Single-Port Laparoscopic Floppy Nissen Fundoplication: A Novel Technique with the Aid of the Cerrahpasa Retractor®

Abstract

Introduction: The retraction of the left lobe of the liver in the laparoscopic upper gastrointestinal procedures is a critical maneuver with its added possible complications. In our study, we utilized the Cerrahpasa retractor® for the retraction of the left liver with a different concept other than utilizing a suturing or silk lace techniques described in previous studies. We present a video of a laparoscopic floppy Nissen fundoplication (LFNF) performed through a single port with the aid of the Cerrahpasa retractor. Materials and Methods: We performed single-port LFNF on 22 patients with symptomatic gastroesophageal reflux disease between September 2009 and April 2011. One 12-mm and two 5-mm trocars were utilized through the SILS™ (Covidien AG, Norwalk, CT) port. The next step was the introduction of a hand-made needle liver retractor (Cerrahpasa retractor, trademark pending), from the midline just below the xiphoid process. The retractor is composed of two parts: the head and the wire. The wire is introduced through a hand-made Seldinger-type needle. The head is introduced through the SILS port, and the two parts are mounted together intracorporeally. Main steps of the operation were dissection of the hepatogastric and Laimer's ligament, dissection and closure of the hiatus, and construction of the short, floppy Nissen fundoplication. The short gastric vessels were not divided. In our technique, we do not fix the fundoplication. Results and Conclusions: All the procedures were performed without any perioperative complications. The mean duration of the operations was initially 110 minutes (initial five operations) and reduced to 60 minutes (last five operations) throughout the 8-month period. No drains were used. The postoperative period was uneventful. All the patients were given oral fluids 12 hours postoperatively and discharged after 24 hours. On the basis of the short term of follow-up, there are no postoperative complications encountered. Until now, the procedures described for retraction in single-port surgery utilize more or less a suturing or silk lace techniques1–3 that potentially could tear the liver or other anatomical structures easily. Alternative technique utilizing anything other than suturing or silk lace technique was described by Gianni et al,4 where the authors used Veress needle for the retraction of the liver. A publication similar to our technique was reported by Cuesta et al5 in 2008. In their study authors performed transumbilical laparoscopic cholecystectomy with the aid of a 1-mm Kirschner wire. The wire was used for gallbladder traction. The Cerrahpasa retractor utilized in this study to elevate the liver was 1 mm in diameter and made of stainless steel. For the use of this needle-retractor, no additional trocar was employed. In our technique, the potential of tearing the liver or other anatomical structures is minimal. We believe that, with the aid of our Cerrahpasa retractor, the problem of liver retraction in single-port laparoscopic surgeries is being solved by a simple and safe technique. No competing financial interests exist. Runtime of video: 5 mins 30 secs The first three cases of this technique were presented in the 17th Turkish National Surgical Congress on May 26–29, 2010, in Ankara, Turkey. This technique is being presented in SAGES TV since SAGES Annual Meeting in San Antonio, TX, March 30–April 2, 2011.