a better surgical field and space, but when to start using it is still controversial. In this study, we used a snake retractor starting in an early stage of the procedure to safely perform surgery and compared the results with a control group in which the procedure depended on operator discretion.

PATIENTS AND METHODS

Twelve patients were enrolled in this study and compared with a control group (n = 12) in which no special technique was used. We used four ports in both right- and left sided cases and used a snake retractor when removing the flank pad to create a better surgical space and field. We compared two groups in operative time, intraoperative blood loss, and body mass index (BMI).

RESULTS

Three surgeons were enrolled. In the intervention group (early use of snake retractor), operative time was 107 to 300 minutes (median 162 min), and intraoperative blood loss was 0 to 462 g (69.5 g). In the control group, operative time was 185 to 485 minutes (258 min) and intraoperative blood loss was 0 to 302 g (40 g). Operative time was significantly shorter in the intervention group than the control group (P = 0.0034). There was no significant correlation with intraoperative blood loss volume and BMI in these two groups. We did not have any patients with metastasis or recurrence of cancer in either group in post-operative follow-up. Only the control group included a case with a slight duodenum injury.

CONCLUSIONS

Early use of the snake retractor in retroperitoneoscopic nephrectomy or nephroureterectomy may produce a significantly safer operative procedure.

Adenosquamous carcinoma of the sigmoid colon treated by the less invasive procedures of endoscopy and laparoscopy: report of a case

A 51-year-old man demonstrated a positive finding for a fecal occult blood test during a screening examination. Total colonoscopy was therefore performed, and a semi-pedunculated polyp was detected in the sigmoid colon. Although this polyp was suspected of invading the submucosal layer, it was removed endoscopically because the preoperative diagnosis was well-differentiated adenocarcinoma. The pathological findings revealed adenosquamous carcinoma that had invaded the submucosal layer with lymphatic invasion. A laparoscopic bowel resection was then performed and a histopathological examination of the surgical specimen showed metastasis to two regional lymph nodes. The patient is alive and recurrence-free 22 months after the operation. Adenosquamous carcinoma has been reported to be rare and to possess a highly metastatic potential. It consists of both squamous cells and glandular cell components. We report a case of adenosquamous carcinoma of the sigmoid colon treated by less invasive approaches consisting of an endoscopic mucosal resection and a subsequent laparoscopic colectomy.