Retraction Of Liver Research Articles

Arantius Ligament Suspension: A Novel Technique for Retraction of the Left Lateral Lobe Liver During Laparoscopic Isolated Caudate Lobectomy.

Laparoscopic isolated caudate lobectomy remains a challenging procedure because of its deep location and proximity to the important vessels. We present a novel technique, Arantius ligament suspension, which could improve operative field exposure in laparoscopic isolated caudate lobectomy through retraction of the left lateral lobe liver. The Arantius ligament suspension technique was performed in 6 selected patients during laparoscopic isolated caudate lobectomy in our center: 2 with symptomatic hepatic cavernous hemangioma and 4 with hepatocellular carcinoma (HCC). The Arantius ligament suspension technique was performed using a 2-0 polypropylene suture (Prolen2-0®; Ethicon, Somerville, NJ), which was secured to the Arantius ligament with surgical clips at its halfway point and the left lateral lobe of liver would be retracted toward the abdominal wall when the suture was tightened. Perioperative data of these patients and follow-up data of HCC patients were retrospectively reviewed. All 6 procedures were completed without conversion to open surgery or requiring additional ports. The mean tumor size was 5.4 cm (2.2-7.8 cm), the mean blood loss was 260 mL (50-440 mL), and no patients required blood transfusion during the operation. The mean time required for this technique was 2 minutes 5 seconds (1 minutes 36 seconds-2 minutes 44 seconds) and the mean duration of entire surgery was 249 minutes (173-300 minutes). The mean postoperative hospital stay was 7 days (5-9 days) and no postoperative complication related to the suspension procedure occurred. Our outcomes demonstrated the Arantius ligament suspension technique is a feasible and ideal method during laparoscopic isolated caudate lobectomy for providing a rapid and safe left lateral lobe retraction.

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

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.

腹腔鏡補助下胃切除術における肝圧排法の検討

目的：腹腔鏡補助下胃切除術（laparoscopy-assisted gastrectomy；以下，LAGと略記）時に行う肝圧排法の操作性と術後肝機能に及ぼす影響を明らかにする．対象と方法：当院で施行したLAG症例で，ペンローズドレーンによる挙上（以下，P法と略記）13例，屈曲型リトラクターによる圧排（以下，S法と略記）19例，Nathanson liver retractorによる圧排（以下，N法と略記）82例を対象とした．肝圧排の所要時間，術前，術後1，7日目のAlanine Aminotransferase（以下，ALTと略記）値を検討した．結果：肝圧排の所要時間は，P法14.1分，S法3.8分，N法2分で，N法はP法，S法それぞれと比較して有意に短時間で肝圧排が可能であった（p＜0.0001）．ALT値の推移は，3群とも術前より術後1日目には有意に上昇し，術後7日目には術後1日目に比較して有意に低下していた．術前値に対する術後1日目ALT値の変化率は，P法よりN法で有意に低値を示した（p=0.0071）．しかし，術後1日目ALT値について，200IU/l以上の症例は，P法では認めなかったが，S法，N法には，それぞれ4例（21.1%），7例（8.5%）認めた．結語：N法は速やかに肝圧排できる有益な方法ではあるが，術後肝機能障害に留意する必要がある．

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

With the advent of single-port laparoscopy, the spectrum of abdominal surgeries performed is widening. The retraction of the left lobe of the liver in the upper gastrointestinal procedures is a critical maneuver with its added possible complications. In our study, we used the Cerrahpasa retractor (trademark pending by E. Eyuboglu and T. Ipek) for the retraction of the left liver in 22 patients with a different concept other than using the suturing or silk lace techniques described in previous studies. 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 is being solved by a simple and safe technique.

Pure SILS Floppy Nissen Fundoplication with Hiatal Repair: A Case Report

Background. Single-incision laparoscopic surgery has recently became popular on behalf of inventing less invasive procedures. In this paper, we present a case of Pure SILS Nissen Fundoplication. Patient and Methods. In February 2010 a 29-year old male patient with a 4 cm sliding hiatus hernia presenting with reflux symptoms had undergone a standard floppy Nissen Fundoplication with a hiatus repair via single 2 cm incision in umbilicus. Results. The procedure had obeyed the standard natural orifice surgery rules, and no needlescopic assistance for any stage of the operation was used so to be a pure single-incision procedure. The operation lasted for 120 minutes without any need of conversion, and the patient was discharged the following day of operation. Conclusion. In the recent time, hybrid single incision laparoscopy techniques have been defined with the use of extra-abdominal supplements for retraction of liver or stomach for Nissen procedure. In addition the main issue in single-incision upper GI and/or hiatus surgery is still the retraction of liver. We succeeded to retract the left lobe of liver through the incision and completed the operation without any need for supplemental access besides the umbilical incision till the end. SILS Hiatus Surgery can be safely and effectively done but the issue needs further clinical studies to state the efficacy when compared to standard laparoscopy.

Single port access (SPA) cholecystectomy: two year follow-up.

Laparoscopy is a constantly evolving field of surgery. New technology, applications, and benefits prompt continual improvement. We have developed a Single Port Access (SPA) surgical technique that allows for the entire cholecystectomy to be performed through a single incision within the umbilicus while maintaining safe standard dissection and retraction techniques of currently performed multiport laparoscopic cholecystectomy. Fifteen consecutive patients underwent SPA cholecystectomy. Indications were cholelithiasis, cholecystitis, CBD stones, and biliary akinesia. The entire procedure was performed through a single umbilical incision measuring <1.8 cm within the umbilicus. Three trocars and a rigid grasper were inserted through separate fascial sites within the same skin incision. The cholecystectomy procedures are then performed in the standard fashion described in multi-port cholecystectomy. Fifteen patients successfully underwent Single Port Access cholecystectomy. One patient required a second 5-mm port site secondary to difficulty with retraction of a large liver. Operative times averaged 107 minutes. Blood loss, patient recovery, and outcomes have been comparable to those of standard multi-port procedures. No umbilical hernias have been seen at 2 years of follow-up. We present the SPA cholecystectomy as an alternative to multi-port cholecystectomy. In the first 2 years, SPA surgery has evolved into a technique easily taught and performed without the restrictions of new equipment or added cost.

A posterior lumbar approach for retroperitoneoscopic adrenalectomy: assessment of surgical efficacy.

To compare the efficacy of retroperitoneoscopic adrenalectomy by a posterior lumbar approach (RPA) with that obtained by a transperitoneal anterior approach (TAA) or retroperitoneal lateral flank approach (RLA). Fifty-one patients underwent endoscopic adrenalectomy by three approaches, including laparoscopic adrenalectomy by TAA in 33, retroperitoneoscopic adrenalectomy by RLA in 5, and retroperitoneoscopic adrenalectomy by RPA in 13. The average adrenal tumor size was 27 mm (range 8 to 65). The average number of trocars required for RPA was 3.2 which was significantly less than that for TAA and for RLA (4.2 and 4.1, respectively). The conversion rate to open surgery was 9.1% by TAA, 0% by RLA, and 7.7% by RPA. The average operating time for TAA was 252 minutes, which was significantly shortened to 194 minutes by RLA and 142 minutes by RPA (P < 0.02). The average blood loss was 101 mL for TAA and was negligible by RLA and RPA (22 and 32 mL. respectively). RPA allowed direct access to the main adrenal vascular supply before the gland was greatly manipulated. Endoscopic adrenalectomy by TAA or even by RLA required extra ports for retraction of liver, spleen, vena cava, or adrenal gland, with higher chance of vein avulsion. RPA was technically feasible and most effective for retroperitoneoscopic adrenalectomy in regard to the simplicity of vascular control. The operating time, perioperative morbidity, and cost were reduced with this approach.

CT of hepatic tumors: prevalence and specificity of retraction of the adjacent liver capsule.

The purpose of this study was to describe the CT features of capsular retraction of the liver adjacent to hepatic tumors and to test the hypothesis that this finding is specific for malignant hepatic tumors. We first retrospectively reviewed the CT scans of eight patients with pathologically proved malignant hepatic tumors (five secondary and three primary) who had CT scans that showed retraction of the overlying liver capsule. Then, using criteria developed from the first eight cases, we prospectively studied 253 patients with pathologically proved hepatic tumors (75 benign, 178 malignant) to determine the prevalence of retraction of the liver capsule shown by CT and the specificity of this finding for malignant hepatic tumors. CT scans in the first eight patients showed two types of capsular retraction. In seven patients, the retracted liver capsule was smooth and regular. In one patient, capsular retraction was associated with central ulceration extending to and eroding the liver capsule. Four of 253 patients studied prospectively had hepatic tumors with associated capsular retraction (prevalence, 2%). In those four cases, the retracted liver capsule was smooth and regular. All four tumors were malignant (one fibrolamellar hepatocellular carcinoma, two carcinoid tumors, one colorectal metastasis). Capsular retraction of the liver adjacent to hepatic tumors is an uncommon CT finding that appears to be specific for malignant hepatic tumors.