An original technique of liver retraction in laparoscopic esophagogastric surgery

Adequate exposure enables an operation to be performed safely and with precision. In most of the upper abdominal operations, good retraction of the hepatic lobe is necessary. A simple, effective and inexpensive method of liver retraction is clearly described in this video. We apply a hand-made liver retractor for access and visualization particularly around lesser curve and esophageal hiatus. A 17cm long and 6mm large penrose drain is used. Our hand-made drain is prepared preoperatively by fixing 3 heavy ties along its length. The middle tie is passed superiorly through a dissected gap in the left triangular ligament while the other ties are separated laterally for retraction of the left lobe of liver. Fine adjustments are made to achieve adequate exposure of the lesser curve and diaphragmatic hiatus.

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An original technique of liver retraction in laparoscopic esophagogastric surgery

Authors

Abstract

Adequate exposure enables an operation to be performed safely and with precision. In most of the upper abdominal operations, good retraction of the hepatic lobe is necessary. A simple, effective and inexpensive method of liver retraction is clearly described in this video. We apply a hand-made liver retractor for access and visualization particularly around lesser curve and esophageal hiatus. A 17cm long and 6mm large penrose drain is used. Our hand-made drain is prepared preoperatively by fixing 3 heavy ties along its length. The middle tie is passed superiorly through a dissected gap in the left triangular ligament while the other ties are separated laterally for retraction of the left lobe of liver.
Fine adjustments are made to achieve adequate exposure of the lesser curve and diaphragmatic hiatus.

Classification

tips and tricks

Keywords

Laparoscopic liver retraction approach for esophagogastric procedure

Media type

Surgical video

Duration

06'20''

Publication

2009-11

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E-publication

WeBSurg.com, Nov 2009;9(11).
URL: http://www.websurg.com/doi-vd01en2793.htm

An original technique of liver retraction in laparoscopic esophagogastric surgery

1. Introduction 00'19''

At our unit, we use a hand-made liver retractor for access and visualization, particularly around the lesser curve and the esophageal hiatus.

2. Laparoscopic exploration 00'33''

Following initial laparoscopic inspection of the abdominal cavity and confirmation of the position of the marking tattoo that should be close to a primary tumor, a liver retractor is inserted for access and visualization particularly around the lesser curve.

3. Introduction of the hand-made retractor 00'50''

We use a Penrose drain of 6mm width and 17cm in length. Our hand-made drain is prepared preoperatively by fixing 3 heavy ties along its length. Namely, the middle portion is fixed by a heavy tie with a black silk and one tip that is 11cm apart from the middle is fixed with a white silk and another tip that is 6cm from the middle is fixed with a stained silk.

4. Incision of the left triangular ligament 01'20''

At first, an incision is made on the superior leaf of the left triangular ligament above the left lobe of the liver with either LCS (Laparoscopic Coagulation Shears) or the Opti 2 while the assistants hold down the liver to apply tension. And also a space is created behind between the liver and the diaphragm with LCS for passage of the middle part of the Penrose drain.

5. Introduction of the retractor 02'30''

The Penrose drain with the black tie is passed from beneath mounted on a curved Karl Storz grasper facing upwards so that the Penrose drain becomes visible from above. The middle tie is passed superiorly through a dissected gap in the left triangular ligament while the other ties are separated laterally for retraction of the left lobe of liver. Occasionally, especially with a large left lobe of liver, the Penrose drain cannot be passed easily and it is necessary to secure the black tie onto the tip of an Endo-mini retractor to help place the drain in position. Let me show you the case for which we use an Endo-mini retractor. As usual, the incision is made on the superior leaf of the left triangular ligament above the left lobe of the liver with either LCS (Laparoscopic Coagulation Shears) or the Opti 2 while the assistants hold down the liver to apply tension.

6. Endo-mini retractor introduction 03'42''

The tip of an Endo-mini retractor where the black tie is secured is passed through the dissected hole of the left triangular ligament to lift the middle portion of the Penrose drain upward. Once the middle portion is delivered above the liver, the white tie is brought to the right and the dye-stained tie to the left for the desired configuration. Three small punctures are made in the epigastric skin with the number 11 blade for suture retrieval with the EndoClose™.

7. Endo-close insertion 05'06''

The EndoClose™ is inserted in the middle hole and its correct entry just to the left of the falciform ligament is confirmed from the inside. The black tie is grasped with the EndoClose™ and brought out to the skin where it is clipped with a mosquito clip. The white tie is then grasped from the right side skin hole and similarly the dye-stained tie from the left side skin hole and the ties are pulled laterally for retraction of the left lobe of the liver. Fine adjustments are made to achieve adequate exposure of the lesser curve and diaphragmatic hiatus and the ties are tightened to lift the liver against the anterior abdominal wall. Ties are usually tightened in the order of white tie, dye-stained tie and finally the black tie to complete the liver retraction.