Editorial Comment for Cho et al.

T he authors describe a low-cost technique for retracting the liver during a right-sided laparoscopic nephrectomy. The technique uses sutures tied through a surgical tape anchored through the skin by hemostat clamps in the epigastric and lateral side wall.

While standard techniques typically use a 5-mm trocar placed in the epigastric region to place a locking grasper for liver retraction, the presented technique attempts to avoid this 5-mm trocar, thereby presenting three potential advantages. The first advantage is cosmesis. The authors estimate a 1-mm puncture site for the Carter Thompson device to pass the stitch through the adominal wall, which results in a negligible scar in this region. While some series report a cosmetic impact of scars from additional trocar sites, these compare single-incision laparoscopy to traditional laparoscopy, where the difference is small. ¹ In addition, patients undergoing laparoscopic procedures for cancer or for kidney donation, may not consider cosmesis a highly important factor. ²

The second possible advantage is that postoperative pain is reduced by avoiding a 5-mm trocar in this region. Other series have suggested that this trocar is a site of significant trocar pain. It is not clear, however, whether this is significant even in single-incision surgery. ³ Additional comparison of the postoperative pain between those with the trocar-retracted liver vs the tape-retracted liver would help determine whether this 5-mm trocar is a significant factor in postoperative pain. In addition to the puncture site in the epigastrium, an additional puncture site is needed on the lateral side wall. This could lead to postoperative pain in this area, particularly if the subcostal nerve is injured. The authors also caution that one should use a 5-mm locking grasper if the lateral site needed to retract the liver appropriately necessitates one to puncture through the diaphragm. As an alternative, one could completely internalize this retraction technique using clips or commercially available anchoring mechanisms to anchor the tape or sutures to the lateral side wall and the anterior abdominal wall.

A third possible advantage is that this method of liver retraction removes the interference that may be caused by the additional port in the epigastrium. In laparoscopic cases, this trocar can interfere with movement of the surgeon's right hand in the upper trocar. In robotic cases, collisions with the robotic arm can lead to dislodgement of the retractor, which can cause patient injury. In addition, these collisions can cause malfunction of the robotic arm.

The authors should be commended for presenting a technique for liver retraction in an organized fashion. This will hopefully encourage others to add this or other trocarless techniques to retract the liver to his/her surgical armamentarium. Additional research into the benefit of this technique for postoperative pain and cosmesis is needed.