Lauren B Mashaud, MD, Angel Caban, MD, Daniel J Scott, MD. Johns Hopkins University, University of Florida, UT Southwestern Medical Center
Introduction: Technology and methods for liver retraction during Single Incision Laparoscopic Surgery (SILS) are lacking. The purpose of this study was to develop and refine methods for intracorporeal liver retraction during SILS Adjustable Gastric Band (AGB) placement.
Methods: SILS AGB (a single incision for insertion of all laparoscopic instruments) was performed in 24 patients. A transumbilical approach was feasible in 16 patients whereas a left upper quadrant approach was required in 8 patients (severe truncal obesity). Three ports (5mm x 2; 12mm x 1) were placed within the single access incision. The liver was internally suspended using suture (n=15, 2-0 polyester Endostitch) or retraction hooks (n=9, 6-12cm length). For the initial suture technique (n=3), a single bite of the diaphragm was taken and 3 suture tails with (n=2) or without umbilical tapes were percutaneously retrieved. In the next 12 cases, a single 48″ suture was used to place alternating bites (5-7) in the peritoneum and diaphragm with knots tied intracorporeally. In the next 9 cases, 2 to 3 pairs of double-armed retraction hooks connected by rubber tubing were placed between the diaphragm and peritoneum to suspend the liver. A 5mm 300 or 450 rigid laparoscope was used for visualization and straight and articulating instruments were used for dissection and AGB placement, as previously described.
Results: Patient demographics were: age 40 years (range 18 – 68); 21 female, 3 male; pre-operative weight 121 ± 22.8 kg, BMI 43.3 kg/m² (range 33 – 57); 15 patients had previous abdominal surgery (hysterectomy, cesarean section, bilateral tubal ligation, inguinal hernia repair and cholecystectomy). Bands were successfully placed in all cases and in 10 cases additional procedures were performed (hiatal or umbilical hernia repairs). In one case a single additional trocar was needed in the RUQ to facilitate retrogastric tunneling; there were no conversions to multi-port laparoscopy or open. Operative time was 129 ± 18.7 minutes (range 96 – 165). Estimated blood loss was 14.6 ± 6.7 cc (4 – 25). Using the suturing retraction strategy yielded excellent gastric exposure but was technically difficult. Intracorporeal suturing was preferred over percutaneous retrieval; however, percutaneous retrieval was necessary in 2 cases of planned intracorporeal suturing due to dislodgement of the suture from the needle. In comparison to suturing, the double-armed hook retraction strategy was simpler, faster (121 minutes less OR time), and allowed additional adjustments as needed during the procedure. There were two minor liver capsule tears (EBL 30cc/suture & 25cc/hook) but no injuries to the diaphragm or adjacent structures. Routine UGI on post-operative day one verified appropriate band placement in all cases. Median hospital stay was 0.9 days (0-1). Over a mean follow-up of 7.3 ± 2 months, no complications were noted and BMI reduction averaged 6 ± 3.5 kg/m². For the 16 transumbilical cases, scars were virtually undetectable on follow-up exam.
Conclusions: Intracorporeal SILS liver retraction is feasible and facilitates “scarless” AGB placement. Hook retraction seems to be the optimal current method; additional investigations are warranted to further refine these techniques and technologies.
Program Number: P041