Review of various liver retraction techniques in single incision laparoscopic surgery for the exposure of hiatus

Mobilization of the Left Liver for Optimal Hiatal Exposure During Bariatric Surgery Procedures

Hepatomegaly, particularly an enlarged left liver lobe, is a well-recognized challenge in bariatric surgery, contributing significantly to staged procedures, conversions to open surgery, and aborted operations. Impaired intraoperative visualization hinders safe access to the hiatus and gastroesophageal junction, increasing the risk of complications. This report focuses on the laparoscopic mobilization of the left liver lobe as a reliable technique to address these challenges, offering improved exposure and facilitating precise surgical dissection. This technique should be considered a last resort to provide proper visualization of the hiatus when other retraction methods have failed. In our experience, this approach was applied in seven patients (six sleeve gastrectomies and one gastric bypass) with good outcomes. All patients tolerated the procedures well, and no intra- or post-operatively complications directly attributable to the mobilization technique were observed. These findings underscore the safety and efficacy of this method, making it a valuable tool for both primary and revisional bariatric surgeries.

Hiatal sling liver retraction technique in bariatric and upper gastrointestinal surgeries - Our 15 year experience with 1874 surgeries

INTRODUCTION

Liver retraction is an important aspect when performing minimal access surgeries, especially bariatric and upper gastrointestinal (GI) surgeries. Various liver retraction methods are available and have been tried. Here, we present our experience with our indigenous hiatal sling technique for liver retraction and compare it with Nathanson liver retractor which is a popular and commonly used liver retraction method.

PATIENTS AND METHODS

This is a retrospective observational study of 1874 patients who underwent bariatric and upper GI surgeries over the last 15 years since September 2009. A secondary study was conducted amongst the two groups of patients who underwent upper GI and bariatric surgeries using hiatal sling technique and Nathanson retractor system for liver retraction between January 2023 and October 2023. End points measured were time taken, conversions and complication along with liver function tests (LFTs) such as aspartate aminotransferase (AST) and alanine transaminase measured between the two groups pre- and postoperatively day 0, day 1, day 3 and day 7.

RESULTS

In our series of 1874 patients, hiatal sling liver traction was possible without any difficulties in all except 2 patients with no associated liver injury and with adequate exposure. In the comparative study, patients in the hiatal sling group (Group B) had significantly lesser elevation in LFTs as compared to the patients in the Nathanson liver retraction group (Group A), with no adverse events in both the groups.

CONCLUSION

Hiatal sling technique for liver retraction is an effective technique which provides adequate exposure of the hiatus and causes lesser liver insult compared to rigid liver retraction system like Nathanson liver retraction system. Hiatal sling does not interfere with surgeons' field causing less errors during surgery and thus making it more ergonomic friendly.

Advancements in liver retraction techniques for laparoscopic gastrectomy

Traditionally, liver retraction for laparoscopic gastrectomy is done via manual methods, such as the placement of retractors through the accessory ports and using a Nathanson retractor. However, these techniques often posed issues including extra abdominal incisions, risk of liver injury or ischaemia, and the potential for compromised visualization. Over the years, the development of innovative liver retraction techniques has significantly improved the safety and efficacy of laparoscopic gastrectomy and similar other hiatal procedures. This editorial will comment on the article by Lin et al, and compare this to the other liver retractor techniques available for surgeons and highlight the pros and cons of each technique of liver retraction.

Water-Mediated On-Demand Detachable Solid-State Adhesive of Porous Hydroxyapatite for Internal Organ Retractions

Novel adhesives for biological tissues offer an advanced surgical approach. Here, the authors report the development and application of solid-state adhesives consisting of porous hydroxyapatite (HAp) biocompatible ceramics as novel internal organ retractors. The operational principles of the porous solid-state adhesives are experimentally established in terms of water migration from biological soft tissues into the pores of the adhesives, and their performance is evaluated on several soft tissues with different hydration states. As an example of practical medical utility, HAp adhesive devices demonstrate the holding ability of porcine livers and on-demand detachability in vivo, showing great potential as internal organ retractors in laparoscopic surgery.

Implementation of Laparoscopic Nissen Fundoplications in a Developing South African Pediatric Surgical Service

Introduction

Pediatric laparoscopic Nissen fundoplication (LNF) has become the standard approach at many centers. We developed a minimal access surgery (MAS) training curriculum to enhance the delivery of MAS for pediatric patients in a resource-limited setting. We reviewed our 10-year experience in implementing and performing LNF at our institution.

Methods

We described the challenges of implementing MAS training for LNF and how we addressed them. Beneficial technical considerations were described. A retrospective review was performed on all pediatric LNFs performed.

Results

We performed 268 LNFs. Specialists or trainees under supervision performed all LNFs. The trainee group performed 43 LNFs (16%). The median operative time for the specialists was 94 min (interquartile range [IQR] 50), and the trainee group was 140 min (IQR 62.5). The median number of cases performed until we improved operative time amongst the trainees was nine (IQR 3). There were seven repeat LNFs, and 11 cases were converted to open. The overall complication rate was 8.9%. A reduction in complications among specialists occurred over the years. The 30-day mortality post-LNF was 0.7%.

Conclusion

LNF can be successfully introduced at a tertiary training centre in South Africa with good outcomes. A comprehensive quality improvement program, including MAS training, supported this.

Liver retraction using n-butyl-2-cyanoacrylate glue during laparoscopic cholecystectomy

There might be a thick "protrusion" in the visceral surface of hepatic quadrate lobe during the laparoscopic cholecystectomy (LC), which affects the surgical fields and consequently triggers high risks of biliary tract injury. Although n-butyl-2-cyanoacrylate (NBCA) glue has been applied to laparoscopic upper abdominal surgery for liver retraction, there is still no consensus on its safety and feasibility in LC. In this study, we investigated the safety, feasibility, and effectiveness of liver retraction using NBCA glue for these patients which have the thick "protrusion" on the square leaf surface of the liver during LC.Fifty-seven patients presenting thick "protrusion" hepatic quadrate lobe were included in our retrospective study. We performed LC in the presence of NBCA glue (n = 30, NBCA group) and absence of NBCA glue (n = 27, non-NBCA group), respectively. NBCA was used to fix the thick "protrusion" of the liver leaves to the hepatic viscera surface, which contributed to the revelation of the gallbladder triangle. The operation time, blood loss, postoperative hospitalization, and liver function were compared between the 2 groups.Both the groups' patients accomplished the operation in the laparoscopy. There was no mortality and no additional incision during operation. No severe complications including bile duct injury were available after surgery and no postoperative NBCA-related complications occurred after 9- to 30 months' follow-up. The time of operation in NBCA group showed significant decrease compared with that of non-NBCA group (48.33 ± 16.15 vs 65.00 ± 22.15 minutes, P < .01). There were no significant differences in blood loss, postoperative hospital stays, and the preoperative and postoperative liver function between the two groups (P > .05). Besides, no significant differences were noticed in major clinical characteristics between the 2 groups (P > .05).Liver retraction using NBCA during LC for thick "protrusion" hepatic quadrate lobe patients is safe, effective, and feasible.

Reduced-Port Sleeve Gastrectomy for Morbidly Obese Japanese Patients: a Retrospective Case-Matched Study

BACKGROUND

Reduced-port laparoscopic surgery remains controversial due to technical challenges that can lead to suboptimal outcomes, and data pertaining to operative and clinical outcomes of reduced-port sleeve gastrectomy (RPSG) vs. conventional laparoscopic sleeve gastrectomy (CLSG) are lacking.

AIMS

This retrospective case-matched study aimed to compare midterm (2-year) outcomes of RPSG and of CLSG.

METHODS

Patients included in the study had undergone laparoscopic bariatric surgery at our center between 2010 and 2017. Thirty-one consecutive female patients who underwent RPSG were compared to a sex-, age-, body mass index-matched group of 31 patients who underwent CLSG. Outcomes were evaluated and compared between groups.

RESULTS

Estimated blood loss volume, incidences of intraoperative and postoperative complications, and length of postoperative hospital stay did not differ significantly between the 2 groups. Operation time was significantly greater in the RPSG group than in the CLSG group (148.7 ± 22.6 vs. 120.2 ± 25.9 min, respectively; p < 0.001). Excess weight loss at 1 year was 105.9% and 109.7%, respectively (p = 0.94) and at 2 years was 101.1% and 105.3%, respectively (p = 0.64). One RPSG patient required placement of additional trocars because of bleeding from short gastric vessels, but conversion to open surgery was not required.

CONCLUSIONS

RPSG is feasible in carefully selected bariatric patients and results in midterm outcomes comparable to those observed after CLSG. Good cosmesis is a potential benefit of RPSG.

Differential advantage of liver retraction methods in laparoscopic fundoplication for neurologically impaired patients: a comparison of three kinds of procedures

AIM OF THE STUDY

Liver retraction during laparoscopic fundoplication is important for obtaining an optimal space. Several methods have been developed, but the risks and benefits are unclear. We compared three different approaches and evaluated their safety and utility.

METHODS

Forty-three neurologically impaired patients who underwent laparoscopic fundoplication between 2005 and 2018 were classified into three groups: A, snake retractor method, n = 18; B, crural suture method, n = 13; C, needle grasper method, n = 12. Patients' characteristics and outcomes were reviewed.

MAIN RESULTS

The liver retraction time was significantly shorter in group C than in A or B (p < 0.05). The operative times were shorter in groups B and C than in A. There were no significant differences in the liver enzyme levels. The liver enzyme levels increased temporarily but improved within a week. The C-reactive protein levels were significantly lower in group B than in A or C (p < 0.05).

CONCLUSIONS

The most convenient method was the needle grasper method, as the other two approaches create conflict with the operator's forceps. The crural suture method damages the liver less, but requires higher surgical skill levels. It is important to select the appropriate method according to the operator's skill and the patient's size and deformity.

Short-term and Long-term Outcomes Following Laparoscopic Gastrectomy for Advanced Gastric Cancer Compared With Open Gastrectomy

INTRODUCTION

To investigate the oncological feasibility and technical safety of laparoscopic gastrectomy with D2 lymphadenectomy for advanced gastric cancer.

METHODS

A total of 186 advanced gastric cancer patients treated by gastrectomy with D2 lymphadenectomy were eligible for inclusion including those with invasion into the muscularis propria, subserosa, and serosa without involvement of other organs, and stages N0-2 and M0. We retrospectively compared the short-term and long-term outcomes between laparoscopic gastrectomy and open gastrectomy.

RESULTS

We analyzed short-term outcomes by comparing distal with total gastrectomy results. We found no significant difference for distal gastrectomy for postoperative morbidity [laparoscopic vs. open: n=4 (4.6%) vs. n=1 (3.6%); P=1.00]. We also found no significant difference in postoperative morbidity for total gastrectomy [laparoscopic vs. open: n=2 (4.0%) vs. n=1 (4.0%); P=1.00]. No deaths occurred in any group.The entire cohort analysis revealed no statistically significant differences in overall-free or recurrence-free survival between the laparoscopic and open groups. For overall survival, there were no significant differences between open and laparoscopic groups for clinical stage II or III (P=0.29 and 0.27, respectively), and for pathologic stage II or III (P=0.88 and 0.86, respectively). For recurrence-free survival, there were no significant differences between open and laparoscopic groups for clinical stage II or III (P=0.63 and 0.60, respectively), and for pathologic stage II or III (P=0.98 and 0.72, respectively).

CONCLUSION

Laparscopic gastrectomy for advanced gastric cancer compared favorably with open gastrectomy regarding short-term and long-term outcomes.

Hepatic retractor in an ex vivo model1

PURPOSE

To discuss the use of models of hepatic retraction by laparoscopy, to present a new Hepatic Retractor (HR) and to evaluate its practicality, efficacy and safety in Esophageal Hiatus Exposure (EHE).

METHODS

Experimental cross - sectional study with a quantitative character. It was carried out in the Laboratory of Health Training of Christus University Center. The sample consisted of 12 livers of adult pigs weighing between 30 and 45 kg. A circular-shaped HR, 5 cm diameter and deformable materials was developed with a polypropylene cloth, metallic guide wire, epidural needle plastic guide and nylon string. The practicality of HR management was measured by the time required to use the instrument, efficacy by exposure to the operative field and safety by macroscopic assessment of liver damage.

RESULTS

The average time to complete the procedure was 3.24 minutes and reached less than 2 minutes after 12 repetitions. In eight experiments the maximum degree of EHE was obtained. No macroscopic lesions were observed.

CONCLUSION

The use of HR described can broaden the operative field, without causing macroscopic liver lesions and prolonging the surgical time.

DEVELOPMENT OF BALLOON-BASED ORGAN RETRACTOR FOR LAPAROSCOPIC SURGERY

Effective organ retraction is essential to ensure safe and efficient surgery, in the case of laparoscopic surgery, organ retraction is particularly difficult to achieve. Currently such as cherry dissectors are used for retraction, however the small size results in excessive stress on the organ being retracted. Therefore, we are developing a balloon-based retractor that provides similar functionality as the cherry dissector, particularly being able to pass through a small port, yet being expandable to provide a much greater contact area as well as improved traction, thus providing increased operating efficiency and improved safety in organ retraction. In this paper, the relative merits and demerits of a number of currently available retractors are compared. Parameters under consideration include shape, size, effective traction (coefficient of friction), type of actuation and ease of use. While parameters such as pressure distribution and effective traction have been objectively measured, other attributes unique to the individual mechanisms are discussed, and finally feedback is provided from surgeons regarding the respective retractor’s ease of use and perceived efficacy.

Evolution and Standardisation of Techniques in Single-Incision Laparoscopic Bariatric Surgery

Bariatric surgery has proven benefits for morbid obesity and its associated comorbidities. Laparoscopic approach is well established for bariatric surgery. Single-incision laparoscopic surgery (SILS) offers even more minimally invasive approach for the same with the added advantage of better cosmesis. We have developed and standardised the SILS approach at our institute. We share our experience and technical "tips" and modifications which we have learnt over the years. Technical details of performing sleeve gastrectomy and Roux-en-Y gastric bypass with special attention to liver retraction, techniques of dissection in difficult areas, creation of anastomoses and suturing have all been described. In our experience and in experience of others, single-incision bariatric surgery is feasible. Use of conventional laparoscopic instruments makes single-incision approach practical for day-to-day practice. Supervised training is essential to learn these techniques.

Intra-abdominal Trocar-Free Vacuum Liver Retractor for Upper-Gastrointestinal Surgery

Background. In laparoscopic upper-gastrointestinal (GI) surgery, an adequate retraction of the liver is crucial. Especially in single-port surgery and obese patients, problems may occur during liver retraction. The current study seeks to evaluate the efficacy and safety of the LiVac trocar-free liver retractor in laparoscopic upper-GI surgery. Methods. The present study is a nonrandomized dual-center clinical series describing our preliminary results using the LiVac system for liver retraction. The primary end points of the present study included the effectiveness and safety of the LiVac device as well as complications and documentation of problems with the device during surgery. Results. The device was used in 11 patients for simple and complex laparoscopic procedures. The mean age of the study population was 59.6 years (SD = 20.6; range = 30-84). There were 6 female and 5 male patients with a mean body mass index (BMI) of 31.9 kg/m2 (SD = 8.1; range = 26.0-45.3). The efficacy of the device was excellent in all cases, reducing the number of trocars needed. There were no device-related complications. Conclusion. The LiVac liver retractor is easy to use and provides a good exposure of the operative field in upper-GI laparoscopic surgery, even in obese patients with a high BMI.