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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1550_Библиотеки_им_академика_М_И_Перельмана
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57
5 Retraction Systems in Single-Incision Laparoscopic Surgery and NOTES
retraction well above the costal margin. Positioning and deployment were per-
formed without dif fi culty, as this con fi guration was quite simple; and cephalad
retraction was excellent as the magnet could be positioned relatively high toward
the diaphragm. However, infundibulum retraction was noted to be dif fi cult due to
problems associated with the use of fl exible endoscopic equipment for this pur-
pose. In addition, dislodgement of the endoclip during the case occurred relatively
frequently, resulting in the need for laparoscopic suturing methods to provide more
secure attachment.
The subsequent MAGS gallbladder grasper described was a fl exible grasper cra-
dle con fi gured to allow two endoscopic biopsy forceps or rat-tooth graspers to trans-
verse through it [ 15 ] (Fig. 5.6 ). This internal component contained a magnet such that
the grasper could be positioned magnetically, and then stabilized with a percutaneous
18-gauge needle anchor. Retraction of the gallbladder fundus and infundibulum was
then achieved using the two fl exible endoscopic graspers supported by the internal
cradle. Tension on the external grasper cables stabilized the grasper retraction
and provided a reasonable element of dynamic control. The gallbladder dissection
Fig. 5.6 MAGS retraction for NOTES cholecystectomy. ( a ) Flexible grasper cradle holding
biopsy forceps that is secured in place by percutaneous needle anchor. ( b ) Placement of needle
anchor after internal component is placed in desired position. ( c ) Intraabdominal view of grasper
cradle that has been stabilized by needle anchor. ( d ) Biopsy forcep grasper retraction of gallblad-
der fundus and infundibulum (With kind permission from Springer Science+Business Media.
Reproduced from Scott et al. [
15 ] )
58
M.L. Hafford and D.J. Scott
was then completed using MAGS electrocautery. While this model proved useful in
performing a completely transvaginal NOTES cholecystectomy without any laparo-
scopic assistance, the fl exible cradle grasper had limitations. Namely, the
infundibulum grasper served the purpose of creating active tension, thus providing
lateral and caudal retraction with expansion of Calot’s triangle. However, it was
often dif fi cult to fully elevate the fundus in a cephalad direction given the relatively
fl exible nature of the endoscopic graspers used.
Dominguez et al. developed magnetic forceps in which an alligator clip and a
magnet are attached [ 17, 18 ] (Fig. 5.7 ). Either one or two such retractors may be
used to elevate the fundus and/or infundibulum. Relatively large external magnets
are used. These techniques have been successfully used in numerous patients by
Dr. Dominguez, with reportedly good results in limited-access and SILS proce-
dures. For NOTES cholecystectomy, Dr. Dominguez’s retractor has also been used
in collaboration with Dr. Horgan’s group, with a magnetic retractor placed trans-
vaginally and attached to the fundus to provide excellent cephalad retraction [ 20 ] .
a
b
Fig. 5.7 ( a ) Magnetic
alligator clips; ( b ) retraction
of fundus and infundibulum
during SILS cholecystectomy
(Reprinted with kind
permission from Elsevier
from Galvani et al. [
19 ] )
59
5 Retraction Systems in Single-Incision Laparoscopic Surgery and NOTES
In a somewhat unusual fashion, Ryou and Thompson described the use of mag-
nets attached to endoclips to elevate the liver for gallbladder retraction during
transcolonic cholecystectomy in a porcine model [ 21 ] . These investigators used sev-
eral magnetic clips placed along the inferior edge of the liver and a very large exter-
nal magnet to elevate the right anterior portion of the liver. This in turn provided
reasonably good exposure of the gallbladder to facilitate dissection with fl exible
endoscopic instruments. After completion of the procedure, the clips were removed
with apparently no major tissue trauma. While feasibility was documented for the
porcine model, no human applications for this strategy have been reported.
While the use of magnetic retraction devices and strategies as described above
overcomes the instrument clashing and triangulation problems associated with SILS
and NOTES, there are limitations associated with their use. Even though no prob-
lems have been identi fi ed in numerous laboratory and clinical investigations, con-
cerns regarding the potential tissue effects of magnet compression have been raised
by various reviewers. Mashaud et al. examined abdominal wall tissue grossly and
histologically after SILS cholecystectomy using a MAGS cautery dissector device
in a porcine model [
14 ] . The average dissection time was 36 min, after which mild
skin erythema was immediately noted with a subsequent rapid resolution. In addi-
tion, there was no histological evidence of tissue necrosis or damage of skin, mus-
cle, or peritoneum.
On the other hand, insuf fi cient coupling strength may be problematic. Magnetic
coupling across the abdominal wall is exponentially related to the distance between
magnets, with magnetic attraction decreasing dramatically as separation distance
increases. In an ex vivo model investigating magnetic force decay, Best et al. found
that static coupling was maintained to a maximum distance of 4.78 cm [ 22 ] . Milad
et al. conducted an investigation in 138 women in which they measured abdominal
wall thickness in the left upper quadrant and umbilicus after insuf fl ation using a
spinal needle during gynecologic laparoscopy [ 23 ] . They found that only 1.5 % of
women with a BMI greater than 40 kg/m
2
had an abdominal wall thickness greater
than 4 cm. While these data do not account for potential frictional forces, current
data suggest that the MAGS platform should be suitable for a signi fi cant portion of
the adult population undergoing procedures such as cholecystectomy.
Liver Retraction Systems
Many advanced laparoscopic foregut procedures require retraction of the left lateral
liver for visualization of the lesser curvature of the stomach or gastroesophageal
junction. Traditionally, this has necessitated placement of a laparoscopic liver
retractor such as a Nathanson™ (Cook Medical, Bloomington, IN), fan, paddle, or
similar device through a separate 5-mm or even 10-mm incision. With the advent of
SILS, several novel techniques have been developed to effectively elevate the liver
without the need for an additional port.
60
M.L. Hafford and D.J. Scott
Several groups, including ours, have described the use of a percutaneous suture
to suspend the left lateral liver [ 24– 26 ] (Fig. 5.8 ). In this technique, a suture is
placed high anteriorly across the right crus of the diaphragm under the left lobe.
Care must be taken to avoid injuring the inferior phrenic vein, as it usually courses
quite close to this area. Care must also be taken to avoid deep bites that could pen-
etrate the full thickness of the diaphragm and cause injury to the pericardium or
heart. Fortunately, the diaphragmatic tissue at this location is suf fi ciently strong
such that a relatively super fi cial bite is more than adequate to anchor the suture to
the diaphragm without dislodgement. Once the diaphragm end is anchored, the ends
of the suture are percutaneously retrieved through separate small stab incisions
using a fascial closure device. The tails may be held under tension using hemostats
externally. Two suture tails may be used such that a “V” shape con fi guration is con-
a
b
c
Fig. 5.8 Percutaneous suture retraction of the liver. ( a ) Endostitch™ (Covidien, Mans fi eld, MA)
device and sutures attached to an umbilical tape; ( b ) “W” con fi guration of suture and umbilical
tape retraction of the liver, providing exposure of hiatal hernia; ( c ) external view of suture
retraction
61
5 Retraction Systems in Single-Incision Laparoscopic Surgery and NOTES
structed; in this case, the tails are usually externalized just below the costal margin
in the left midclavicular line and to the left of the falciform ligament, respectively.
Alternatively, three tails may be used by attaching the primary suture to an addi-
tional suture strand or even an umbilical tape such that a “W” shape con fi guration is
constructed; in this case, the third suture strand is externalized in the right mid-
clavicular line.
Concerns have been raised regarding suture strands cutting through the capsule
or parenchyma of the liver. However, using 2-0 braided suture, we have had no such
problems. The advantage of this method is its simplicity. While signi fi cant skill may
be required to place the suture through the diaphragm during a SILS procedure, it is
quite easy from a technical standpoint to retrieve the suture tails percutaneously.
This method provides relatively good exposure, especially if three suture strands are
used in a “W” fashion, such that both the lateral and medial aspects of the liver are
lifted off the underlying stomach.
Similarly, Scott et al. described a purely intracorporeal suture approach [ 9, 26 ]
(Fig. 5.9 ). In this method, a 48-in. 2-0 prolene suture on an endostitch device is used
to take alternating bites between the diaphragm crura and the peritoneum in a
W-shaped con fi guration. The initial suture is passed through a loop tied at the suture
tail prior to beginning the procedure, so that the suture is anchored to the crus. The
fi nal knot is tied intracorporally as well, thus eliminating the need for any skin inci-
sions or percutaneous retrieval.
Intracorporeal suture retraction of the liver in general has been found to be more
technically challenging and tedious than percutaneous methods. This is primarily
felt to be due to dif fi culty elevating the liver with a grasper to expose the diaphragm
and maintaining tension on the suture during placement of sequential bites [ 26 ] . The
percutaneous method has less of a learning curve but is not without inherent risks,
such as potential bleeding from piercing abdominal wall vasculature. In addition,
this technique has less cosmetic bene fi t compared to the completely intracorporeal
method.
Fig. 5.9 Intracorporeal
suture retraction of the liver
during SILS band placement
62
M.L. Hafford and D.J. Scott
Uyama et al. described a modi fi cation of the suture strategy whereby the liver
was retracted using a penrose drain [ 27 ] . Prior to introducing the drain into the
abdomen, nylon sutures were secured at the ends and in the center of the drain. A
window was made in the left triangular ligament through which the central suture
was placed and pulled inferiorly to superiorly onto the ventral surface of the liver.
Using an EndoClose™ (Covidien, Mans fi eld, MA) device, this suture was then
pulled through the abdominal wall and exteriorized in the right and left subcostal
areas, respectively. Interestingly, Uyama et al. reported that using the Penrose drain
technique liver retraction during laparoscopic gastrectomy ( n = 47) was associated
with a signi fi cantly lower postoperative transaminitis than seen with the use of a
Nathanson™ retractor ( n = 64) [
27 ] . Although the observed transaminitis was tran-
sient, there may be some clinical bene fi t in this method of retraction as potentially
less traumatic, which may be especially bene fi cial in patients with baseline liver
dysfunction. However, advanced skills may be required to safely create the window
in the left triangular ligament and to perform this strategy.
Huang et al. developed a liver suspension tape technique by creating a device
consisting of the fl at portion of a Jackson–Pratt drain with 2-0 prolene sutures on a
Keith needle secured on each end [ 28, 29 ] . The drain portion of the device was
placed underneath the liver. One of the prolene sutures was used to pierce the lateral
edge of the left liver and externalized in the left subcostal area. The second needle
pierced the left lobe near the falciform and was externalized near the midline. The
sutures were secured externally under tension and effectively held the liver against
the anterior abdominal wall. While the liver suspension tape method as described
seemed to provide excellent retraction, critics have raised concerns about potential
liver injury or hemorrhage since the parenchyma is intentionally trans fi xed.
Given the technical dif fi culties associated with suture retraction, we developed a
novel method of liver retraction that utilizes components of the LoneStar™ (Cooper
Surgical, Trumbull, CT) retractor system [ 9, 26 ] (Fig. 5.10 ). The LoneStar system
is typically used for anorectal, urological, and gynecological procedures. The sys-
tem consists of hooks connected to rubber tubing that may be used to facilitate
effacement of the anus, vagina, or other perineal tissues. The hooks are disposable,
available in several sizes, and packaged separately (the cost is approximately $80
for a pack of 8); our preference is to use the 3-mm hooks (white), which are rela-
tively small but facilitate suf fi cient bites of tissue. Two hooks are trimmed and
sutured together to create an overall length of approximately 8 cm, functionally
creating a double-armed retraction hook. Using a laparoscopic grasper to elevate the
liver, one LoneStar hook is placed in the anterior right crus and its opposing hook is
placed high anteriorly into the fi brous portion of the falciform ligament; this fi rst
construct serves to elevate much of the liver off the proximal stomach and provide
exposure of the diaphragmatic crura (suf fi cient to perform a hiatal hernia repair). A
second pair of LoneStar hooks are placed extending from high on the gastrohepatic
ligament to a slightly more caudal location on the falciform ligament so that the
retractors are parallel and the more medial aspect of the left hepatic lobe is elevated.
Together these act to effectively suspend the liver and have provided excellent expo-
sure in 18 of our patients who underwent single-incision adjustable gastric banding
63
5 Retraction Systems in Single-Incision Laparoscopic Surgery and NOTES
procedures, with a wide variety of BMIs (up to 58 kg/m
2
). Should adjustments be
needed, the hooks can be relatively easily repositioned. While this approach does
require advanced laparoscopic skills, it is relatively simple and reproducible from a
technical standpoint. To our knowledge, the LoneStar system is not FDA-labeled for
intraabdominal usage, and thus performing this technique is at the discretion of the
surgeon as “off-label” usage of an FDA-approved device. Certainly, if a hook were
to become lost within the abdominal cavity, there would be concerns regarding the
use of a foreign body; however, this has not been our experience. Our primary prob-
lem in using the hooks is inadvertent tissue or trocar interactions. Care must be
taken to avoid catching the hooks on parts of the seals of the trocar during insertion
or removal; protecting the hook within a laparoscopic grasper is quite helpful to
avoid this problem. Similarly, the hooks may “snag” on omentum or other intraab-
dominal tissues, and their manipulation must be visualized to avoid these unwanted
interactions. In our experience, we have had no such complications using a very
vigilant approach. The rubber segments of the retractors have been quite atraumatic
on the liver parenchyma, with no injuries to the liver, as well.
a
bc
Fig. 5.10 LoneStar™ (Cooper Surgical, Trumbull, CT) retraction of the liver. ( a ) LoneStar device
con fi gured as a double-armed retraction hook; ( b ) elevation of left liver lobe using parallel LoneStar
hooks; ( c ) postoperative scarless cosmesis from using this technique
64
M.L. Hafford and D.J. Scott
Galvani et al. also reported using the LoneStar hook retractor connected to a
bulldog clamp for liver retraction during single- and dual-incision adjustable gastric
band placement [ 19 ] (Fig. 5.11 ). This group describes attaching the bulldog clamp
to the pars fl accida membrane and the LoneStar hook to the falciform ligament.
From their paper, this method seems to provide reasonable exposure to the upper
stomach. However, the lesser curvature of the stomach seems to become somewhat
distorted anatomically as the gastric tissue near the bulldog clamp becomes quite
elevated. Also, the medial aspect of the left hepatic lobe is not elevated using this
technique as described.
a
b
Fig. 5.11 ( a ) LoneStar™ (Cooper Surgical)
retractor attached to a laparoscopic bulldog
clamp; ( b ) exposure of the gastroesophageal
junction using LoneStar/bulldog clamp
attached from the pars fl accid to the
falciform
65
5 Retraction Systems in Single-Incision Laparoscopic Surgery and NOTES
A relatively new device designed speci fi cally for the purpose of liver retraction
is the Endolift™ and is manufactured by the same company that makes the Endograb
(Virtual Ports, Inc., Misgav, Israel) (Fig. 5.12 ). This device is FDA-approved and
consists of dual spring graspers connected by a metal rod. Similar to the Endograb,
the Endolift requires a separate reusable delivery device (5-mm laparoscopic tool).
The retractor is backloaded into the introducer device and placed into the abdominal
cavity. One grasper is placed on the anterior right crus and the other grasper is
placed on the peritoneal surface near the falciform ligament or in the right upper
quadrant. The metal rod between the two graspers is spring-loaded, adjustable
(much like a shower curtain rod), and rigid, such that the liver is lifted. Per the
manufacturer, one Endolift is suf fi cient in most cases; occasionally, a second
Endolift may be necessary, especially for cases involving enlarged or redundant liv-
ers. Clinical experience with this device is currently limited, but the design seems
quite robust. Costs of the device and delivery system are $250 and $700, respec-
tively, which may be prohibitive to widespread adoption.
There are several shared bene fi ts of these alternative methods of liver retraction
beyond avoiding the placement of a separate incision and/or trocar (Table 5.2 ).
Since all of these methods effectively use self-retaining strategies, there is no need
for external retractor components, such as an iron intern or similar mechanical arms,
to hold a traditional liver retractor in place. Thus, the surgeon’s reliance on the
operative team (scrub and OR nurse) to coordinate such retractors is eliminated, as
are the cost and the need for sterilization of such components. Additionally, the OR
setup is simpli fi ed, as fewer components are needed. This latter aspect deserves
Fig. 5.12 Endolift™ (Virtual
Ports, Inc., Misgav, Israel)
device
Table 5.2 Comparison of liver retraction methods
Exposure
provided
Technical
dif fi culty
Risk of adjacent
organ injury Expense
Percutaneous suture + + + −
Intracorporeal suture + ++ + −
Penrose drain + ++ + −
Liver suspension tape ++ ++ ++ +
LoneStar™ (Cooper Surgical) ++ ++ + +
Endolift™ (Virtual Ports) ++ ++ + ++
66
M.L. Hafford and D.J. Scott
emphasis, as in many operating rooms individual pieces of such retractor systems
may be missing and cause operative delays and frustration. We fi nd it very exciting
that such novel retraction systems may decrease postoperative aberrations in liver
function tests as described earlier in this chapter. Certainly, a further re fi nement of
currently available devices and techniques seems warranted, as does developing
additional instrumentation.
Retraction in Other Advanced Procedures
Bariatric, foregut, and colorectal procedures are increasingly being performed via
single-incision laparoscopic and NOTES approaches. As with other advancements
in minimally invasive surgical procedures, several retraction systems have been
adopted to facilitate these techniques.
We have developed methods for gastric retraction during single-incision adjust-
able gastric band placement [ 30– 32 ] . Using an Endostitch (Covidien, Mans fi eld,
MA), a suture is placed high on the gastric fundus and then externalized through the
working port (Fig. 5.13 ). This provides exposure to the angle of His. After division
of the pars fl accida, a second suture is placed on the lesser curvature incorporating
a
b
Fig. 5.13 Suture retraction during
dual-incision adjustable band. ( a ) Suture
placement on gastric fundus and on the
lesser curvature incorporating the right curs;
( b ) peritoneal suture allowing suture
retraction to act as a pulley system for
manipulation during the operation
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