Randomized controlled trial comparing three methods of liver retraction in laparoscopic Roux-en-Y gastric bypass

American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass

BACKGROUND

Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU).

METHODS

PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee.

RESULTS

Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures.

CONCLUSIONS

This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.

Elastic Intra-corporeal Retractor for Bariatric and Upper Gastrointestinal Surgery

INTRODUCTION

In minimally invasive upper gastrointestinal and bariatric surgery, proper organ retraction, especially liver retraction, is essential to achieve better per-operative precision and safety. Most currently used methods require specific material which might not be available in all hospitals. We introduce an easily reproducible low-cost trocar-less elastic intra-corporeal retractor (ICR).

MATERIALS AND METHODS

ICR was created then used in two institutions where around 500 upper gastrointestinal and bariatric procedures are jointly performed yearly. Its design and application require an elastic rubber band, three staples, and a needle holder. For liver retraction, ICR is anchored to the right diaphragmatic crus and the anterior abdominal wall, creating a triangular shaped retractor.

RESULTS

ICR requires around 2-3 min for application and can be easily repositioned for adequate exposure. Its trocar-less and intra-corporeal characteristics offer the advantage of decreasing the risk of bleeding, infection, and liver injury accompanying additional trocars, transcutaneous punctures and conventional retractors.

CONCLUSION

ICR is a safe, effective, inexpensive, and easily reproducible intra-corporeal organ retractor which can be used in both laparoscopic and robotic bariatric surgery.

CT characterization of retractor related liver injuries after pancreaticoduodenectomy: Retrospective analysis of a single institution experience

PURPOSE

Retractor related liver injuries (RRLI) are reported after upper gastrointestinal tract surgeries; most commonly laparoscopic cholecystectomy and gastric surgeries. The aim of this study was to characterize the incidence, identification, type, severity, clinical features and risk factors for RRLI after open and robotic pancreaticoduodenectomy.

METHODS

A 6-year retrospective study of 230 patients was performed. Clinical data was extracted from the electronic medical record. Post-operative imaging was reviewed and graded using the American Association for the Surgery of Trauma (AAST) liver injury scale.

RESULTS

109 patients met eligibility criteria. RRLI occurred in 23/109 (21.1%), with a higher incidence in the robotic/combinedapproach (4/9) compared with open (19/100). Most common injury was an intraparenchymal hematoma (56.5%), grade II (78.3%), located in segments II/III (77%). 39.1% of injuries were not reported on the CT interpretation. There was a statistically significant elevation of postoperative AST/ALT in the RRLI group [median AST 219.5 vs. 72.0 (p < 0.001), ALT 203.0 vs. 69.0 (p < 0.001)]. Trends toward lower preoperative platelet counts and longer operations were observed in the RRLI group. No significant difference in hospital length of stay or post-operative pain scores were noted.

CONCLUSION

RRLI occurred frequently after pancreaticoduodenectomy, however most injuries were low grade and the only clinical significance was a transient increase in transaminases. A trend toward higher injury rates was observed in robotic cases. In this population, RRLI was often unrecognized on postoperative imaging.

Is It Possible to Estimate the Liver Left Lobe Volume Using Preoperative Data Before Bariatric Surgery?

PURPOSE

Retraction of the left lobe of the liver (LLL) is an important step in bariatric surgical procedures. A good liver retraction will both facilitate the operation and reduce complications. The aim of the study is to identify patients with large LLL with preoperative anthropometric and laboratory data, and to reveal complications due to large LLL.

MATERIALS AND METHODS

The data of 245 patients who underwent bariatric surgery in our department between April 2019 and March 2021 were retrospectively analyzed. The patients were divided into two groups according to the visibility of the caudate lobe of the liver, the left diaphragmatic artery-vein, and the fat pad on the esophagus after liver retraction.

RESULTS

Univariate analyses revealed significant differences in BMI, waist and hip circumferences, TG, DM, and HbA1c values, but only BMI (p = 0.001) and the presence of DM (p = 0.017) were found to be independent predictors of LLL size. BMI ≥ 42.1 kg/m² indicates the size of LLL with 83% sensitivity and 49% specificity. Retractor-related complications were significantly higher in the large LLL group (p = 0.036). There was no difference between the two groups in terms of complications related to trocar insertion (p = 0.014) and postoperative liver enzyme levels (p = 0.714). The operation time (laparoscopic sleeve gastrectomy [LSG]; p = 0.021) (laparoscopic Roux-N-Y gastric bypass [LRYGB]; p = 0.020) and the amount of bleeding (LSG; p < 0.001) (LRYGB; p = 0.011) are higher in patients with large LLL.

CONCLUSION

Large LLL can be predicted and complications may be reduced with the help of preoperative data.

Comparison of the Pretzelflex Retractor and Nathanson Retractor in Laparoscopic Sleeve Gastrectomy Surgery

PURPOSE

Retraction of the left lobe of the liver is an important step in most bariatric surgical procedures. The left lobe of the liver may be enlarged, and laceration, hematoma, or necrosis may develop in the liver due to retraction. In this study, the results of use of the Nathanson retractor (NR) and PretzelFlex retractor (PFR) in the patients undergoing laparoscopic sleeve gastrectomy (LSG) were compared.

MATERIALS AND METHODS

The patients who underwent LSG were divided into three groups based on the type of liver retraction device used. Group 1: NR was used fixed during the operation; Group 2: PF retractor was used; Group 3: NR were used only for fundus dissection and when necessary. All groups were evaluated in terms of demographic characteristics, liver function tests, and developing complications.

RESULTS

The study was conducted with a total of 120 consecutive patients. Operation time in the second group was found to be significantly lower than the other two groups (p = 0.009; p = 0.001; p < 0.01). The duration of retractor use in the first group was significantly higher than the other two groups (p = 0.001; p = 0.001; p < 0.01). While aspartate aminotransferase (AST) values were found to be high in Group 1, alanine aminotransferase (ALT) values were found to be high in Groups 1 and 3.

CONCLUSION

PFR has shorter operating and retraction times. It causes less measurable liver damage. Although the NR will be used, intermittent use causes less damage to the liver as in PFR.

TÉCNICA DE EXPOSIÇÃO DA JUNÇÃO ESOFAGOGÁSTRICA OBTIDA POR MEIO DE AFASTADOR FLEXÍVEL DE FÍGADO EM CIRURGIA BARIÁTRICA: ENSAIO CLÍNICO RANDOMIZADO

In the Roux-en-Y gastric bypass technique, classic laparoscopic surgical retractors are usually rigid, require an additional incision for its installation, or must be handled by an assistant during the surgical procedure, involving a risk of liver injury.

Iatrogenic hepatic granuloma (suspected liver metastatic lesion on imaging) caused by liver retraction during laparoscopic gastrectomy: A case report

There are no previous reports of hepatic granuloma secondary to intraoperative liver retraction. Using softer hepatic retraction instruments and keeping hepatic retraction time to a minimum are vital in preventing postoperative liver damage.

K-Wire Retractor, a Trocar-Free Liver Retraction Technique in Bariatric Surgery

BACKGROUND

Liver retractor helps in the provision of an adequate operative field in bariatric surgery. Though several retractors have been introduced, an optimal retraction method is yet to be desired. We have developed a K-wire retractor, a simple trocar-free liver retractor used in our bariatric surgery. The efficacy and safety of the K-wire retractor were examined.

METHODS

A retrospective review was performed on patients undergoing laparoscopic bariatric surgery from January 2016 to April 2019. Based on the application of liver retractors during surgery, patients were divided into the K-wire retractor group and the suture-based retractor group for comparative analyses. Patients with severe liver injury or missing data, or treated with other types of retractors were excluded.

RESULTS

A total of 317 patients were included in our study and there was no conversion to open surgery. There were no significant differences in patient demographics (age, gender, BMI) and types of bariatric surgery between the two groups. The time taken for placement of retractor was significantly shorter in the K-wire retractor group, in addition to higher operative view score and lesser ALT/AST elevation compared with the suture-based retractor group. Although the K-wire retractor group was less inclined to require additional retraction techniques, patients with BMI ≥ 50 Kg/m² were associated with higher risk (OR:3.8; 95% CI: 1.2, 12.8) of requiring additional retractors. There were no severe K-wire retractor-related complications observed.

CONCLUSION

The trocar-free K-wire liver retractor is safe, simple, and effective as a standard liver retraction method in bariatric surgery.

Novel Trocar-Free Elastic Liver Retractor in Bariatric Surgery Patients: Comparison of a Standard Laparoscopic Retraction With the First Series Using the LiVac Sling System

During upper gastrointestinal surgery, retraction of the liver plays an essential role in the visualization and creation of an optimal surgical field. Liver retraction may be problematic, particularly in obese patients. The use of conventional liver retractors requires additional skin incision and has the potential to cause pain as well as liver injuries. The present study is the first to evaluate the performance and safety of the LiVac Sling (Livac Pty Ltd, Melbourne, Australia) trocar-free retractor system in bariatric surgery patients. In this retrospective study, data from laparoscopic primary or revisional bariatric surgeries that were performed with the LiVac Sling system and a standard retractor between May 2017 and December 2017 were collected. Demographic data, body mass index, type of surgery, number and indication of LiVac Sling system used, surgery time, and complications were analyzed. In total, 51 procedures were included. Twenty Sling devices have been used in 17 patients (13 female; 75%). The distribution of baseline characteristics was similar between the standard retractor group and LiVac Sling retractor group. In the LiVac Sling group, the number of trocars used was significantly reduced over the study period. Within 30 days postoperatively, no complications could be identified, and no device-related adverse events were reported. In this bariatric population, the use of the LiVac Sling for liver retraction was safe. No device-related adverse events were registered, and compared with standard retraction, the number of trocars used could be reduced by one.

Comparison of Two Types of Liver Retractors in Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

BACKGROUND

Retraction of the left lobe of the liver is an important step in most bariatric surgical procedures. Bariatric patients may have enlarged, fatty livers and retraction can be complicated with injuries, haematoma, or necrosis. The aim of this study was to compare the effects of two standard liver retractors, Nathanson and PretzelFlex on patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

All consecutive patients undergoing LRYGB in our center from April 2017 to January 2019 were analysed. The type of retractor used was dependent on the surgeon's preference and the availability of instruments. Patients were divided into two groups, based on the type of liver retraction device used. Each group was assessed and compared for postoperative pain score, presence of nausea or vomiting, blood test results (liver function tests and C-reactive protein), and length of hospital stay.

RESULTS

LRYGB was performed on 167 patients in which Nathanson was used in 93 patients and PretzelFlex in 74 patients. The duration of surgery was similar in both groups. Alanine transaminase (ALT) levels and C-reactive protein (CRP) were significantly higher in the group where Nathanson's retractor was used. The postoperative pain score and length of stay were also higher when Nathanson's retractor was used but it did not reach statistical significance.

CONCLUSION

The PretzelFlex liver retractor causes significantly less measurable liver damage and is associated with less postoperative pain and nausea when compared with Nathanson's retractor.

Low-Cost Incisionless Liver Retraction for Laparoscopic Sleeve Gastrectomy: A Prospective Controlled Trial

Background: Laparoscopic bariatric surgery has been performed safely since 1991. In a persistent search for fewer and smaller scars, single port, needlescopic surgery, and other approaches have been implemented. Our goal was to analyze the safety and feasibility of using incisionless autostatic liver retraction for sleeve gastrectomy. Materials and Methods: Candidates for sleeve gastrectomy were selected, excluding those <18 and having had prior upper left quadrant surgery. Patients were randomized 1:1 to either a standard five-port technique with a fan-type liver retractor (Group A); or a four-port technique with the liver retracted using a polypropylene 1 suture passed through the right crura and retrieved at the epigastrium employing a fascial closure needle (Group B). All surgeries were performed by the same surgeon. The primary endpoint was surgery duration. Secondary outcomes were quality of surgical-field visualization, complications inherent to liver retraction, and postoperative morbidity. Results: One hundred patients were recruited (n = 50/group). The groups (both 90% females) were demographically and anthropomorphically comparable. Surgery duration was 30.4 ± 4.6 and 29.6 ± 4.7 minutes for Groups A and B, respectively (P = .41). Visualization was considered very good in 80% versus 82%, good in 16% versus 12%, and poor in 4% versus 6% (P = NS). Two patients from each group (4%) had self-limited minor bleeding from the liver attributed to the retraction technique. No 30-day morbidity was observed. Conclusions: Liver retraction using a polypropylene suture was both effective and inexpensive. Visualization and the duration of surgery were comparable to a standard liver retractor. This low-cost alternative may diminish the need for expensive instruments and reduce the number of scars without jeopardizing the safety and quality of sleeve gastrectomy.

Hepatic retractor in an ex vivo model1

PURPOSE

To discuss the use of models of hepatic retraction by laparoscopy, to present a new Hepatic Retractor (HR) and to evaluate its practicality, efficacy and safety in Esophageal Hiatus Exposure (EHE).

METHODS

Experimental cross - sectional study with a quantitative character. It was carried out in the Laboratory of Health Training of Christus University Center. The sample consisted of 12 livers of adult pigs weighing between 30 and 45 kg. A circular-shaped HR, 5 cm diameter and deformable materials was developed with a polypropylene cloth, metallic guide wire, epidural needle plastic guide and nylon string. The practicality of HR management was measured by the time required to use the instrument, efficacy by exposure to the operative field and safety by macroscopic assessment of liver damage.

RESULTS

The average time to complete the procedure was 3.24 minutes and reached less than 2 minutes after 12 repetitions. In eight experiments the maximum degree of EHE was obtained. No macroscopic lesions were observed.

CONCLUSION

The use of HR described can broaden the operative field, without causing macroscopic liver lesions and prolonging the surgical time.

Atraumatic Liver Retraction Using Nelaton Catheters During Totally Laparoscopic Gastrectomy

This study introduces a novel technique for liver retraction during laparoscopic gastrectomy and assesses its impact on postoperative recovery. This study included 139 patients in whom Nelaton catheters (n=57) or Nathanson retractors (n=82) were used for liver retraction. Serum liver enzyme levels were measured preoperatively and on the first, second, third, fifth, and seventh postoperative days. Clinicopathologic features and postoperative recovery variables between the 2 groups were compared. The aspartate aminotransferase, alanine aminotransferase, and C-reactive protein levels were significantly lower (P<0.001, P<0.001, and P=0.007, respectively), and the day of first flatus, the day of initiating a soft diet, and the length of hospital stay were shorter in the Nelaton catheter U-shaped retractor group than those seen in the Nathanson retractor group (P=0.035, P=0.002, and P=0.024, respectively). Atraumatic liver retraction with Nelaton catheters is recommended in laparoscopic gastrectomy.

Intra-abdominal Trocar-Free Vacuum Liver Retractor for Upper-Gastrointestinal Surgery

Background. In laparoscopic upper-gastrointestinal (GI) surgery, an adequate retraction of the liver is crucial. Especially in single-port surgery and obese patients, problems may occur during liver retraction. The current study seeks to evaluate the efficacy and safety of the LiVac trocar-free liver retractor in laparoscopic upper-GI surgery. Methods. The present study is a nonrandomized dual-center clinical series describing our preliminary results using the LiVac system for liver retraction. The primary end points of the present study included the effectiveness and safety of the LiVac device as well as complications and documentation of problems with the device during surgery. Results. The device was used in 11 patients for simple and complex laparoscopic procedures. The mean age of the study population was 59.6 years (SD = 20.6; range = 30-84). There were 6 female and 5 male patients with a mean body mass index (BMI) of 31.9 kg/m2 (SD = 8.1; range = 26.0-45.3). The efficacy of the device was excellent in all cases, reducing the number of trocars needed. There were no device-related complications. Conclusion. The LiVac liver retractor is easy to use and provides a good exposure of the operative field in upper-GI laparoscopic surgery, even in obese patients with a high BMI.

A percutaneous technique of liver retraction in laparoscopic bariatric & upper abdominal surgery

BACKGROUND

Laparoscopic bariatric surgery requires retraction of the left lobe of the liver to provide adequate exposure of the hiatus and the stomach. Currently used approaches utilize retractors that require additional incisions and prolong operative time.

OBJECTIVES

A retrospective evaluation of the efficacy and safety of a percutaneous liver retractor in a large series of patients undergoing laparoscopic bariatric surgery.

SETTING

Private practice, United States.

METHODS

A retrospective chart review was performed on 2601 patients undergoing bariatric surgery from January 2011 to September 2015. A percutaneously introduced grasper (Teleflex MiniLap Percutaneous Surgical System, Morrisville, NC) was used to retract the left lobe of the liver in all cases. The retractor could be repositioned as necessary by releasing and regrasping the diaphragm at different locations.

RESULTS

This technique was used in 2601 patients from January 2011 until September 2015. The average body mass index was 43.1 (range: 20.6-80.3). In all patients, this new method was found to be satisfactory to complete the bariatric procedure. The majority of procedures included laparoscopic Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric band placement. No intraoperative liver injuries occurred with use of the Teleflex retractor.

CONCLUSION

Percutaneous retraction of the liver using the Teleflex MiniLap Percutaneous Surgical System was found to be safe and effective in this large series of morbidly obese patients. The rate of complications involving this technique is extremely low. This novel method provides safe and effective retraction with less trauma and better cosmesis than conventional technique.

Systematic Review of Retraction Devices for Laparoscopic Surgery

Background. Retraction plays a vital role in optimizing the field of vision in minimal-access surgery. As such, a number of devices have been marketed to aid the surgeon in laparoscopic retraction. This systematic review explores the advantages and disadvantages of the different instruments in order to aid surgeons and their institutions in selecting the appropriate device. Primary outcome measures include operation time, length of stay, use of staff, patient morbidity, ease of use, conversion rates to open surgery, and cost. Methods. Systematic literature searches were performed in MEDLINE, EMBASE, The Cochrane Library, Current Controlled Trials, and ClinicalTrials.gov. The search strategy focused on studies testing a retraction device. The selection process was based on a predefined set of inclusion and exclusion criteria. Data were then extracted and analyzed. Results. Out of 1360 papers initially retrieved, 12 articles were selected for data extraction and analysis. A total of 10 instruments or techniques were tested. Devices included the Nathanson’s liver retractor, liver suspension tape, the V-List technique, a silicone disk with or without a snake retractor, the Endoloop, the Endograb, a magnetic retractor, the VaroLift, a laparoscope holder, and a retraction sponge. None of the instruments reported were associated with increased morbidity. No studies found increased rates of conversion to open surgery. All articles reported that the tested instruments might spare the use of an assistant during the procedure. It was not possible to determine the impact on length of stay or operation time. Conclusions. Each analyzed device facilitates retraction, providing a good field of view while allowing reduced staff numbers and minimal patient morbidity. Due to economic and environmental advantages, reusable devices may be preferable to disposable instruments, although the choice must be primarily based on clinical judgement.

A Simple Method of Liver Retraction for Various Types of Laparoscopic Upper Gastrointestinal Surgeries: The Prolene Hanging-Up Method

This study describes a safe and the simple method for liver retraction during various types of laparoscopic upper gastrointestinal surgeries. The technique was performed using only a 75 cm 2-0 prolene suture, which was passed through the abdominal wall with a straight needle at the two points of the epigastrium and at the pars condensa of the gastrohepatic ligament without any protective material or knotting. Seventy-six patients who underwent various types of laparoscopic upper gastrointestinal surgeries from August, 2012 to March, 2013 at Incheon St. Mary's Hospital were included in the study. The mean time for the liver retraction was 2.7 ± 0.6 min. Among the 76 cases, complication of this method was one case of the puncture site bleeding on the abdominal wall. The mean levels of alanine aminotransferase and aspartate aminotransferase on the day of the surgery were 54.9 ± 26.3 U/L and 45.2 ± 23.1 U/L, respectively, and these had decreased to 22.4 ± 13.2 U/L and 21.8 ± 14.0 U/L, respectively, on the fourth postoperative day. The prolene hanging-up method is very simple and safe, and it can be used in various types of laparoscopic upper gastrointestinal surgeries.