Saudi Surgical Journal

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 6  |  Issue : 4  |  Page : 132--135

Pain-free liver retraction: A simple technical innovation


JS Rajkumar, Anirudh Rajkumar, Hema Tadimari, Dharmendra Kollapalayam Raman, S Akbar, V Sai Vishnupriya 
 Department of General and Laparoscopic Surgery, Lifeline Institute of Minimal Access, Chennai, Tamil Nadu, India

Correspondence Address:
Dr. J S Rajkumar
Lifeline Institute of Minimal Access, No. 47/3, New Avadi Road, Kilpauk, Chennai - 600 010, Tamil Nadu
India

Abstract

Aim: To present an innovative pain –free liver retraction. Introduction: Retraction of the left lobe of the liver is a vital step in most of the upper gastrointestinal laparoscopic surgeries. For these procedures, a subxiphoid port, 5 or 10 mm, is used to insert a liver retractor to keep the left lobe of the liver out of the operative field. We describe a simple, but effective and economical alternative technique, using the core shaft of the dismantlable laparoscopic hand instruments. Patients and methods: Over a 3-month period, all upper gastrointestinal laparoscopic surgeries, were done with the liver retraction performed with the core shaft of the dismantlable laparoscopic instrument. There were 41 surgeries in all, which were mainly bariatric surgeries, antireflux surgeries, and Heller's myotomy. The endpoint of the study was to evaluate how useful this modified liver retraction was as a technique, and failure of the retractor was defined as a need to convert into a 5-mm fan liver retractor. Results: Of the 41 patients operated in a 3-month period, only in two cases, both undergoing RYGB, who had enlarged fatty liver, a 5-mm metallic fan retractor was found to be necessary to complete the proposed surgery, with a conversion ratio of 4.9%. Conclusion: The two mm 'insert', the shaft of the dismantlable laparoscopic hand instruments is a safe and effective option for liver retraction in most of the upper GI laparoscopic surgeries.



How to cite this article:
Rajkumar J S, Rajkumar A, Tadimari H, Raman DK, Akbar S, Vishnupriya V S. Pain-free liver retraction: A simple technical innovation.Saudi Surg J 2018;6:132-135


How to cite this URL:
Rajkumar J S, Rajkumar A, Tadimari H, Raman DK, Akbar S, Vishnupriya V S. Pain-free liver retraction: A simple technical innovation. Saudi Surg J [serial online] 2018 [cited 2019 Mar 23 ];6:132-135
Available from: http://www.saudisurgj.org/text.asp?2018/6/4/132/247413


Full Text

 Introduction



The postoperative period of bariatric surgical patients, and patients undergoing other upper gastrointestinal surgeries, is often punctuated with epigastric pain from the subxiphoid port. A 5-mm or a 10-mm liver retractor (fan retractor) is usually used to retract the liver. With the general shift toward being less invasive, the 10-mm retractor has been progressively replaced by the 5 mm retractor.

The 10-mm fan retractor has been used in our practice by the senior author since 1993. Patients often complain of severe pain in the epigastric port in the early postoperative period. This can confuse the immediate postoperative period, especially if accompanied by tachycardia, increasing the suspicion of a leak. We then shifted to the 5-mm fan retractor, but still encountered pain, limiting movement in a proportion of these patients. As a further extension, it was decided to use the Veress needle for liver retraction as it is frequently done for patients undergoing single-port laparoscopic surgeries. However, the Veress needle is neither long enough to retract larger livers nor strong enough to retract bulky livers. Moreover, the tip of the needle sometimes lacerates the capsule of the liver.

A V-suture over the crus of the diaphragm has been used in surgeries with a single port. However, this is technically challenging. Corrugated drain retraction of the left lobe of liver was also tried in a few patients undergoing surgeries with a single port. Both these methods require advanced skills and are not easily reproducible.

As an alternative, the core shaft of the dismantlable laparoscopic hand instruments, also known as the “insert,” was used for a 3-month period for all upper gastrointestinal surgeries. This has a diameter of about 2 mm, and as it is completely solid (and not hollow like the Veress needle), it is much stronger and can retract efficiently. Moreover, the nonactive tip of this shaft is like a ball [Figure 1], and it does not cause liver injuries. Bariatric surgeries (sleeve gastrectomy, Roux-en-Y gastric bypass [RYGB], and mini gastric bypass), antireflux surgeries, and Heller's cardiomyotomy were performed using this innovative liver retractor. There were 41 cases in all and we needed to convert only two, by inserting a 5-mm port. In both these cases, the liver was excessively fatty and the lower edge of the liver was seen beyond the greater curve of the stomach. We believe that it is possible to use this as a marker to decide on the type of retraction required. Both were the patients undergoing RYGB, and the liver retraction obtained by the insert was found to be insufficient. The only other problem encountered was a minor capsular liver tear in one patient. This instrument shaft retraction provides excellent liver retraction as an alternative to the conventional liver retractors [Figure 2].{Figure 1}{Figure 2}

 Patients and Methods



Over a 3-month period, all upper gastrointestinal laparoscopic surgeries, irrespective of gender or body mass index, were done with the liver retraction performed with the instrument shaft. There were 41 surgeries in all, which were mainly bariatric surgeries, antireflux surgeries, and Heller's myotomy [Table 1]. The endpoint of the study was to evaluate how robust this modified liver retraction was as a technique, and failure of the retractor was defined as a need to convert into a 5-mm or 10-mm liver retraction.{Table 1}

An “all-comers” approach was used for patients undergoing upper gastrointestinal laparoscopic surgeries, with no exclusion criteria. The central shaft of the dismantlable instruments is known as the insert. It consists of a solid cylindrical shaft, with a solid ball at one end and the jaws of various instruments at the other end. The ball clicks into a hollow receptor held by the handle of the laparoscopic instruments. This insert can be used with the ball tip end inserted into the abdomen and the jaws outside. After the camera port was inserted, a 2-mm incision was made with a size 11 blade in the subxiphoid region, the ball tip end of the instrument shaft was put in, the central tendon of the diaphragm was reached, and the insert was held against the same. Then, the ball was lifted upward to effect proper traction, predominantly of the left lobe of liver. The liver retraction was marked as unsuccessful if it was insufficient, and a 5-mm port had to be put in to apply a fan retractor.

 Results



Of the 41 patients operated in a 3-month period, 39 patients underwent successful liver retraction with the insert, without additional ports or change to 5-mm liver retractor. In two cases, both undergoing RYGB, who had enlarged fatty liver, and conversion into 5-mm metallic fan retractor was found to be necessary to complete the gastrojejunal anastomosis. In both these patients, the span of the liver extended to the greater curvature of the stomach, at the level of the crows foot. This laparoscopic sign may indicate the need for a conventional liver retraction. The robust shaft was found to effectively retract and hold up the left lobe of the liver in 39 cases, permitting safe and easy surgery. There were no adverse events attributable to insufficient liver retraction, like difficulty in freeing the short gastric vessels, or difficulty in right or left crural dissection, or difficulty in performance of the gastrojejunal anastomosis for the gastric bypass.

 Discussion



During laparoscopic upper gastrointestinal surgeries, the surgeon's intraoperative view is often obscured by the hypertrophic left lobe of the liver.[1] The use of a conventional liver retractor mandates an additional subxiphoid wound, results in pain and scar formation, in addition to the risk of iatrogenic liver injury during insertion of the retractor.[2]

Various liver suspension techniques have been described, involving advanced suturing skills. Huang et al. developed a technique of liver suspension called as V-LIST (V-shaped liver suspension technique) using a Penrose drain and laparoscopic stapler.[3] Mechanical retractors of various shapes and designs, like the Iron Intern™ and the fan and snake retractors, have been used in laparoscopic upper gastrointestinal and bariatric surgeries to retract the left lobe of the liver and to provide a proper view of the operative field.[4],[5] Sakaguchi et al. described a J-shaped retractor to lift the left lobe of the liver during the laparoscopic gastrectomy for gastric cancer, also using a drain and sutures.[6] Another simple suture technique to suspend the liver has been described by Roger et al., which requires an additional stab wound to place anchoring sutures over the anterior abdominal wall using a suture passer.[7] Shabbir et al. have reported a technique of combined retraction of both the left lobe of liver and the falciform ligament effectively using a suture retraction technique in laparoscopic total gastrectomy surgeries.[8] Another technique often used, especially in single-port fundoplication surgeries, is the Istanbul technique.[9]

Passing a suture to the crus of the diaphragm and bringing it out of the skin is another well-described technique, known as the crural sling.[10] However, it is difficult to perform in very fatty and enlarged livers. Any technique modification should have a dependable degree of reproducibility and only then it can stand the test of time. All of the above techniques, while being effective and avoiding a subxiphoid port, demand a high degree of technical expertise and can cause injuries. There have been reports of liver damage, leading to elevated liver function test values with the use of a Nathanson liver retractor in laparoscopic gastrectomy surgeries,[11] in addition to the often seen complication of a liver hematoma using the same. Some authors have reported the method of liver suspension with a suture-gauze technique safely.[12]

The dismantlable laparoscopic hand instruments are a useful addition to the surgeon's armamentarium. To establish good ergonomics, the shaft of these instruments needs to be of solid metal, and the tips blunt to engage the handle portion of the instrument [Figure 1]. At our center, after a few years of Veress needle retraction, it was decided to utilize these solid steel shafts to engage the left lobe of the liver for retraction during the performance of laparoscopic upper gastrointestinal surgery. In a way, one is improving the utilization of every part of the instrument to deliver effective laparoscopic surgery, with no additional cost. There were no significant liver injuries in our series, possibly because of the blunt tip. There was an insignificant failure of liver retraction, because of the solid steel and the length of the instrument. A visual analog scale for measurement of pain was not done, as this was merely a pilot study.

 Conclusion



This pilot study of a novel technique of liver retraction with the shaft of the dismantlable hand instruments indicates prima facie that it is effective. It is a safe and economical option. Liver retractors of 5 mm may perhaps only be required in the unusually large liver. Of 41 patients in the first 3 months of our study, 39 had successful liver retractions with this technique. It does not involve any extra cost or operative time and can be used by surgeons practicing laparoscopic upper gastrointestinal surgery, for the benefit of patients, as discomfort will certainly be less, compared to 5- or 10-mm ports.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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