[Laparoscopy in Hepatobiliary Surgery] Liver traction method

The exposure of the field of view during the operation is very important for the successful implementation of single-port laparoscopic surgery, especially in the operation of the stomach, spleen, and pancreas. Due to the obstruction of the left liver lobe, the exposure of the stomach, pancreas, spleen and other organs is often poor, which affects the operation. process and increase the difficulty of surgery.

Therefore, scholars have developed many liver retractors or methods to expose the surgical field of view of the upper abdomen, increase the operating space, and ensure the smooth progress of the operation.

External abdominal traction technique

Nathanson liver retractor

In 1990, Nathanson et al. reported the Nathanson liver retractor. It is a curved blunt metal hook that pulls the left lobe of the liver intraperitoneally, securing the outside to a supporting metal arm to increase traction on the liver. This traditional device can be easily placed where needed even in obese patients, and the exposure effect is also good. Kitajima et al. analyzed 114 cases of laparoscopic gastrectomy, of which 94 cases applied the improved Nathanson liver retractor, the median ALT was 30 U/L (6~320 U/L) and the median AST was 35 U/L ( 17~333U/L), in 20 cases with traditional Nathanson liver retractor, the median ALT was 40U/L (12~166U/L) and the median AST was 44U/L (20~151U/L) on the first day after operation , P values were 0.042 and 0.021, respectively, it may be considered to move the position of the retractor intermittently before the liver parenchyma discoloration, so as to avoid the retractor pressing a certain part of the liver for a long time, so as to reduce the damage to the liver.

Snake liver pusher

Tatsushi et al. reported that a snake-shaped liver pusher was used in 70 cases of radical gastrectomy. This is a miniature retractor that can be pulled left or right to expose a clear surgical field under laparoscopy, which is more convenient for lymph nodes to be cleaned and shortened. operation time. Sung et al. compared 326 cases of traditional single-hole 3-channel with 89 cases of single-hole 4-channel snake-shaped liver pusher. The operation time of the 3-channel group was (53.0±25.8) min, and the operation time of the 4-channel group was (51.9±18.6) min (P =0.709), in the 3-channel group (3.0±3.3) days in hospital, in the 4-channel group (2.6±0.9) days (P=0.043), in the 3-channel group 6 cases (1.8%) were transferred to multi-hole, in the 4-channel group 3 (3.4%) ,P=0.411), there was no conversion to laparotomy in both groups. Myung et al. also made a similar study, and believed that the effect of exposed surgical field is better, and it is completely applicable in single-port laparoscopic gallbladder surgery. However, because it is a small retractor, the pushing force is limited, so there are still some shortcomings in the application in obese patients who need more space.

Suture liver stretching technique

De la torre et al. reported a new type of liver retractor technique, the suture method. This technique exposes the left lobe of the liver by securing the silk thread to the abdominal wall while threading the suture under the liver and pulling the suture taut to elevate the liver to expose the surgical field. Mati et al. reported that this technique was used in 100 cases of laparoscopic gastrostomy, and believed that this technique is not only efficient, but also easy to learn, and plays an important role in visual field exposure in minimally invasive upper abdominal surgery. Although this technique has the above-mentioned advantages, it has a certain cutting effect on the liver due to the thin suture, which may easily lead to liver cutting injury.

Some studies have improved this method, and put gauze between the suture and the liver to reduce the cutting effect on the liver: Ren Mingyang et al. reported 59 cases of laparoscopic gastric surgery, and Woo et al. reported 92 cases of laparoscopic radical gastrectomy. Therefore, it is considered that this method has little damage to the liver and is easy to operate, and can be applied in laparoscopic gastric surgery.

In 2013, Zachariah et al.2 proposed the "T-shape" method to stretch the liver, and 12 cases of upper abdominal surgery (including 2 cases of laparoscopic Roux-en-Y gastric bypass, 6 cases of laparoscopic sleeve gastrectomy and laparoscopic Adjustable gastric band resection in 4 cases, including multi-hole and single-hole surgery and combined cholecystectomy in 3 cases) mainly put the suture thread through the middle part of the cigarette drainage tube (3~4cm in length) and fixed it in the middle several times ( 3 or 4 times), forming a "T-shape", and then penetrating the liver directly to the outside of the abdominal wall, pulling externally, they believe that this technique is simple and easy, and provides a good surgical space between the esophagus and the stomach. The method is small in size, flexible and maneuverable in the abdominal cavity during the process of entering the abdominal cavity. But it also reported a potential disadvantage of needing to penetrate the liver, leading to liver damage.

Intra-abdominal stretching technique

Liver Suspension Band Technique

Huang et al. 3 reported 3 cases of single-hole laparoscope using a new type of liver traction method, that is, "type V liver suspension belt". The method is to fix the middle of the cigarette drainage tube on the fascia at the junction of the esophagus and stomach, and then fix the two ends on the anterior abdominal wall, and hang the liver by lifting the deep part of the gastrointestinal ligament to form a "V" shape. The suspension pull, which reported the average time required to complete this device was 8min21s.

In 2012, Goel et al. analyzed the clinical data of 19 cases of laparoscopic Roux-en-Y gastric bypass surgery using the liver suspension band technique. The preoperative ALT level was (56.4±31.1) U/L, and the ALT level immediately increased to (75.9 ±35.2) U/L (P<0.01), peaked at (83.9±50.2) U/L (P=0.04) after 1 week, decreased at 1 month, but did not return to the normal range; compared with traditional Nathanson liver retraction Compared with other instruments, this technique has less damage to the liver, less postoperative pain, and faster recovery, which is of great significance in single-port laparoscopic surgery. Lee et al. (3 reported 76 cases of upper gastrointestinal surgery, the time to install the technology was (2.7±0.6) min, ALT and AST increased on the day of operation, respectively (54.9±26.3), (45.2±23.1) U/L, After 4 days, it decreased to (22.4±13.2) U/L and (21.8±14.0) U/L, and puncture site bleeding occurred in 1 case (1.3%). Lee et al. compared and analyzed 57 cases of liver suspension belt technique in laparoscopic gastrectomy Compared with 82 cases of Nathanson retractor, the time of starting to eat and the time of hospitalization were significantly shortened (P=0.002, P=0.024). Therefore, it is believed that this technique can be applied to upper abdominal surgery, with good exposure effect and less damage to the liver. Recovery is fast.

liver paste technique

Wu et al. reported the application of the liver paste method in 50 cases of single-port laparoscopic surgery. The liver was pasted on the diaphragm with medical glue to increase the operating space in the upper abdomen. This technique took an average of 1.5 minutes (0.8-2.0 minutes). The average ALT and AST were 25.7 and 32.0 U/L on the first day after operation, and the average ALT and AST were 18.8 and 24.5 U/L on the seventh day. On the 7th day after the operation, it can basically return to the normal range. Therefore, it is considered that the use of medical glue to establish adhesion between the left outer lobe of the liver and the diaphragm is an effective way to achieve liver traction, and it is an effective way to add good operation in single-incision laparoscopic upper abdominal surgery. View and space. Wu Shuodong and others successfully completed 112 cases of single-port laparoscopic surgery with the assistance of liver paste technology, without complications such as liver tearing and bleeding. Preoperative ALT (16±11) U/L, AST (18±7) U/L, ALT (31±21) U/L, AST (34±26) U/L on the first day after operation, the difference was statistically significant (P<0.05), ALT (19±17) U/L, AST (19±12) U/L, no statistically significant difference compared with preoperative (P>0.05), so it is believed that the liver sticking technique is safe, has strong plasticity, can achieve good exposure effect, is easy to operate, and is suitable for single-hole Auxiliary exposure of the surgical field during laparoscopic left hypochondrium surgery.

Patients with lesions on the diaphragmatic surface of the liver, such as liver cirrhosis, cysts on the liver surface, hemangioma, etc., or those who are too obese, are not suitable for this method because they are likely to cause liver damage or the exposure effect is not good.

Vacuum-type liver stretching technology (LiVac retractor)

Gan et al reported 10 cases of laparoscopic surgery (6 cases of laparoscopic cholecystectomy, 3 cases of laparoscopic gastric banding, 1 case of laparoscopic esophageal hiatal hernia repair + fundoplication) using "vacuum laparoscopic liver traction". The device consists of a flexible silicone ring connected to a suction tube and connected to a regulated suction source. The suction tube enters the abdominal cavity along the existing trocar and places it in the liver and Suction was applied between the diaphragms to create a vacuum pressure in the ring, so that the liver was tightly adsorbed on the diaphragm, thereby exposing the surgical field. It was considered that the exposure effect was good and there was no clinically significant damage. Christian et al. studied the application of LiVac technology in 11 obese patients (BMI31.9) in single-port partial gastrectomy through a non-randomized double-center clinical series. They believed that the exposure effect was good, and there were few complications directly related to the technology. This technique provides a good surgical field even in obese patients with a high body mass index.

Conventional instrumental liver suspension method

1. Automatic Liver Suspension Device:

The automatic liver suspension device is made of purse wire and rubber tube. The puncture needles on both sides of the rubber tube pass through the left liver lobe parenchyma, peritoneum, subcutaneous tissue and skin in sequence, and are tied and fixed outside the abdominal wall to suspend the left liver lobe. Puncture the liver parenchyma about 2 cm away from the edge of the liver. On the one hand, it can ensure the suspension effect, and on the other hand, it can avoid the main blood vessels and bile ducts, so as to avoid postoperative bleeding and bile leakage. When fixing the suspension device with a knot outside the abdominal wall, the strength should be appropriate to avoid liver function abnormalities caused by the purse-string wire cutting the liver parenchyma. Postoperatively, electric coagulation was used to coagulate the puncture hole on the surface of the liver to prevent secondary bleeding and bile leakage.

2. Simple suspension method of chest trocar:

The simple suspension method of the chest trocar is to wrap the end of the No. 10 silk thread along the midpoint of the ordinary syringe cap and tie it in a knot. The other end of the silk thread is passed through to complete the suspension device. During the operation, a suspension device was placed in the main Trocar, and the needle holder was inserted vertically from the left outer lobe of the liver to insert the needle from the left outer lobe of the liver. After the needle was exposed, the needle was slowly and gently pulled from the liver until the needle was completely until exposed. The operator presses and positions the external intercostal space of the abdominal wall, and inserts the needle vertically at the positioning point in the abdominal wall. After the needle tip is exposed to the skin, the needle holder pulls the needle vertically out to suspend the liver. Observe the suspension height of the liver in the abdominal cavity, stop the silk thread at a suitable position, and take a vascular clamp from the abdominal wall to fix the root of the exposed silk thread. After the operation is completed, remove the suspension device, observe whether there is bleeding at the puncture point, and end the suspension of the liver.

3. Simple suspension method:

The simple suspension method is mainly aimed at the exposure of the biliary tract surgery area. Put one end of the double No. 7 silk thread into the abdominal cavity from the Trocar 2cm below the xiphoid process, let the outer end of the No. 7 silk thread come out of the Trocar and pull it outside the abdominal wall, and then pull the abdominal cavity The inner double No. 7 silk thread bypasses the round ligament of the liver, and the silk thread is tightened and fixed outside the abdomen, so that the liver can be suspended. This method avoids liver function damage caused by puncture of the liver, reduces the chance of bleeding, exposes clearly, and avoids the trauma caused by artificially lifting the liver to expose the common bile duct during the operation. The operation is simple and only uses the puncture hole under the xiphoid process, without Extra punches or penetrates the skin.

4. T-shaped suspension method:

The materials required for the T-shaped suspension method include: Jackson-Pratt drainage tube, 2-0 Prolene suture, Teflon tube, and straight needle. First, cut the Jackson-Pratt drainage tube 2-5 cm for traction of the gallbladder. Prolene sutures pass through the middle of the Teflon tube to make a T-shaped suspension device. The T-shaped suspension device is placed into the abdominal cavity through the Tractor, and blunt abdominal cavity is used to The endoscopic instrument lifts the left lobe of the liver so that the lower surface of the liver is clearly visible. Then the lower surface of the liver is punctured, and the needle is inserted on the upper surface. The puncture needle was exposed by puncturing the anterior abdomen and secured with a hemostat. The liver is suspended and kept in place, supported by the Jackson-Pratt drainage tube, the hemostat clamps the Prolene suture to keep the suspension, and the tension on the suture is adjusted by the hemostat to adjust the degree of liver suspension.

5. Penrose drainage tube suspension method:

A 6 mm Penrose drainage tube was selected, and three 2-0 nylon sutures were used to pass through the Penrose drainage tube with a distance of 5 cm each. Between the diaphragm and the small hole below the liver, pull the nylon suture to the ventral side of the liver through the small hole, use End Close to pull the suture out of the abdominal cavity, and insert it into the abdominal cavity from the far right side to the right rib, so that It passes through the abdominal wall and appears on the right side of the hepatic falciform ligament, pulls the nylon suture on the right side of the Penrose drainage tube to the outside of the abdominal wall, and finally inserts the End Close into the abdominal cavity from the left costal arch, and the nylon suture on the left is drawn out of the body , the liver is finally suspended by these three points. This method is simple and safe to operate, can be completed without special training, and reduces damage to liver function. This method is applicable not only to laparoscopic gastrectomy, but also to laparoscopic antireflux surgery, vagotomy, and obesity surgery.

Liver Suspension Method with Special Instruments

1. Medical glue fixation of the left outer lobe of liver:

Medical glue is a new generation of adhesive sealant. Its components are n-butyl cyanoacrylate and n-octyl cyanoacrylate. It has fast curing speed and strong adhesive force. It can be completely degraded in the body within 4 weeks. Based on the above characteristics, some scholars have applied medical glue to liver suspension. First, use gauze to dry the surface of the left liver diaphragm and the top of the diaphragm. The assistant uses an intestinal forceps to penetrate into the left lobe of the liver near the lesser omentum to lift up the left lobe of the liver, and at the same time wrap the tip of the other intestinal forceps with gauze The free edge of the left lobe was lifted gently so that the left hepatic diaphragm was close to the top of the diaphragm. The chief surgeon inserted a long needle into the abdominal cavity from 1-2 cm below the xiphoid process, and evenly sprayed medical glue on the left hepatic diaphragm. The left lobe of the liver was propped against the top of the diaphragm for 20-30 seconds until the glue was firmly fixed and the liver could be suspended.

2. Nathanson retractor liver suspension method:

Nathanson retractor (Nathanson's retractor, NR) is widely used in laparoscopic surgery because of its simplicity, which can provide a wide surgical field, but the liver is congested due to the continuous compression of the retractor during the operation Edema, bleeding and other complications. Studies have reported that the Nathanson retractor caused elevated transaminases in patients, and prolonged compression led to hepatic ischemic necrosis, liver failure, and liver atrophy. In a study, 14 of 52 patients who underwent laparoscopic gastric cancer resection had postoperative liver abnormalities after using NR, and 2 of 11 patients who underwent laparoscopic bariatric surgery had abnormalities through CT observation.

3. Modified Nathanson retractor liver suspension method:

In order to avoid liver damage caused by the use of NR, Kitajima proposed that intermittent use of NR to stretch the liver can effectively protect the liver. The key points of the improvement are to shorten the duration of liver traction, increase the release frequency of the retractor, and preserve the variable left hepatic artery as much as possible. For example, after the greater curvature of the stomach is dissected, the tractor is used to keep it in a released state, so as to avoid congestion of the liver parenchyma due to long-term compression. Transection of the duodenum requires sufficient surgical space. Insert the liver retractor close to the xiphoid process and place it near the hilum below the lateral liver segment. After transection of the duodenum, move the retractor laterally to the segment to The lesser curvature of the stomach is stretched, which makes the operative field wider and makes it easier to dissect lymph nodes along the lesser curvature of the stomach.

4. Clipping and Suture Liver Suspension Technique

The flexible liver retraction with clipping and suturing technique (FLRCS) uses a 48 mm straight needle, 2-0 prolene suture and a visceral retractor to suspend the liver. Puncture the right rib with a straight needle during pneumoperitoneum and elevate the liver crown to the right with sutures; after dissecting the lesser omentum, fix the retractor at the edge of the lesser omentum; at the right edge of the xiphoid process Puncture, pass the suture through the retractor, and export the suture out of the abdominal cavity by puncturing the right quarter rib, and finally achieve liver suspension through external traction on the suture. The FLRCS method can continuously draw the liver to the upper right side of the patient, so as to obtain a clear surgical field. At the same time, according to the needs of the liver position and changes in normal breathing, the traction force of the suture can be adjusted to avoid postoperative liver damage, and Reduce additional skin punctures.

5. DS suspension method:

The silicon disk of the DS suspension method (disk suspension, DS) is a leaf-shaped device made of a silicon rubber film, which has the characteristics of memory shaping. Firstly, the silicon disc is placed under the lateral hepatic segment by Trocar, and the serpentine retractor is placed into the abdominal cavity from the right side of the xiphoid process. The lateral hepatic segment is lifted with the silicon disc, and the falciform ligament is pulled by the serpentine retractor. Finally, the rubber The tendon is attached to the shaft end of the snake retractor, and sutures are used to sew the rubber band to the skin. Compared with suspending the liver with a serpentine retractor alone, the DS suspension method can meet the requirements of the operation field and prevent liver function damage caused by liver compression or traction and tearing. In addition, since the rubber band can assist the suspension, the snake-shaped tractor can move synchronously with the heartbeat and breathing, and the synchronous movement reduces the pressure on the liver and avoids liver congestion.

The DS suspension method allows the assistant's hands to be used freely when operating the two forceps, which relieves the surgeon of additional operations, thus contributing to the accuracy and safety of the surgical operation. If the DS suspension method cannot obtain a satisfactory surgical field in some cases, you can move the serpentine retractor to different positions to improve the field of vision; at the same time, observe the color of the liver through the transparent silicon membrane to confirm whether the liver is congested or blood flow obstacle. When lavage is required during the operation, the silicon disc is transferred from the liver to the left upper abdomen, and suction is performed above the silicon disc to prevent the inhalation of fat. This approach is suitable not only for laparoscopic gastrectomy, but also for other procedures including bariatric surgery, even for patients with hepatomegaly.

6. Red catheter suspension method:

Take a red urinary catheter, whose central position is marked with a silk thread, and the main Trocar inserts the marked red urinary catheter into the abdominal cavity, separates the lesser omentum, and fixes the central point of the catheter to the lesser omentum stump with a Hemrlock clamp ( Liver side), under the xiphoid process, use mosquito forceps to puncture and clamp both ends of the catheter, and adjust the pulling length outside the abdominal wall to adjust the appropriate exposure position.

7. Hepatic round ligament self-suspension method:

Disconnect the round ligament of the liver from the distal end, turn up the distal round ligament of the liver, separate the left triangular ligament, free the left outer lobe of the liver, wrap the left outer lobe from back to front, suture the broken end to the peritoneal layer of the abdominal wall for suspension Hang the liver (as shown in Figure 2). Through this method, additional punctures in the abdominal wall are avoided, and at the same time, abnormal liver function caused by puncture or compression of the liver is avoided. The round ligament self-suspension method uses simple instruments, but compared with the red catheter method, the operation time is relatively longer.

The liver suspension technology researched by our center has the following advantages:

(1) Non-invasive exposure, no risk of damage to the liver and other parts.

(2) The suspension effect is good, and the surgical field of view is well exposed.

(3) There is no need for additional fixation by assistants, and there is no need for another Trocar to increase puncture and cost.

(4) The required materials are easy to obtain, and there is no need to purchase additional equipment.

(5) High adjustability. For example, the length and tension of the catheter can be adjusted at any time according to the intraoperative situation to improve and change the exposed area.

(6) The recovery of the operating range can be confirmed after the operation is completed, and there is no need to worry about postoperative complications caused by exposure operations.

(7) It is easy to popularize, and the patient benefit rate is high.