An Easy and Safe Method of Liver Retraction Using a Silicone Disc and Needle Forceps for Laparoscopic Gastrectomy

Introduction

To perform laparoscopic gastrectomy safely and effectively, it is important to obtain a sufficient visual field. Various methods of liver retraction during laparoscopic gastrectomy have been reported.^1–7 Although we have previously employed the so-called Penrose drain method (Fig. 1), ⁷ by which a good visual field was obtained, we were motivated to devise an easier method of liver retraction using a silicone disc and needle forceps (Fig. 2), because by the Penrose drain method, we sometimes experienced cases in which much time was needed for dissection between the liver and the diaphragm, or bleeding from the liver occurred.

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FIG. 1.

Liver retraction by the Penrose drain method.

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FIG. 2.

Liver retraction using a silicone disc and needle forceps.

This method of liver retraction involves elevation of the lateral segment of the liver using a silicone disc supported by needle forceps, which grasp the right crus of the diaphragm, and one thread that pulls the disc. This method is relatively easy, and helps to reduce the incidence of postoperative liver dysfunction resulting from liver retraction. We herein report this procedure.

Patients and Methods

We analyzed retrospectively 36 patients with clinical stage I gastric cancer, who underwent laparoscopic distal gastrectomy (LDG) at Yamagata University Hospital between January 2013 and July 2016. These included 18 consecutive patients in whom liver retraction was performed with a silicone disc and needle forceps (Silicone group) between January 2015 and July 2016, and 18 consecutive patients in whom the Penrose drain method (Penrose group) was employed between January 2013 and August 2015 before devising the method of the silicone disc and needle forceps. We excluded chronic hepatitis patients. LDG with D1+ or D2 lymph node dissection followed by Billroth I or Roux-en-Y reconstruction was performed under pneumoperitoneum at 10 mmHg, using four working ports.

The following data were collected and evaluated: patient age, sex, body mass index, operation time, time needed for liver retraction, and blood loss. A liver to spleen CT attenuation ratio for the evaluation of hepatic steatosis was examined using preoperative plain CT. Intraoperative complications related to liver retraction were assessed, and the perioperative levels of aspartate transaminase (AST) and alanine aminotransferase (ALT) on the preoperative day and on postoperative days (PODs) 0 (soon after operation), 1, 3, and 7 were evaluated.

All patients provided written informed consent before surgery. This study was approved by Institutional Review Board of Yamagata University Faculty of Medicine.

Surgical procedure

Under general anesthesia, the patient was placed supine on a broad base. A 2-0 silk thread was connected to one side hole of the longitudinal axis of a silicone disc (small elliptical type with a 120 × 80-mm hole; Hakko, Japan). A 4-cm vertical incision, which was necessary to extract the resected specimen, was made in the umbilical region as well as in a surgery by the Penrose drain method, and the prepared silicone disc was inserted into the abdominal cavity through this incision. Subsequently, a 12-mm trocar was placed for the camera port. After carbon dioxide pneumoperitoneum (10 mmHg) had been created, 5- and 12-mm trocars were inserted into the right upper quadrant and right middle quadrant of the abdomen, respectively, and the other 5- and 12-mm trocars were inserted similarly on the left side of the abdomen.

The lesser omentum was divided, preserving the hepatic branches of vagus nerve and exposing the right crus of the diaphragm. Subsequently, the silicone disc was positioned under the lateral segment of the liver, making the connecting-fiber side into right-hand side. An Endo Relief shaft guide Plus (Hope Electronic, Inc.) was inserted into the abdominal cavity through the epigastrium, depending on the inferior edge of the elevated lateral segment of the liver (Fig. 3A). Using the shaft guide, the 5-mm forceps tip and shaft of the Endo Relief (Hope Electronic, Inc.) was introduced into the abdominal cavity through the right-hand 12-mm trocar; then the shaft was introduced into the extracorporeal space, and the handle of the Endo Relief was attached. Subsequently, the right crus was grasped by the Endo Relief, achieving elevation of the lateral segment by the silicone disc (Fig. 3B).

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FIG. 3.

(A) Insertion of the Endo Relief shaft guide into the abdominal cavity. (B) Grasping the right crus of the diaphragm by the needle forceps (Endo Relief). (C) Exteriorization of the thread connected to the silicone disc. (D) Towing the silicone disc and elevation of the hepatic round ligament by the thread. (E) Position of ports and needle forceps on the surface of the body. (F) Lymph node dissection around the lesser curvature

The 2-0 thread connected to the silicone disc was exteriorized through the abdominal wall using an EndoCloth (Covidien, Inc., Japan) from the right side of the round ligament of the liver and retracted, achieving elevation of the round ligament (Fig. 3C, D). Figure 3E shows the spatial relationship between the needle forceps and the port on the body surface once liver retraction using the silicone disc and needle forceps had been completed.

Results

The patients' background factors did not differ between the two groups (Table 1). By liver retraction using the silicone disc and needle forceps, a good visual field for LDG was obtained in all cases. Lymph node dissection around the lesser curvature of the stomach was possible within the sufficient visual field obtained by this method (Fig. 3F). There was no instance of trouble with the operative procedures, and we were able to complete the procedures in all cases of two groups.

The mean time required for completion of liver retraction by the silicone disc method and the Penrose method was 633.8 ± 286.6 seconds and 639.8 ± 328.6 seconds, respectively (P = .954). As a complication accompanying liver retraction, we observed hemorrhage from the abdominal wall in one Silicone group case, and hemorrhage from the liver in one Penrose group case.

The preoperative AST and ALT levels were normal in all patients of both groups, but postoperative elevation of AST, ALT, or both was recognized in 13 (72.2%) of the Silicone group patients and 18 (100%) of the Penrose group patients (P = .016) (Table 2). As shown in Figure 4, elevations of the mean AST and ALT levels were observed on PODs 0 and 1 in the Silicone group, and on PODs 0, 1, and 3 in the Penrose group.

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FIG. 4.

Elevation of AST level (A) and ALT level (B) after laparoscopic distal gastrectomy. *Significant difference between two groups (all P < .01). ALT, alanine aminotransferase; AST, aspartate transaminase.

The mean AST and ALT levels in the Silicone group were significantly lower than those in the Penrose group on PODs 0, 1, and 3. The mean AST and ALT levels on POD 1, when the intergroup differences were most significant, were 51.9 ± 27.60 IU/L and 49.4 ± 30.17 IU/L in the Silicone group and 119.5 ± 68.18 IU/L and 134.8 ± 85.73 IU/L in the Penrose group (AST; P = .0004, ALT; P = .0003), respectively.

Discussion

Obtaining a good visual field is very important for LDG, and liver retraction is indispensable to performing this procedure safely. Various procedures have already been reported.^1–7 Although we have adopted the so-called Penrose drain method, there are sometimes cases that require a longer period of separation between the diaphragm and liver because of hemorrhage from the liver, even when the surgeon is skilled, and therefore a simple and safer method of liver retraction has been required.

Several methods of liver retraction with a silicone disc have been reported, including use of a Snake retractor by Shibao ⁵ and the use of four threads by Takemura. ⁶ As a simpler silicone disc procedure for liver retraction, we devised the method of supporting the suspension of the disc with needle forceps (Endo Relief) and a thread.

The Endo Relief consists of a grasping forceps with a 2.4-mm shaft having sufficient hardness for liver retraction, and a 5-mm tip that is strong and stable for grasping. To use the 2.4-mm needle forceps, creation of a direct abdominal wall wound does not pose a significant cosmetic problem. The shaft and handle of the needle forceps on the surface of the body did not interfere with the procedure for total laparoscopic gastrectomy.

The insertion point of the needle forceps is very important, since the inferior edge of the liver may be pushed and bended by the forceps shaft if the forceps is inserted from a more cranial position without considering the size of the liver. Elevation of the liver may be minimized if the forceps is inserted from separating site from liver inferior edge.

Pulling the thread connected to the right-hand side of the silicone disc provides stability and a sufficient visual field by elevating the hepatic round ligament. We were able to complete LDG in all patients using this liver retraction method. When a sufficient visual field could not be secured, such as when lymph node dissection was required at the lesser curvature top of the stomach, pressing on the silicone disc temporarily with the assistant's forceps resolved the problem. This procedure was successfully applicable to not only LDG but also laparoscopic total gastrectomy and laparoscopic proximal gastrectomy.

Comparison between the Silicone and Penrose groups showed that the mean period needed for liver retraction was shorter in the former, but not to a significant degree. However, in the Silicone group, the retraction time tended not to vary widely among cases. On the other hand, in the Penrose group, the liver retraction time tended to depend on intraabdominal conditions such as liver volume, as dissection of the liver was needed.

Liver dysfunction after distal gastrectomy has often been reported, and liver retraction has attracted attention as a possible cause.^7–9 Although this study was a retrospective analysis, liver retraction using the silicone disc method was found to ameliorate the postoperative elevation of hepatic enzyme levels in comparison with the Penrose drain procedure. Several reasons for this can be considered: (1) the tension imposed on the liver during retraction is distributed more evenly, (2) a degree of “looseness” allowed by the needle forceps decreases the degree of direct pressure on the liver, and (3) dissection of the liver is not required. Furthermore, the protective effect of the silicone disc against liver damage caused by forceps or an automatic stapler can also be considered.

As shown in Figure 4, the postoperative elevation of hepatic enzyme levels recovered to almost normal range on POD 7, and in our experience, there was no case in which such a liver dysfunction adversely affected the short- or long-term postoperative outcomes. However, several cases of liver necrosis or liver infarction by liver retraction in gastric surgery have been reported.^8,10,11 Tamhankar et al. ¹⁰ reported a case of retraction-related liver lobe necrosis, which progressed to septic shock followed by left lateral sectionectomy after laparoscopic gastrectomy using a Nathanson liver retractor. Therefore, although these cases might be rare, it would be desirable to employ a safer method of liver retraction.

As this study was retrospective, and the number of cases enrolled was small, a prospective study will be needed to clarify the usefulness of this liver retraction method using a silicone disc and needle forceps.

Conclusions

Retraction of the liver using a silicone disc and needle forceps is simple and safe, and yields a good visual field for laparoscopic gastrectomy. This technique is considered to reduce the incidence of postoperative liver dysfunction.