BACKGROUND: A sufficient operative field and an adequate working space are critical factors that determine the success of laparoscopic surgery. Although some liver lifting methods have been reported, insufficient operative field, liver disfunction, and risk of liver laceration, particularly for obese patients, have been serious problems. We have developed a novel and safe technique that retract the liver and falciform ligaments simultaneously using a Silicon Disk (Hakko, Japan), a snake retractor, and an elastic band. Silicon Disk was originally developed as an endoscopic surgery device that displaces the lung during thoracoscopic esophageal surgery. This product has a flexible frame, silicon membrane, and smooth leaf shape. We performed this new method for gastric cancer patients during laparoscopic gastrectomy and evaluated its feasibility and effects on the liver function.
PATIENTS AND METHODS: 36 patients with gastric cancer were divided into two groups: Disk Suspension group (DS group: snake retractor and elastic band fixation with Silicon Disk) and Fixed Retractor group (FR group: snake retractor and nonelastic band fixation without Silicon Disk). 25 cases of laparoscopic distal gastrectomy and 11 cases of laparoscopic total gastrectomy were performed under general anesthesia. Snake retractor was inserted from 5-mm trocar which was placed at the right side of the xiphoid process, and lifted up the lateral segment of the liver with or without Silicon Disk. The falciform ligament was lifted up with a shaft of the snake retractor. Elastic or nonelastic band was applied to support the shaft of snake retractor. To evaluate the effects on liver function, Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were measured preoperatively and on post-operative day 1.
RESULTS: In DS group, all livers were adequately retracted and hepatoduodenal and gastrohepatic ligaments were fully exposed from the porta hepatis to the esophageal hiatus. As the elastic band works as a suspension, the snake retractor continues moving which synchronized with heart beat and diaphragm movement, and it decreases a pressure to the liver and prevent congestion. This procedure took less than three minutes. On the other hand, five of 18 cases in the FR group showed insufficient surgical field during laparoscopic gastrectomy. These five cases had soft and/or large liver. Although pre-operative AST and ALT levels were not significally different between two groups, both AST and ALT levels in FR group were significantly increased on post-operative day 1 compare to DS group (124.2 ± 37.7 IU/L vs. 50.2 ± 8.4 IU/L, p = 0.07 for AST, 106.1 ± 36.2 IU/L vs. 35.6 ± 6.4 IU/L, p=0.07 for ALT). No complications regarding liver retraction was observed in DS group, but six cases of liver congestion and two cases of minor liver injury during the suturing of esophagojejunostomy were seen in FR group.
CONCLUSION: DS method is a simple method that provides a better surgical field during laparoscopic surgery for upper abdomen without damaging the liver. This method would be helpful not only in laparoscopic gastrectomy, but also in bariatric surgery, since it is applicable even for patients with large and heavy livers.
Session: Video Channel
Program Number: V052
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