A Simple Method of Intracorporeal “W-shaped” Liver Retraction Technique for Minimally Invasive Gastric Cancer Surgery

Abstract

Background: Minimally invasive gastric cancer surgery requires an extended liver retraction in order to provide optimal operative view, working space for lymph node dissection, and esophageojejunal reconstruction. Ideally, it should avoid reposition of the retractor, additional skin incision or puncture, and liver parenchyma injury. Herein, we introduced an intracorporeal W-shaped liver retraction technique (W-LRT) for minimally invasive gastric cancer surgery without an additional incision or abodminal puncture.Methods: Between October 2013 and October 2016, the W-LRT was applied in 80 patients undergoing minimally invasive gastric cancer surgery. The W-LRT was performed using one 75 cm 3-0 monocryl suture with its end fixed to one hemoclip. The perioperative outcome was recorded.Results: The W-LRT was applied in 80 gastric cancer patients using either laparoscopic approach (N = 69) or robotic approach (N = 11). The mean age was 62.7 ± 14 years and the mean body mass index (BMI) was 24.1 ± 3.6 kg/m 2 . The time required for W-LRT was 5.6 ± 5.2 minutes in laparoscopic approach and 6.2 ± 4.7 minutes in robotic approach. This technique was successfully applied in all procedures and no other technique or additional instrument was required. Major complications developed in 7 patients (8.8%), classified as greater than Clavien-Dindo classification II; however, there was neither any intraoperative nor postoperative major complication related to W-LRT. The length of hospital stay was 9.1 ± 4.4 days. Conclusions:In laparoscopic or robotic gastric cancer surgery, the W-LRT can provide excellent operative view during lymph node dissection and reconstruction of esophagojejunostomy and eliminate an additional skin incision or abdominal puncture.

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“…The assistant surgeon stands between the patient's legs. The left lobe of the liver is retracted using the W-shaped liver retraction technique to expose the porta hepatis [23]. The transverse colon is lifted upward to expose the fourth part of the duodenum and the proximal jejunum is subsequently divided at 20 cm distal to the ligament of Treitz.…”