Novel use of the Nathanson liver retractor to prevent postoperative transient liver dysfunction during laparoscopic gastrectomy

A silicone disc for liver retraction in laparoscopic gastrectomy reduces the postoperative increase in the liver enzyme level

PURPOSE

To compare changes in liver enzyme levels on postoperative day 1 between patients with and without silicone disc (SD) use during liver retraction in laparoscopic gastrectomy for gastric cancer and laparoscopic gastric mobilization for esophageal cancer.

METHODS

This prospective randomized controlled phase II trial was conducted between June 30, 2020, and November 30, 2022, to investigate the benefits of using an SD with a Nathanson liver retractor (NLR) compared with those using an NLR in laparoscopic gastrectomy and gastric mobilization. The primary endpoint was the change in transaminase level on postoperative day 1.

RESULTS

A total of 86 patients received randomized assignments and were included in the analysis, with 44 assigned to the SD (-) group and 42 to the SD (+) group. On postoperative day 1, the SD (+) group showed a significantly lower increase in the aspartate aminotransferase levels than the SD (-) group (SD [+], 94.4% vs. SD [-], 179.8%; p = 0.012). Similarly, the SD (+) group showed a significantly lower increase in alanine aminotransferase levels than the SD (-) group (SD [+], 71.6% vs. SD [-], 201.5%; p = 0.014).

CONCLUSION

In laparoscopic gastrectomy, the use of an SD combined with an NLR appears to mitigate postoperative liver dysfunction.

Application of a New Retraction Method in Laparoscopic Gastrectomy for Gastric Cancer

BACKGROUND

Better exposition is important for lymph node dissection in the suprapancreatic region and lesser curvature region of the stomach, and digestive tract reconstruction, especially without excellent assistants.

PATIENTS AND METHODS

We developed a new laparoscopic retraction method with the use of two internal retractors (TIRs) punctured along with suture. Clinicopathological data, surgical data, and postoperative outcomes were assessed.

RESULTS

Of the 143 patients included, 51 underwent surgery with the double-sling suture method and 92 underwent surgery with the TIRs method. Laparoscopic radical gastrectomy was successfully performed in all patients. There were no significant differences in patient characteristics or preoperative data in the 2 groups. The operative time was significantly shorter in the TIR group, but the amount of bleeding did not differ. No retraction-related complications both in clipped tissue and liver occurred in all patients.

CONCLUSIONS

Our new retraction technique provided an optimal surgical field and make surgery lower requirements for assistants.

Feasibility of Roux-en-Y Gastric Bypass with the novel robotic platform HUGO™ RAS

Introduction

Robotic assisted surgery is a rapidly developing field of minimally invasive bariatric surgery in the last 20 years. Its wide diffusion has led to the development and standardization of robotic assisted approaches for bariatric operations. In this study, we present the first four Roux-en-Y Gastric Bypass (RYGB) operations performed with the new Hugo™ RAS system (Medtronic, Minneapolis, MN, USA).

Methods

In January and February 2023, 4 consecutive patients scheduled for minimal invasive Roux-en-Y-Bypass were selected and underwent the procedure robotic-assisted with the new platform. No exclusion criteria were applied.

Results

Four patients, two females and two males, underwent RYGB with a median BMI of 40 Kg/m² (range: 36-46) and diabetes mellitus in two cases. The median docking time was 8 min (range: 7-8.5) and the median console time was 127.5 min (range: 95-150). A description of the operating theatre, robotic arms and docking setup is provided. Procedures were performed without intraoperative complications and no conversion to laparoscopy or open surgery was noted. No additional ports were needed to be placed. System's function and docking were uneventful. No early post-operative complications were observed.

Conclusions

Based on our initial experience, RYGB with the Hugo™ RAS system is feasible. This study provides the configurations necessary to perform RYGB with the Hugo™ RAS system as well as general information and insights from our preliminary experience.

A sandwiching method that simplifies hepatic left lateral segment inversion to secure an optimal surgical view around the esophageal hiatus in laparoscopic and robotic gastrectomy for upper gastric and esophagogastric junction cancers

PURPOSE

In laparoscopic surgery for upper gastric and esophagogastric junction (EGJ) cancer, it is important to achieve optimal exposure of the esophageal hiatus to secure an appropriate workspace. In recent years, hepatic left lateral segment (HLLS) inversion has been used to achieve an optimal surgical field. We present a simple technique to perform a modified HLLS inversion.

METHODS

As a simple modified method, suturing a 2-0 straight needle to the peritoneum of the round ligament and pulling it to the outside of the abdominal cavity, the falciform, left triangular, and coronary ligaments were dissected. The HLLS was inverted by moving it to the right through the space of the transected falciform ligament. By ligating the thread through the round ligament, the HLLS was sandwiched between the rest of the liver and abdominal wall. The short-term surgical outcomes of patient who underwent simple modified HLLS inversion were retrospectively reviewed.

RESULTS

This study investigated consecutive 24 patients who underwent laparoscopic proximal and total gastrectomies using the simple modified HLLS inversion technique between June 2021 and April 2022. This series of procedures could be completed in approximately 16 min. A Nathanson liver retractor was used in three patients due to difficulties in completing the HLLS inversion in our institution. Postoperative serum liver enzyme levels indicated there was a small effect on the liver.

CONCLUSIONS

The simple modified HLLS inversion technique may be a safe and useful procedure and can provide an enhanced surgical field during laparoscopic surgery for upper gastric and EGJ cancers.

Liver Dysfunction After Use of Nathanson Retractor During Laparoscopic Gastrectomy for Gastric Cancer

Background: Cardiopulmonary complications and liver dysfunction are also specific complications and problems associated with laparoscopic surgery. The main causes of postoperative liver dysfunction, which may often occur after laparoscopic surgery, include carbon dioxide pneumoperitoneum and ligation of the aberrant left hepatic artery. Hepatic steatosis may develop as a natural consequence of neoadjuvant therapy, although rarely, owing to chemotherapy. Nathanson retractor may cause a prolonged elevation in liver enzymes of these patients compared with those who do not receive neoadjuvant therapy. Materials and Methods: The data of 151 patients who underwent laparoscopic radical gastrectomy between January 2017 and January 2022 for histologically proven primary gastric cancer in our clinic were retrospectively reviewed. Results: The mean length of hospital stay was 6.21 days. The mean time normalization of the aspartate aminotransferase (AST) value was 2.45 ± 1.83 (range, 0-12) days postoperatively. The analysis of the correlation between the preoperative and postoperative 1-day values of alanine aminotransferase (ALT) and AST revealed a significant difference between the preoperative and postoperative 1-day median values of both parameters (P < .001). Each one unit increase in ALT led to an increase of 0.338 days in the length of intensive care stay and an increase of 0.345 days in the overall length of hospital stay. As the time to normalization of the AST value increased, the length of both intensive care stay and hospital stay increased. Each one unit increase in AST resulted in an increase of 0.316 days in the length of intensive care stay and an increase of 0.376 days in the overall length of hospital stay. Conclusion: Alternative retraction methods can be used safely in laparoscopic surgery for gastric cancer patients receiving neoadjuvant therapy. We are of the opinion that the Nathanson retractor should be used only during dissection of the relevant regions to shorten the intraoperative intermittent release or the time of use.

Laparoscopic distal gastrectomy for gastric cancer in a patient with situs inversus: a case report

Background

Situs inversus (SI) is a rare congenital condition characterized by organ transposition from their normal positions. Careful preoperative planning is important for the safe operation of patients with SI because only a few surgeons have operated on such patients. Here, we report the case of a patient with SI who underwent laparoscopic distal gastrectomy (LDG) with D2 lymph node dissection (LND) for advanced gastric cancer (GC).

Case presentation

The patient was a 72-year-old man diagnosed with GC. Upper endoscopy revealed a type 3 tumor in the anterior wall of the stomach body. Multidetector computed tomography showed no obvious GC metastasis or inverted organs. The preoperative diagnosis was cStage IIB (i.e., cT3, cN0, and cM0) GC with SI. Although liver retracting and intracorporeal suturing required special attention, LDG with D2 LND and Billroth-I reconstruction were safely performed by reversing the usual procedure. The patient was discharged 10 days after the surgery.

Conclusions

To safely perform laparoscopic surgery for GC in patients with SI, sufficient preoperative preparation is necessary. In particular, a reversible method of liver retraction should be prepared.

Risk Factors for Postoperative Liver Enzyme Elevation After Laparoscopic Gastrectomy for Gastric Cancer

BACKGROUND/AIM

Laparoscopic gastrectomy (LG) is more frequently associated with postoperative liver enzyme elevation (PLEE) than open gastrectomy in phase III clinical trials for Japanese gastric cancer patients. The aim of this study was to determine the risk factors for PLEE after LG for gastric cancer.

PATIENTS AND METHODS

This study enrolled 153 consecutive patients with gastric cancer who underwent LG. The patient characteristics, the liver retraction method [silicone disc (SD) or Nathanson liver retractor (NLR)], and perioperative outcomes were compared between patients with and without PLEE.

RESULTS

PLEE was observed in 26 patients (17%). The patients with PLEE exhibited longer operative times (p=0.005) and more frequent use of the NLR for liver retraction (p=0.022). In the multivariate analysis, liver retraction using the NLR (p=0.003) and aberrant left hepatic artery (ALHA) ligation (p=0.042) were independent risk factors of PLEE.

CONCLUSION

Liver retraction with the SD during LG was shown to be the safer method that is less likely to cause postoperative liver dysfunction. ALHA preservation may contribute to avoiding postoperative liver dysfunction.

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 use of the Nathanson liver retractor to prevent postoperative transient liver dysfunction during laparoscopic gastrectomy

INTRODUCTION

The Nathanson liver retractor (N) has been known to cause postoperative transient liver dysfunction (POTLD) in laparoscopic gastrectomy (LG). To reduce the incidence of POTLD, specifically we added to the retractor the use of a disk (N + D) to reduce the localized pressure, and furthermore repositioned the retractor every 30 minutes (N + D TM) to reduce the liver retraction time. Before and after introducing this retractor, we assessed four consecutive retraction procedures. These included the following disk suspension methods (D), N, N + D, and N + D TM.

METHODS

We retrospectively enrolled 85 patients who underwent an LG. In the D, N, N + D, and N + D TM groups, we evaluated the postoperative serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values.

RESULTS

For the D and N groups, the AST value significantly increased from the immediate post-operation time point (IPOT) to the third postoperative day (POD3). Additionally, the ALT value increased from IPOT to POD7. In the N + D group, the only decrease was in the ALT value at IPOT compared to the N group. The N + D TM group decreased in both the AST value from IPOT to POD3 and in the ALT value from IPOT to POD7, compared to the N group.

CONCLUSIONS

Our findings demonstrate the importance of reducing both the localized pressure and liver retraction time when using the Nathanson retractor to prevent POTLD during an LG. To make this possible, we successfully introduced the use of both a disk and the repositioning of the retractor at 30 minute intervals.