How to improve exposure in the obese patient at laparoscopic cholecystectomy: the looped omental retractor.

Laparoscopic cholecystectomy in an obese patient is common, and can be challenging, beyond the underlying biliary pathology. The gallbladder fundus cannot be adequately retracted caudally due to the stiff, steatotic liver, while significant reverse Trendelenburg position and table‐tilt may not be tolerated. Thus, the duodenum, colon and excessive omentum can obscure the laparoscopic view (Fig. 1a).

Fig. 1

(a–f) The looped omental retractor – steps of retraction and the laparoscopic view. (a) Pre‐retraction view. (b) View above Rouvier's sulcus & base of Seg 4b (blue arrowed line) after omental retraction. (c) Application of Endoloop to omentum (Step 1). (d) Percutaneous introduction of the Endo close device to retrieve the Endoloop suture (Step 2). (e) Schematic of port sites/sizes (mm) and usual direction of omental retraction. (f) Securing the tension of Endoloop/omental retraction with an artery forcep on the skin (Step 3).

Strasberg's critical view of safety requires adequate exposure of the hepatocystic triangle. Connor suggests that Rouvier's sulcus and the base of liver segment 4b define a level of safe dissection to preserve the bile duct and right posterior radicals.

Various strategies to achieve this safe laparoscopic view are in use. Additional port placement permits the use of a fan retractor, or extra laparoscopic grasper to control the omentum. These can traumatize the underlying tissue, require active control and even a second assistant. Suture plication of omentum and subsequent retraction beside an existing port, as is often performed at hiatal surgery, can be technically challenging, is limited in the direction of retraction, and the suture can hinder instrument movement.

We describe a simple method to retract the omentum and enhance exposure to the hepatocystic triangle and Rouvier's sulcus without these drawbacks. This technique is in occasional use but not widely known, and inspired by Endoloop retraction of the gallbladder fundus at single‐incision laparoscopic cholecystectomy. We find it useful in the obese patient, and hence wish to publicize the technique. We employ an 0‐PDS II Endoloop (Ethicon) and Endo Close device (Covidien) to retract a tongue of omentum towards the abdominal wall to provide optimal view of the hepatocystic triangle (Fig. 1b).

Here, this technique is described at 4 port ‘American’ set‐up laparoscopic cholecystectomy. The operation was performed for a 58 year‐old male, with central obesity and BMI 35, presenting with gallstone pancreatitis. Consent was provided by the patient and is held at the treating institution. The need for omental retraction was noted after difficulty achieving adequate view of the hepatocystic triangle.

Step 1: A laparoscopic grasper is used to identify the optimal tongue of omentum to retract (Fig. 1c), and by trial identify the direction of retraction that will provide best exposure. An 0‐PDS II Endoloop is introduced through a port, and used to secure a tongue of omentum ideally in proximity to Hartmann's pouch.

Step 2: A small incision is made in the skin of the right abdomen at the chosen site, the EndoClose device is passed trans‐fascially, and is used to retrieve the 0‐PDS Endoloop under vision (Fig. 1d). Due to use of the Endo Close, the direction of retraction is independent of existing ports, and can be tailored to the patient's anatomy (Fig. 1f).

Step 3: The Endoloop is tensioned to provide adequate retraction without traumatizing the omentum or its attachments and secured at the abdominal wall with an artery forcep (Fig. 1e). This provides retraction of the omentum, colon, and by attachment, flattens out the duodenum, to optimize the hepatocystic triangle view.

At the end of dissection, the Endoloop is divided to liberate the omentum. The omentum can be checked for bleeding or infarction, however in our experience intervention is not typically required. The Endoloop is retrieved, and the skin incision does not require sutured closure.

We propose the Looped Omental Retractor as a simple yet elegant technique in laparoscopic surgery. We describe its use in the obese cholecystectomy as a way to ensure a safe operating view without risk of tissue trauma, the need for a second assistant, and the reliance on existing port‐sites. The required equipment (Endoloop and Endo Close) is readily available and inexpensive. This technique is not technically demanding, and we would encourage its use at cholecystectomy, and as part of a general surgeon's armamentarium for other laparoscopic exposure.

Author contributions

Shantanu Joglekar: Conceptualization; resources; visualization; writing – original draft; writing – review and editing. Alistair Rowcroft: Supervision; writing – review and editing. Nezor Houli: Supervision; writing – review and editing.