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

BACKGROUND: The main aspect of concern for upper GI procedures has been the retraction of the liver especially large left lobes as commonly encountered in Bariatric surgery. Not doing so would compromise the view of the hiatus, hence theoretically reducing the quality of the surgery and increasing the possibility of complications. The aim of this study was to review the various liver retraction techniques in single incision surgery being done at our institute and analyze them.
MATERIAL AND METHODS: A retrospective study of the various techniques and a subsequent analysis was made based on advantages and disadvantages of each method. Objectively a quantitative measure of hiatal exposure was done using a scoring system based on the grade of exposure after reviewing the surgical videos. From January 2011 to January 2013 total 104 patients underwent single incision surgery with the various liver retraction techniques with following grades of exposure -liver suspension tube technique with naso gastric tubing (2.11) and with corrugated drain (2.09) needlescopic method (1.2), Umbilical tape sling (1.95), crural stitch method (2.5). Needeloscopic method has the best grade of exposure and is the easiest to start with. The average time to create the liver retraction was 2.8 to 8.6 min.There was no procedure related morbidity or mortality.
CONCLUSIONS: The mentioned liver retraction techniques are cost effective and easy to learn. We recommend using these techniques to have a good exposure of hiatus, without compromising the safety of surgery in single incision surgery.

INTRODUCTION

Single incision laparoscopic surgery is a rapidly emerging form of laparoscopic technique with increasing demand from the patient community for its potential advantages, mainly relating to the cosmetic aspect with increasing satisfaction rate compared to conventional multiport laparoscopy.[1234] Hence, many surgeons have started to adopt this technique even for more complex procedures. Although it was initially considered as a bridge between traditional laparoscopy and natural orifice transluminal endoscopic surgery (NOTES),[56] it has now emerged as an integral part of laparoscopy on a select subset of patients. But still, the progress has been quite slow considering the intrinsic technical difficulties which are predominantly related to the ergonomics. In fact these difficulties are associated with certain minor steps which make the entire procedure difficult.

The main area of concern in upper GI procedures has been the retraction of the liver especially large left lobes as commonly encountered in Bariatric surgery.[6] To counteract this, many surgeons even compromise the quality of the surgery by avoiding liver retraction with a compromised view of the hiatus,[78] hence, theoretically reducing the quality of the surgery and increasing the possibility of complications. In any surgery basic principles should not be violated while pursuing innovation. Hence, we need certain innovative techniques to avoid these compromises depending upon the nature of the surgery.

With regard to liver retraction in single incision laparoscopic surgery, a variety of different techniques are described in literature including the suspension tape technique,[6] Istanbul technique[9] suture retraction method[1011] etc.

Here we review and describe the various possible ways of retracting the liver during single incision laparoscopy for upper GI procedures performed at our institute. These could also be applicable in conventional multiport laparoscopy.

MATERIALS AND METHODS

A retrospective study of the various techniques performed between January 2011 to January 2013 was done and a subsequent analysis was made based on advantages and disadvantages of each method. Objectively a quantitative measure of hiatal exposure was done using a scoring system which was based on the grade of exposure after reviewing the surgical videos, as shown in Table 1. An average grade of exposure with each of the various techniques was calculated subsequently. The choice of liver retraction method was made on a case to case basis.

Table 1

Grading of hiatal exposure with liver retraction technique

All cases were operated after informed consent by experienced laparoscopic surgeons who have operated more than 10 single incision laparoscopic surgeries and the study was approved by the institutional review board.

We follow a single incision multi port technique as described by us previously[12] where we use a periumbilical incision of about 3–4 cms after retraction of the umbilicus without raising any flaps. Conventional one 10 mm and two 5 mm trocars are placed through the incision, an additional 3 mm trocars used whenever required. At the end of surgery the defects were closed with 2–0 Ethilon™.

A brief summary of different techniques of liver retraction in single incision surgery is described.

Umbilical Tape Sling Method

In this method, a tunnel is created in the left triangular ligament and an umbilical tape is passed across to suspend the left lobe like a sling as shown in Figure 1. This will be brought outside using a 2 mm incision using a suture retrieving instrument.

Figure 1

Liver retraction with umbilical tape

Crural Stitch Method

In this method a stitch with 1–0 Ethilon™ is taken on the anterior crura and the suture exteriorized which acts like a sling to support the liver as shown in Figure 2.

Figure 2

Liver retraction with a suture through right crus

Liver Suspension Tube Technique

In this method, we use a small portion of a corrugated drain with a 1–0 Ethilon™ (Ethicon, USA) suture mounted on a straight needle at the ends of the drain. Once introduced inside the abdomen this needle punctures the liver about 2 cms from the edge of the liver. These needles are the brought out of the abdomen and secured with clamps. This suspends the liver like a sling.

At the end of the procedure the clamps are released, the stitches cut from inside and the drain removed and the bleeding points are cauterized with bipolar cautery. Alternatively a nasogastric tube can also be used for suspension as shown in Figure 3.

Figure 3

Liver retraction with nasogastric tube

Needloscopic Method

A needloscopic instrument can be used through a 3.5 mm needle trocar (Karl Storz™, Germany) as shown in Figure 4, which can lift the left lobe. Alternatively a 2.3 mm alligator grasper (Stryker™, USA) can be used. One needs to be cautious using this instrument considering the sharp tipped nature of the instrument. This is especially applicable in large fatty livers where in the other techniques may be difficult to perform. These skin punctures heal without leaving behind a significant scar.

Figure 4

Retraction with 3 mm instrument

RESULTS

Total number of cases surgery wise performed between January 2011 to January 2013 and reviewed were 104. The average time required for retraction for the mentioned techniques was between 2.8 to 8.6 min. There were no complications or morbidity related to any of the retraction techniques.

Methods of retraction, number of cases, average grade of exposure and time required for each method is as mentioned in Table no 2. Details of the type of cases, the sex distribution average BMI and operative time for each procedure is as mentioned in Table 3.

Table 2

Methods of retraction, number of cases and average time required for each method

Table 3

Procedural statistics

DISCUSSION

Any new technique or technology, however great it may be, is always accepted only after an initial period of skeptism. This includes minimal access surgery too, for example laparoscopic cholecystectomy itself had to cross a controversial phase before being accepted. One important attributable reason was the increased incidence of bile duct injuries in the initial reported series.[131415] The other possible reasons include improper retraction, unfamiliar anatomy, ergonomics, lack of tactile feedback etc. But in the longterm as we know it has clearly established itself as an safe and a gold standard procedure.[1617]

Anticipating such a revolution, single incision laparoscopic surgery was increasing done in the beginning even for more complex procedures like colon/rectum resections, operations for gastro-esophageal reflux disease (GERD), bariatric surgery etc.[618] But this was more in the form of case reports and series only, addressing the feasibility of such procedures. Emerging long term results have hinted the possibility of more complications with single incision laparoscopic surgery mainly owing to compromise of certain essential and integral steps of laparoscopy.[19]

Single incision surgery is known to have an ergonomic disadvantage and one may end up compromising certain essential steps because of the reduced port usage.[2021] Hence to prevent the demise of such a technique, one needs to innovate/re-innovate certain techniques or even convert to conventional laparoscopy as per the need dictates.

When considering upper GI procedures like fundoplications, cardiomyotomy, bariatric surgery etc this difficulty has been mainly in the step of liver retraction especially when the livers are large and fatty.[6] Hence, at many instances surgeons end up attempting the procedure without any liver retraction thus by compromising the vision and theoretically increasing the possibility of complications. We have also brought out this issue in one of our comments to another article.[8]

We would like to highlight the fact that, any new surgeon attempting single incision upper GI procedure should start with conventional technique of liver retraction that he/she is experienced with and resort to other techniques as described in this article with gaining experience.

The umbilical tape method is a very simple technique where there is no need to puncture the liver and the liver lobe does not sag down much, even in the case of large fatty livers. But incising the triangular ligament itself might be difficult in large livers and railroading the umbilical tape may also be even more difficult in these situations. There is also a theoretical risk of hepatic vein injury during the incision. The Istanbul Technique[9] is an similar technique of atraumatic suspension of the liver with a mechanism like a hammock using a Penrose drain.

The liver suspension technique with a corrugated drain/nasogastric tube is simple and can be used even on large livers without much difficulty, but has the theoretical risk of bleeding/biliary radicular injury at puncture points, although we did not had any such problems with this technique. Additional suspension tapes can be used wherever necessary. This is a very good technique for large fatty livers in experienced hands. In fact this has become our standard technique for bariatric surgery. Huang[6] has described a similar method of retraction.

Crural stitch technique is another alternate technique with very good visualization of the GE junction and the hiatus as the suture is actually taken on the anterior crus, but taking the suture itself may be sometimes difficult at certain times and not a very good technique if the left lobe is long laterally which may create a dome like effect which will compromise the vision and also has the possibility of cutting-through in case of soft fatty livers. Hence one needs to be cautious while applying this procedure. A similar technique has been described previously.[1011]

The method of need loscopic retraction as described above requires additional instrument which has to be strong enough to bear the weight of left lobe of liver. Some might argue that this method requires an additional puncture, but a 3.5 mm puncture might not make a significant difference in cosmesis. In fact, it the best in terms of exposure grading and also the easiest and best to start with for the inexperienced surgeons. An alternative would be to use a 3 mm Natahansons retractor.

Texeira[22] reported a technique for liver retraction, by introducing a 5-mm liver retractor through the same 4-cm incision where the trocars were placed to avoid any additional incision.

As per technique described by Carlos A. Galvani[23] the Nathanson liver retractor and an internal liver retractor was utilized. Some of the drawbacks of this technique include the need for a 10-mm trocar for the introduction of the bulldog clamp. Both of these techniques require additional trocars and instrumentation making instrument movements cumbersome in an already crowded space.

We have tried to describe the various techniques from a practical standpoint. These techniques have only a small learning curve and are cost effective as well. But a word of caution here is that in applying these methods one should have a low threshold for insertion of additional ports whenever necessary if the exposure is inadequate or deemed risky. It will also be advisable to try these techniques during conventional multiport laparoscopy before attempting during single incision laparoscopy.

CONCLUSION

Liver retraction is an important aspect in upper GI procedures and in an attempt for single incision surgery safety should not be compromised. We have reviewed the various possible techniques to aid in this process which are easy to learn and also cost effective. Many more can be developed, but what we need is reproducibility and good exposure.

We recommend using any of the techniques to have a good view of the hiatus and the gastro esophageal junction while performing single incision upper abdominal surgery.

DISCLOSURE

Paper was presented at—

13th World Congress of Endoscopic Surgery — Mexico 2012

Masicon 2012-Annual meeting of Maharashtra State chapter of Surgeons. India in the best paper category.