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47
4 LESS: Ports and Instrumentation
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49
A. Rane et al. (eds.), Scar-Less Surgery,
DOI 10.1007/978-1-84800-360-6_5, © Springer-Verlag London 2013
Keywords Retraction systems • Single-incision laparoscopic surgery • Natural
ori fi ce transluminal endoscopic surgery • Magnetic anchoring guidance system
Laparoscopic liver retraction • Endograb • Endolift • Suture retraction • Magnetic
retraction systems
Introduction
As minimally invasive surgery techniques evolve to include methods such as
single-incision laparoscopic surgery (SILS) and natural ori fi ce translumenal endo-
scopic surgery (NOTES), a major challenge has been maintaining surgical exposure
through limited incisions in which instruments are introduced within the same axis.
One of the basic tenets of laparoscopic surgery is triangulation. This allows for
maximal exposure of the surgical fi eld and the optimal retraction required for tissue
dissection. Dif fi culties adhering to these principles secondary to instruments enter-
ing the abdomen through a common port, and therefore a parallel alignment, have
led to the development of several novel retraction systems. These systems provide
the necessary exposure to safely perform the operation. The Natural Ori fi ce Surgery
Consortium for Assessment and Research (NOSCAR) was developed to address
potential barriers to adoption of NOTES into clinical practice, one of which was
M. L. Hafford , M.D. (*)
Department of Surgery , University of Texas Southwestern ,
5323 Harry Hines Blvd , Dallas , TX 75390 , USA
e-mail: mhaffordmd@gmail.com
D. J. Scott , M.D., FACS
Department of Surgery , University of Texas Southwestern ,
5323 Harry Hines Blvd , Dallas , TX 75390 , USA
e-mail: daniel.scott@utsouthwestern.edu
Chapter 5
Retraction Systems in Single-Incision
Laparoscopic Surgery and NOTES
Melanie L. Hafford and Daniel J. Scott
50
M.L. Hafford and D.J. Scott
found to be challenges with spatial orientation [ 1 ] . The subsequent NOSCAR white
paper states that the incorporation of conventional laparoscopic principles, such as
triangulation, may be necessary for safe NOTES operations [ 1 ] . The Laparoendoscopic
Single Site Surgery Consortium for Assessment and Research (LESSCAR) released
a consensus statement and identi fi ed similar challenges for retraction during SILS
procedures [ 2 ] . Hence, much work has been done to develop retraction systems in
this environment as well. The purpose of this chapter is to review established and
developing innovations in retraction systems for SILS and NOTES procedures.
Retraction Systems in Cholecystectomy
Laparoscopic cholecystectomy is one of the most basic and commonly performed
laparoscopic operations. Much of the work reported to date using novel retraction
methods of the gallbladder during cholecystectomy have been during SILS proce-
dures. In 1997 Navarra et al. fi rst described a SILS cholecystectomy using transab-
dominal stay sutures to allow for gallbladder retraction [ 3 ] . A suture on a Keith or
straight needle is introduced through the working trocar. The suture is passed
through the gallbladder fundus and secured to the gallbladder by passing the needle
through a loop tied on the end of the suture, cinching the loop down onto the tissue.
The needle may then be passed through the abdominal wall subcostally, and the
suture is secured externally using a clamp. Additional individual sutures are then
placed in the same fashion through the gallbladder body and infundibulum to pro-
gressively gain suitable exposure. Whereas the upper fundic and body sutures serve
to elevate the gallbladder, the infundibular suture(s) serve to lateralize the lower
gallbladder and expand the triangle of Calot. The materials for this approach result
in negligible costs, and numerous investigators have reported the use of this tech-
nique with good results [
4– 7 ] .
However, there are several potential drawbacks (Table 5.1 ). With the lower
sutures lateralizing the triangle of Calot, it may be dif fi cult to dissect the attach-
ments on the right side of the gallbladder; thus, it may be helpful to perform an
initial dissection on this side prior to placement of the fundic suture. Bile spillage
may occur due to penetration of the gallbladder by the needle, but in our experience
the volume of bile spilled has been minimal and of no clinical signi fi cance. There is
Table 5.1 Comparison of retraction methods for SILS cholecystectomy
Bile spillage
Supracostal
retraction
Technical
dif fi culty
Risk of
adjacent
organ injury Expense
Percutaneous suture + − + + −
Intracorporeal suture + + ++ − −
Endoloop − − − − +
Endograb™ (virtual
ports)
− + − − ++
51
5 Retraction Systems in Single-Incision Laparoscopic Surgery and NOTES
inherently some limitation in cephalad retraction of the gallbladder, as most sur-
geons are only comfortable externalizing the fundic retraction suture below the cos-
tal margin to avoid any risk of pneumothorax. Accordingly, this tissue is not retracted
to the same cephalad extent as would be conventionally achieved using a rigid lap-
aroscopic grasper. In some cases, complete exposure of Calot’s triangle may be
dif fi cult to achieve, especially when very large, redundant gallbladders are encoun-
tered. Using several sutures to elevate the gallbladder progressively may overcome
this problem. There is also the potential risk of bleeding from piercing abdominal
wall blood vessels during passage of the needle externally, though this risk is mini-
mal. While this technique is simple, reproducible, and can be taught relatively
easily, advanced laparoscopic skills are required. Speci fi cally, the Keith needle is
6 cm in length and may be particularly awkward to manipulate, especially given the
parallel orientation of the instruments in the SILS environment and when instru-
ment con fl icts are encountered. Hence, care must be taken to avoid injuries to adja-
cent organs related to the use of this needle type.
It may also be cumbersome to pass the needle outside the abdominal cavity, so
the needle transverses through a loop on the end of the suture, fi xating the suture to
the gallbladder. One alternative is to use the small rubber plunger from a 1-cc TB
syringe [
7 ] (Fig. 5.1 ). This plunger may be tied to the end of the suture prior to
insertion of the needle into the abdominal cavity. The needle can then penetrate the
gallbladder and be retrieved externally, and, when pulled tight, the plunger serves to
anchor the suture against the gallbladder. While this technique is quite effective and
obviates the time associated with needle passes through a trocar, the usage of the
plunger may introduce concerns over a foreign body being retained inside the abdo-
men should the suture break or if the plunger somehow becomes dislodged. Hence,
we might recommend the use of pledgets for this purpose, as they have been used
for many years as adjuncts to suturing in the abdomen for surgical procedures.
One modi fi cation of the suture retraction technique involves the addition of
endoclips on each side of the suture to allow for additional external control in a
“puppeteering” fashion, as described by Rawlings et al. [ 8 ] . For this technique, a
prolene suture on a Keith needle is passed through the gallbladder fundus and then
through the abdominal wall in the midclavicular line, allowing for cephalad retrac-
tion. A second suture was placed in a similar fashion through the infundibulum and
exteriorized in the right mid-axillary line. Endoclips were then placed on the
infundibulum suture on each side of the gallbladder. This technique essentially
allows the lower gallbladder to be retracted either laterally or medially, such that
both sides of Calot’s triangle may be exposed.
Intracorporeal suture retraction has also been described, which eliminates the
need to pass a needle through the abdominal wall [
7, 9 ] (Fig. 5.2 ). In this method, a
long suture on a conventional curved (SH) needle is placed through the gallbladder
fundus and then through the anterior-lateral peritoneum well above the costal mar-
gin. The two ends of the suture are externalized through a trocar and knots are tied
extracorporeally using a knot pusher. This effectively elevates the gallbladder fun-
dus cephalad, similar to using a standard rigid laparoscopic grasper. The infundibu-
lum is sutured by encircling a bite of tissue within a pretied loop at the suture tail
52
M.L. Hafford and D.J. Scott
(the needle is passed through this loop). The needle is then passed through the lat-
eral peritoneum and externalized though a trocar. The tail is left long and secured
with a hemostat such that pulling on this tail retracts the infundibulum laterally,
since the suture is created in a pulley con fi guration. Thus, dynamic retraction is
facilitated, whereby tension may be progressively adjusted. While this method is
advantageous for several reasons, it is relatively complex and dif fi cult to teach.
Instead of suture, an endoloop may also be used as described by Mintz et al.
[ 4, 10 ] (Fig. 5.3 ). This method involves placing an endoloop around the gallbladder
fundus; a suture passer is then used to retract the endoloop transabdominally and
provide anterior retraction. While simple and feasible, the endoloop is more costly
than other suture materials. Additionally, the use of a suture passer usually requires
a larger incision compared to the almost invisible scar associated with passage of a
needle through the skin. And, as with percutaneous needle placement, there is a risk
of bleeding with passage of the suture passer.
a
c
e
b
d
Fig. 5.1 Percutaneous suture retraction during SILS cholecystectomy. ( a ) The gallbladder is
pierced at the fundus with a Keith needle. ( b )The suture may be preattached to a rubber plunger that
is then apposed against the gallbladder. ( c ) Percutaneous suture retraction of the fundus at the costal
margin. ( d ) Exposure of Calot’s triangle after placement of additional sutures at the infundibulum.
( e ) Completion of cholecystectomy with gallbladder suspended by percutaneous sutures
53
5 Retraction Systems in Single-Incision Laparoscopic Surgery and NOTES
a
b
c
Fig. 5.2 Intracorporeal suture retraction during SILS cholecystectomy. ( a ) Fundus suture
providing cephalad retraction. ( b ) Lateral suture retraction at infundibulum. ( c ) Resulting exposure
of Calot’s triangle using this technique (With kind permission from Springer Science+Business
Media. Reproduced from Rivas et al. [
7 ] )
Fig. 5.3 Endoloop ( arrow )
retraction of fundus during
SILS cholecystectomy (With
kind permission from
Springer Science+Business
Media. Reproduced from
Schlager et al. [
4 ] )
54
M.L. Hafford and D.J. Scott
Only one purpose-built FDA-approved device for gallbladder retraction is
currently available in the United States. Namely, the Endograb™ (Virtual Ports,
Inc., Misgav, Israel) device is a deployable retraction system that may be espe-
cially useful during SILS or even NOTES procedures [ 4, 9, 10 ] (Fig. 5.4 ). This
a
e
d
c
b
Fig. 5.4 Endograb™ (Virtual Ports, Inc., Misgav, Israel) retraction in SILS cholecystectomy. ( a )
Endograb device; ( b ) delivery device; ( c ) Endograb device and delivery tool demonstrating deploy-
ment; ( d ) placement of Endograb on fundus and infundibulum; ( e ) resulting exposure after place-
ment of Endograb
55
5 Retraction Systems in Single-Incision Laparoscopic Surgery and NOTES
system consists of a reusable hand instrument (insertion tool) and a disposable
grasper unit. The hand instrument is introduced via a 5-mm port and the
Endograb™ device is deployed into the abdominal cavity. The device consists
of two spring-loaded graspers connected by a curved wire. For cholecystec-
tomy, one of the graspers is attached to the gallbladder fundus and the other end
is attached to the anterior-lateral peritoneum cephalad to the costal margin. A
second Endograb™ is placed on the lower gallbladder and connected to the
lateral peritoneum such that the infundibulum is retracted laterally, exposing
Calot’s triangle. The speci fi c attachment points may be adjusted by simply
opening the grasper and reattaching it to a different location. For instance, the
infundibular grasper may be connected to a midline peritoneal location to expose
the right side of the gallbladder. The connecting wire has suf fi cient memory
such that a gentle continuous tension on the tissue may be afforded; thus, as the
dissection progresses, the gallbladder is progressively lifted toward the anterior
abdominal wall.
For SILS procedures, the Endograb™ is usually placed through a working trocar,
and then this trocar may be used for other instrumentation. For NOTES procedures,
the Endograb™ has been used during hybrid procedures in which a 5-mm umbilical
trocar is available for introduction of the device. Because this device is deployable,
it may be quite helpful in providing triangulation and relatively good exposure,
including fundic retraction above the costal margin. Because of the spring-loaded
design, occasionally part of the grasper device may obscure visualization of the
operative fi eld or simply prevent dissection of an area of interest. In this case, we
have found that simply removing the grasper, rotating it 180°, and reattaching it
tends to move the spring portion of the grasper out of the way and facilitate improved
exposure.
Despite this device’s utility, there is a potential risk of tissue shearing and hem-
orrhage at the grasper fi xation locations (diaphragm or abdominal wall). However,
in our experience and in the reported literature, this risk is minimal. There may
also be potential for bile spillage should the gallbladder tear at the site of grasper
fi xation, but this has not been part of our experience. The primary disadvantage is
cost; the reusable introducer device costs approximately $700 and each dispos-
able Endograb™ device costs approximately $150, with two devices normally
used per case.
The use of articulating instruments during NOTES cholecystectomy has been
particularly helpful in facilitating tissue retraction. Horgan et al. reported on the
use of an extra-long RealHand™ grasper (Novare, Inc., Cupertino, CA) to per-
form a hybrid transvaginal cholecystectomy [
11, 12 ] . The RealHand™ instru-
ment was advanced transvaginally through a trocar and used to retract and
manipulate the gallbladder. The remainder of the dissection was performed via a
5-mm umbilical port and using the transvaginally placed fl exible endoscope.
Other groups in Europe have reported similar retraction strategies using extra-
long laparoscopic graspers placed transvaginally during NOTES cholecystec-
tomy [ 13 ] . Additionally, dedicated multifunctional single-access platforms are
being developed by several manufactures, but are outside the purview of this
chapter.
56
M.L. Hafford and D.J. Scott
Magnetic Retraction Systems in Cholecystectomy
The use of magnets may be quite useful in retracting tissue during limited-access
procedures. The Magnetic Anchoring and Guidance System (MAGS) was devel-
oped by Cadeddu and Scott. This group fi rst developed the technology in 2001, well
ahead of its time, in an effort to facilitate “trocarless” surgery. MAGS is an innova-
tive method that aims to overcome limitations in spatial orientation and retraction
inherent to NOTES and SILS. MAGS consists of a mobile magnet placed intraab-
dominally and then coupled to an extracorporeal handheld neodymium magnet
across the abdominal wall. MAGS instruments, which include a camera, tissue
retractors, and monopolar cautery, are then controlled transabdominally, allowing
for unrestricted intraabdominal movement and improvement in spatial orientation
and instrument spacing during SILS and NOTES. Alternatively, the internal magnet
can be attached to an 18-gauge percutaneous needle lock, anchoring the platform to
allow removal of the external magnet. This reduces unintended coupling between
other magnetic instruments, permits hands-free control, and increases the force
reaction capabilities of the intraabdominal instrument [
14– 16 ] .
In one series, transvaginal NOTES cholecystectomy was performed in a porcine
model using MAGS for gallbladder retraction [ 15 ] (Fig. 5.5 ). This was achieved by
using either an attachable magnet or a fl exible grasper cradle. In the former, an
internal magnet was attached to a suture loop that was then secured to the gallblad-
der fundus with an endoclip deployed via a fl exible endoscope. The internal mag-
net was then coupled with an external magnet, providing dynamic cephalad
Fig. 5.5 Fundus retraction
using a magnet fi xated with
endoclips to provide cephalad
retraction during NOTES
cholecystectomy (With kind
permission from Springer
Science+Business Media.
Reproduced from Scott et al.
[
15 ] )
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