Instrumentless liver suspension for liver retraction in robotic pancreatoduodenectomy.

The popularity of robotic pancreatoduodenectomy (RPD) is increasing, yet it remains a complex procedure. Outcomes are influenced by various factors, including patient-specific variables, disease characteristics, and surgical technique. Numerous and intricate details contribute to the technical success of RPD. In this study, our focus is on achieving effective and "gentle" liver retraction. The use of liver retractors has been associated with the risk of retractor-related liver injury (RRLI), which can have serious consequences. Here, we introduce a refined technique for instrumentless liver retraction in RPD, developed progressively through a series of over 300 procedures. The core concept of this technique involves suspending the liver to the diaphragmatic dome. This is accomplished by securing the round ligament to the anterior abdominal wall using transparietal sutures and attaching the fundus of the gallbladder and the anterior margin of liver segment number 3 to the diaphragm. Our consecutive series of over 300 RPDs demonstrates the feasibility and safety of this approach, with no clinically relevant RRLI observed. Instrumentless liver retraction offers a valuable refinement in RPD, streamlining the procedure while reducing potential complications associated with dedicated retractors.

A bioinspired switchable adhesive patch with adhesion and suction mechanisms for laparoscopic surgeries.

Medical adhesives play an important role in clinical medicine because of their flexibility and convenient operation. However, they are still limited to laparoscopic surgeries, which have demonstrated urgent demand for liver retraction with minimal damage to the human body. Here, inspired by the suction cup structure of octopus, an adhesive patch with excellent mechanical properties, robust and switchable adhesiveness, and biocompatibility is proposed. The adhesive patch is combined by the attachment body mainly made of poly(acrylic acid) grafted with N-hydroxysuccinimide ester, crosslinked biodegradable gelatin methacrylate and biodegradable biopolymer gelatin to mimic the adhesive sucker rim, and the temperature-sensitive telescopic layer of microgel-crosslinked poly(N-isopropylacrylamide-co-2-hydroxyethyl methacrylate) to shrink and form internal cavity with reduced pressure. Through mechanical tests, adhesion evaluation, and biocompatibility analysis, the bioinspired adhesive patch has demonstrated its capacity not only in adhesion to tissues but also in potential treatment for medical applications, especially laparoscopic technology. The bioinspired adhesive patch can break through the limitations of traditional retraction methods, and become an ideal candidate for liver retraction in laparoscopic surgery and related clinical medicine.

Magnetic liver retraction in bariatric surgery: Is it possible?

One of the recent advances in bariatric surgery is the use of magnetic devices. This research paper describes magnetic liver retraction in morbidly obese patients during bariatric surgery. A descriptive, prospective and observational study was carried out, analyzing 100 patients in whom magnetic retraction was used. Mean and SD body mass index was 46.1 ± 5.09 kg/m2. The magnetic system was successfully used for liver retraction in 95% of cases; in only 5% of cases was its use not possible due to hepatomegaly and severe hepatic steatosis. According to the results, magnetic liver retraction can be safe and used in bariatric surgery, regardless of body mass index and with a low percentage of complications.

A Practical Guide to Inflow Control, Retraction, and Exposure for Robotic Hepatectomy.

Establishment of inflow control and gentle effective retraction of the liver for optimal exposure are critical to safe hepatectomy. Multiple methods have been previously reported for inflow control in minimally invasive (MIS) hepatectomy including Huang's Loop.1-3 We describe here the assembly and use of our modified version of Huang's loop that permits adjustable, atraumatic, and totally intracorporeal inflow control. We use a soft 16-French urinary catheter with a single premade opening near the blunt tip, across which a small slit is created. A beveled cut is made to the catheter 12-15 cm from the blunt tip and a suture sewn there that can be grasped to pull this beveled tail through the slit and window around the porta hepatis; this loop can be tightened or loosened with ease. For liver retraction, current techniques can be traumatic, especially when instruments apply traction directly onto the liver.4 Our preferred approach utilizes a liver sling made from a soft, rolled surgical sponge with 15-cm silk ties secured at each end; the length of the sling can be adjusted on the basis of thickness of the liver. The sling applies gentle, atraumatic "pulling" traction and is especially useful for exposure of the right posterior sector. We also use external band retraction to align the transection plane with the camera.5 Both also provide countertraction when advancing instruments into a firm or fibrotic liver. These techniques are commonly used in our MIS practice, and we have found them to be cost-efficient, easily reproducible, and effective.

Is It Possible to Estimate the Liver Left Lobe Volume Using Preoperative Data Before Bariatric Surgery?

PURPOSE: Retraction of the left lobe of the liver (LLL) is an important step in bariatric surgical procedures. A good liver retraction will both facilitate the operation and reduce complications. The aim of the study is to identify patients with large LLL with preoperative anthropometric and laboratory data, and to reveal complications due to large LLL. MATERIALS AND METHODS: The data of 245 patients who underwent bariatric surgery in our department between April 2019 and March 2021 were retrospectively analyzed. The patients were divided into two groups according to the visibility of the caudate lobe of the liver, the left diaphragmatic artery-vein, and the fat pad on the esophagus after liver retraction. RESULTS: Univariate analyses revealed significant differences in BMI, waist and hip circumferences, TG, DM, and HbA1c values, but only BMI (p = 0.001) and the presence of DM (p = 0.017) were found to be independent predictors of LLL size. BMI ≥ 42.1 kg/m2 indicates the size of LLL with 83% sensitivity and 49% specificity. Retractor-related complications were significantly higher in the large LLL group (p = 0.036). There was no difference between the two groups in terms of complications related to trocar insertion (p = 0.014) and postoperative liver enzyme levels (p = 0.714). The operation time (laparoscopic sleeve gastrectomy [LSG]; p = 0.021) (laparoscopic Roux-N-Y gastric bypass [LRYGB]; p = 0.020) and the amount of bleeding (LSG; p < 0.001) (LRYGB; p = 0.011) are higher in patients with large LLL. CONCLUSION: Large LLL can be predicted and complications may be reduced with the help of preoperative data.

Liver retraction using an L-shaped retractor during sleeve gastrectomy.

PURPOSE: The Nathanson liver retractor (NLR) and the snake liver retractor (SLR) are commonly used in bariatric surgery and their use is associated with some disadvantages. We developed an L-shaped liver retractor (LLR) and herein evaluated its efficacy and safety. METHODS: The present retrospective study enrolled patients undergoing sleeve gastrectomy in our department between June 2014 and December 2020. The patients were divided into three groups according to the liver retractor used (LLR, SLR or NLR) for a comparative analysis of the efficacy and safety of the devices. The procedural time (PT) of each retractor type, defined as the time from retractor insertion to liver fixation, was compared. RESULTS: In total, 140 patients successfully underwent laparoscopic sleeve gastrectomy. The LLR, SLR and NLR were used in 37, 91, and 12 of these patients, respectively. The PT for the LLR was the shortest. AST/ALT elevation was significantly more frequent in the NLR group than in the SLR group and tended to be less frequent in the LLR group in comparison to the NLR group (p = 0.09). The length of hospital stay in the NLR group was significantly longer in comparison to the LLR group. CONCLUSION: Our study suggested that the LLR was superior to the conventional liver retractors used in sleeve gastrectomy.

Risk Factors for Postoperative Liver Enzyme Elevation After Laparoscopic Gastrectomy for Gastric Cancer.

BACKGROUND/AIM: Laparoscopic gastrectomy (LG) is more frequently associated with postoperative liver enzyme elevation (PLEE) than open gastrectomy in phase III clinical trials for Japanese gastric cancer patients. The aim of this study was to determine the risk factors for PLEE after LG for gastric cancer. PATIENTS AND METHODS: This study enrolled 153 consecutive patients with gastric cancer who underwent LG. The patient characteristics, the liver retraction method [silicone disc (SD) or Nathanson liver retractor (NLR)], and perioperative outcomes were compared between patients with and without PLEE. RESULTS: PLEE was observed in 26 patients (17%). The patients with PLEE exhibited longer operative times (p=0.005) and more frequent use of the NLR for liver retraction (p=0.022). In the multivariate analysis, liver retraction using the NLR (p=0.003) and aberrant left hepatic artery (ALHA) ligation (p=0.042) were independent risk factors of PLEE. CONCLUSION: Liver retraction with the SD during LG was shown to be the safer method that is less likely to cause postoperative liver dysfunction. ALHA preservation may contribute to avoiding postoperative liver dysfunction.

Magnetic Liver Retraction Decreases Postoperative Pain and Length of Stay in Bariatric Surgery Compared to Nathanson Device.

Objective: Retrospective case-matched comparison of magnetic liver retraction to a bedrail-mounted liver retractor in bariatric surgery specifically targeting short-term postoperative outcomes, including pain and resource utilization. Background: Retraction of the liver is essential to ensure appropriate visualization of the hiatus in bariatric surgery. Externally mounted retractors require a dedicated port or an additional incision. Magnetic devices provide effective liver retraction without the need of an incision. Methods: The sample consisted of primary and revisional bariatric surgery patients, including Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and biliopancreatic diversion with duodenal switch (BPD-DS) operations. Propensity score analysis was used to match patients with magnetic retraction to patients with a bedrail-mounted retractor with a 1:2 ratio using preoperative characteristics. Baseline characteristics and postprocedure outcomes were compared using two-sample t-tests or Wilcoxon rank sum tests and chi-square or Fisher's exact test as appropriate. Results: One hundred patients met inclusion criteria for the use of magnetic liver retraction (45 RYGB, 35 SG, 20 BPD-DS) with 196 suitable matched external retractor patients identified. Patients were matched and comparable for all preoperative characteristics except for transversus abdominus plane block (27% versus 47%). Patients in the magnet cohort had significantly decreased mean 12-hour postoperative pain scores (2.9 versus 4.2, P = .004) and decreased hospital length of stay (LOS) (1.5 versus 1.9 days, P = .005) while operating room supply were higher in the magnet cohort ($4600 versus $4213, P = .0001). Conclusions: Magnetic liver retraction in bariatric surgery is associated with decreased postoperative pain scores, decreased hospital LOS, and increased operating supply costs.

Iatrogenic hepatic granuloma (suspected liver metastatic lesion on imaging) caused by liver retraction during laparoscopic gastrectomy: A case report.

There are no previous reports of hepatic granuloma secondary to intraoperative liver retraction. Using softer hepatic retraction instruments and keeping hepatic retraction time to a minimum are vital in preventing postoperative liver damage.

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.

Comparison of Two Types of Liver Retractors in Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity.

BACKGROUND: Retraction of the left lobe of the liver is an important step in most bariatric surgical procedures. Bariatric patients may have enlarged, fatty livers and retraction can be complicated with injuries, haematoma, or necrosis. The aim of this study was to compare the effects of two standard liver retractors, Nathanson and PretzelFlex on patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: All consecutive patients undergoing LRYGB in our center from April 2017 to January 2019 were analysed. The type of retractor used was dependent on the surgeon's preference and the availability of instruments. Patients were divided into two groups, based on the type of liver retraction device used. Each group was assessed and compared for postoperative pain score, presence of nausea or vomiting, blood test results (liver function tests and C-reactive protein), and length of hospital stay. RESULTS: LRYGB was performed on 167 patients in which Nathanson was used in 93 patients and PretzelFlex in 74 patients. The duration of surgery was similar in both groups. Alanine transaminase (ALT) levels and C-reactive protein (CRP) were significantly higher in the group where Nathanson's retractor was used. The postoperative pain score and length of stay were also higher when Nathanson's retractor was used but it did not reach statistical significance. CONCLUSION: The PretzelFlex liver retractor causes significantly less measurable liver damage and is associated with less postoperative pain and nausea when compared with Nathanson's retractor.

Low-Cost Incisionless Liver Retraction for Laparoscopic Sleeve Gastrectomy: A Prospective Controlled Trial.

Background: Laparoscopic bariatric surgery has been performed safely since 1991. In a persistent search for fewer and smaller scars, single port, needlescopic surgery, and other approaches have been implemented. Our goal was to analyze the safety and feasibility of using incisionless autostatic liver retraction for sleeve gastrectomy. Materials and Methods: Candidates for sleeve gastrectomy were selected, excluding those <18 and having had prior upper left quadrant surgery. Patients were randomized 1:1 to either a standard five-port technique with a fan-type liver retractor (Group A); or a four-port technique with the liver retracted using a polypropylene 1 suture passed through the right crura and retrieved at the epigastrium employing a fascial closure needle (Group B). All surgeries were performed by the same surgeon. The primary endpoint was surgery duration. Secondary outcomes were quality of surgical-field visualization, complications inherent to liver retraction, and postoperative morbidity. Results: One hundred patients were recruited (n = 50/group). The groups (both 90% females) were demographically and anthropomorphically comparable. Surgery duration was 30.4 ± 4.6 and 29.6 ± 4.7 minutes for Groups A and B, respectively (P = .41). Visualization was considered very good in 80% versus 82%, good in 16% versus 12%, and poor in 4% versus 6% (P = NS). Two patients from each group (4%) had self-limited minor bleeding from the liver attributed to the retraction technique. No 30-day morbidity was observed. Conclusions: Liver retraction using a polypropylene suture was both effective and inexpensive. Visualization and the duration of surgery were comparable to a standard liver retractor. This low-cost alternative may diminish the need for expensive instruments and reduce the number of scars without jeopardizing the safety and quality of sleeve gastrectomy.

Magnetic Liver Retraction: an Incision-Less Approach for Less Invasive Bariatric Surgery.

BACKGROUND: In bariatric surgery, retraction of the liver is essential to ensure appropriate visualization of the surgical field. Many devices are currently employed for this purpose. Generally, these devices require constant use of a port, or an additional incision. Magnetic technology provides a novel solution, by allowing liver retraction during bariatric procedures that do not require a dedicated port nor an extra incision. METHODS: Retrospective review of consecutive patients who underwent magnetic-assisted liver retraction during primary or revisional laparoscopic bariatric surgery at the Duke Center for Metabolic and Weight Loss Surgery between October 2016 and August 2017. RESULTS: The 73 cases were comprised of 29 primary sleeve gastrectomies, 24 gastric bypasses, 10 duodenal switches, 3 gastric band removals, and 7 revisions. All cases were completed laparoscopically. Mean pre-operative BMI was 43.6 kg/m2 (range 18.3-67.7 kg/m2). Mean operative times for primary cases were similar to published averages. Two patients experienced minor 30-day morbidities, neither of which were attributed to the device and did not require further interventions. There were no 30-day mortalities. Surgeons described subjective overall surgical exposure as adequate and device utilization as technically simple even for the large livers. CONCLUSIONS: Magnetic-assisted retraction is a novel approach that allows a safe, reproducible, incision-less technique for unconstrained, port-less intra-abdominal mobilization. The device successfully permitted optimal liver retraction during laparoscopic bariatric surgery, enhancing surgical exposure while decreasing the number of abdominal incisions.

A novel liver retraction method in laparoscopic gastrectomy for gastric cancer.

BACKGROUND: Retracting the lateral liver segment during laparoscopic distal gastrectomy is important for achieving an optimal surgical field. However, excessive force may injure the liver, causing temporary abnormalities of liver function tests after laparoscopic surgery. We developed a new liver retraction method and assessed its safety and utility. PATIENTS AND METHODS: We retrospectively analyzed records in our surgical database of consecutive surgical patients who underwent laparoscopic distal gastrectomy for early gastric cancer. We divided the 229 patients into two groups based on the liver retraction method used, either flexible liver retraction with clipping and suturing (FLICS) or the Nathanson retractor (NR). One-to-one propensity score matching was performed to match patients, resulting in the records of 53 pairs of cases extracted from the database. Operative and postoperative outcomes were assessed, including following the values of serum liver enzymes, total bilirubin, and C-reactive protein until postoperative day 30. RESULTS: There were no significant differences in patient characteristics or preoperative data in the two groups. The retraction method was not changed intraoperatively for any patients. The operative time was significantly shorter in the FLICS group, but the amount of bleeding did not differ. Liver injury was not observed as a result of liver retraction during surgery. In both groups, serum liver enzymes temporarily increased after surgery but improved rapidly thereafter. The postoperative increases in aspartate transaminase, alanine transaminase, and C-reactive protein levels were significantly lower in the FLICS than in the NR group. No serious complications associated with liver retraction were observed in either group. CONCLUSIONS: Our new liver retraction technique provided an optimal surgical field without inducing liver dysfunction. It is a simple, safe, and effective liver retraction technique.

An Easy and Safe Method of Liver Retraction Using a Silicone Disc and Needle Forceps for Laparoscopic Gastrectomy.

BACKGROUND: For safe laparoscopic gastrectomy, it is essential to secure a good visual field by employing liver retraction. We have developed a safe and easy method for liver retraction using a silicone disc, and evaluated its feasibility. METHODS: We analyzed retrospectively 36 patients with gastric cancer, who underwent laparoscopic distal gastrectomy employing liver retraction by a silicone disc and needle forceps (Silicone group) or by the Penrose drain method (Penrose group) between January 2013 and July 2016. The time needed for liver retraction, complications resulting from it, and postoperative liver dysfunction were compared between the two groups. RESULTS: In all patients in both groups, the operation was performed successfully, obtaining an appropriate visual field. The mean time required for liver retraction was 633.8 ± 286.6 seconds in the Silicone group and 639.8 ± 328.6 seconds in the Penrose group (P = .954). Postoperative elevation of either aspartate transaminase (AST) or alanine aminotransferase (ALT) level was recognized in 13 (72.2%) of the Silicone group patients and 18 (100%) of the Penrose group patients (P = .0160). The mean AST and ALT levels in the Silicone group were significantly lower than those in the Penrose group on postoperative days 0, 1, and 3. Among intraoperative complications related to liver retraction, hemorrhage from the abdominal wall occurred in one Silicone group case and hemorrhage from liver occurred in one Penrose group case. CONCLUSION: Liver retraction using a silicone disc and needle forceps in laparoscopic gastrectomy is easy and safe, offering a good visual field and a reduced degree of liver dysfunction.

Modified exposure method for gastric mobilization in robot-assisted esophagectomy.

BACKGROUND: We describe a modified method to facilitate gastric mobilization in robotic esophagectomy. Furthermore, we performed a prospective comparative analysis of surgical outcomes between the conventional method and described technique. METHODS: From April 1st, 2016 to December 31st, 2016, 59 consecutive patients were included who underwent robot-assisted McKeown esophagectomy for esophageal squamous cell carcinoma in our institution. They were subdivided into two groups based on the method of gastric exposure: a grasper retraction (GR) group (n=27) and a thread retraction (TR) group (n=32). For the GR patients, robotic instruments were directly used to expose the surgical field for gastric mobilization. However, for TR patients, the right gastroepiploic arcade and the short gastric vessels were fully exposed via a polyester tape combined with a thread loop. RESULTS: There was no incidence of postoperative 30-day mortality. The median gastric mobilization time was 53 min (range, 38-77 min). It took significantly less time in the TR group compared to the GR group (P=0.005). The median amount of blood loss was 8 mL (range, 5-14 mL), and no significant difference was found between the two groups (P=0.573). The median number of dissected lymph nodes was 10 (range, 7-16), and there was no significant difference between groups (P=0.386). Similarly, the postoperative morbidity rates did not statistically differ between the two groups (P=0.942). CONCLUSIONS: The robot-assisted McKeown procedure presented is a safe and easy to perform technique for stomach retraction during gastric mobilization. Compared with the conventional GR method of gastric mobilization, TR requires less operating time and allows for an excellent operative field. The technique could, therefore, help surgeons to overcome some of the defects of robotic esophagectomy during gastric mobilization.

A percutaneous technique of liver retraction in laparoscopic bariatric & upper abdominal surgery.

BACKGROUND: Laparoscopic bariatric surgery requires retraction of the left lobe of the liver to provide adequate exposure of the hiatus and the stomach. Currently used approaches utilize retractors that require additional incisions and prolong operative time. OBJECTIVES: A retrospective evaluation of the efficacy and safety of a percutaneous liver retractor in a large series of patients undergoing laparoscopic bariatric surgery. SETTING: Private practice, United States. METHODS: A retrospective chart review was performed on 2601 patients undergoing bariatric surgery from January 2011 to September 2015. A percutaneously introduced grasper (Teleflex MiniLap Percutaneous Surgical System, Morrisville, NC) was used to retract the left lobe of the liver in all cases. The retractor could be repositioned as necessary by releasing and regrasping the diaphragm at different locations. RESULTS: This technique was used in 2601 patients from January 2011 until September 2015. The average body mass index was 43.1 (range: 20.6-80.3). In all patients, this new method was found to be satisfactory to complete the bariatric procedure. The majority of procedures included laparoscopic Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric band placement. No intraoperative liver injuries occurred with use of the Teleflex retractor. CONCLUSION: Percutaneous retraction of the liver using the Teleflex MiniLap Percutaneous Surgical System was found to be safe and effective in this large series of morbidly obese patients. The rate of complications involving this technique is extremely low. This novel method provides safe and effective retraction with less trauma and better cosmesis than conventional technique.

A clinical study of the LiVac laparoscopic liver retractor system.

BACKGROUND: All retractors for laparoscopic operations on the gallbladder or stomach apply an upward force to the under-surface of the liver or gallbladder, most requiring an additional skin incision. The LiVac laparoscopic liver retractor system (LiVac retractor) comprises a soft silicone ring attached to suction tubing and connected to a regulated source of suction. The suction tubing extends alongside existing ports. When placed between the liver and diaphragm, and suction applied, a vacuum is created within the ring, keeping these in apposition. Following successful proof-of-concept animal testing, a clinical study was conducted to evaluate the performance and safety of the retractor in patients. METHODS: The study was a dual-centre, single-surgeon, open-label study and recruited ten patients scheduled to undergo routine upper abdominal laparoscopic surgery including cholecystectomy, primary gastric banding surgery or fundoplication. The study was conducted at two sites and was approved by the institutions' ethics committees. The primary objective of the study was to evaluate the performance of the LiVac retractor in patients undergoing upper abdominal single- or multi-port laparoscopic surgery. Performance was measured by the attainment of milestones for the retractor and accessory bevel, where used, and safety outcomes through the recording of adverse events, physical parameters, pain scales, blood tests and a post-operative liver ultrasound. RESULTS: The LiVac retractor achieved both primary and secondary performance and safety objectives in all patients. No serious adverse events and no device-related adverse events or device deficiencies were reported. CONCLUSION: The LiVac retractor achieved effective liver retraction without clinically significant trauma and has potential application in multi- or single-port laparoscopic upper abdominal surgery. As a separate incision is not required, the use of the LiVac retractor in multi-port surgery therefore reduces the number of incisions.