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1*Hamdy Abd EL Alim Mohammed Farag and 2Ahmed Abdel Mawgood E L Tokhy 1,2MD General Surgery Department Al Azhar University Hospitals .

Article Received on 0 8/05/2017 Article Revised on 2 8/05/2017 Article Accepted on 18 /06/2017


Laparoscopic bariatric surgeries are chal lenging

procedures to perform. A high body mass index (BMI)

and an enlarged liver increase the surgery’ difficulty .

Preoperative weight loss can help to decrease the size of

the liver. However, an enlarged liver can impede optimal

visualization of the stomach during surgery. The

challenge for many surgeon s is how to retract the left

lobe of the liver to obtain an adequate exposure of vision

and maximum working space. Currently, the most

common techniques (i.e., Nathanson & Snowden –

Pencerretractors) require an additional subxiphoid

incision, involve attachm ent to the operating room table

and increase riskof iatrogenic injury. [1] Furthermore,

operative time is required to setup these retractors .

Several more recently reported liver retraction

techniques eliminate the subxiphoid incision. These

methods require modified surgical drains, liver

suspension tape, silicone disks, combinations of clamps

and retractors and suture – based techniques .[2,12] No

single technique has proven to be ideal. However, It is

widely accepted that these techniques involve the risk of

iatrogenic liver injury, postoperative pain,and organ

scarring. [3,13] Therefore, the ideal technique for liver

retraction during laparoscopic bariatric surgery would

displace the liver to allow for optimal exposure of the

hiatus in a non traumatic fashion and does not consume

extra time. Additionally, if this can be achieved without

incision or trocar, using a percutaneous retractor it would

be preferable as Regard cost as well as cosmetic

view.( Fig. 1) .

10 ml trocar followed by stone forceps without port

(figure 1)


This is a large case s of consecutive bariatric operations

by a multiple surgical group s. A tota l 12 0 patients

SJIF Impact Factor 4.161

Research Article

ISSN 2394 -3211





ejpmr, 2017,4(7), 177 -179

*Corresponding Author: Hamdy Abd EL Alim Mohammed Farag

MD General Surgery Department Al Azhar University Hospitals .


Background : Laparoscopic bariatric surgery requires retraction of the left lobe of the liver to provide adequate

exposure of the hiatus and the stomach. The most co mmon used approaches are use of retractors that require

another incisions and prolong ed operative time. Objectives : A prospective assessment of the efficacy and safety of

a percutaneous stone forceps as liver retractor in patients undergoing laparoscopic b ariatric surgery. Methods : A

prospective revie w was performed on 120 patients undergoing bariatric surgery from January2016 to January 2017

in Al azhar university hospitals. A percutaneous stone forceps was used to retract theleft lobe of the liver in a ll

cases. The retractor can be repositioned as necessary by releasing and regrasping the diaphragm at different sites.

Results: This technique was used in 120 patients from January2016 until january 2017. The average body mass

index was 50 (range:35 –65). I n all patients, this method was found to be enough to complete the bariatric srgery.

The majority of procedures included laparoscopic Roux -en-Y gastric bypass, sleeve gastrectomy. No intraoperative

liver injuries occurred with use of this technique. Conclusion : Percutaneous retraction of theliver using the

percutaneous stone forceps grasper was found to be safe and effective in those morbidly obese patients. The rate of

complications involving this technique is very low. This novel method provides saf e and effective retraction with

less trauma and better cosmesis than conventional technique.

KEYWORDS : bariatric surgery, liver retraction, percutaneous technique .


Hamdy et al. European Journal of Pharmaceutical and Medical Research


underwent bariatric surgery using the stone forceps

grasper as a percutaneous live r retractor . The patients’

medical rec ords were reviewed for demo graphic

information, co-morbidities, and 30 -day complica tion

rate . The patients were prepped and draped in the usual

fashion. A Vere us needle was inserted into Palmer’s

point and used to establish pneumoperitoneum.

A5 -mmop tical trocar was inserted into the left upper

quadrant. After inspecting all 4 abdominal quadrants,

additional trocars were inserted as needed for that

particular bariatric surgery. Next, the stone forceps

retractor was introduced inferior to the xiphoid process

under direct laparoscopic visualization. The left lobe of

the liver was retracted anteriorly to the abdominal wall

by directing the instrument underneath the liver and

attaching it to the peritoneum covering the apex of the

diaphragmatic crura (Fig. 2 and 3). The liver retractor

can be easily manipulated as needed to facilitate

maximum exposure of the hiatus. At the end of the case,

the retractor was removed under direct laparoscopic


After retr action hiatus is completely seen (figure 2)

Post port healing (figure 3)


A total of 120 bariatric surgery patients underwent liver

retraction using this technique by multiple surgical group

in Al azhar university hospitals .

Table 1 : is a summary of the patients’ characteristics.

Value Pat ient characteristics


22 _ 56

Age in years





Gender (n %)




38 _46


Mean (SD)


BMI : body mass index; n : number of patients; SD :

standard deviation; Yr : year.

The patients who underwent bariatric surgery we re

pre dominantly female and morbidly obese (mean BMI:

42 kg/m2; range: 38 –46). Laparo scopic sleeve

gastr ectomies, 85 Roux -en-Ygas tric bypasses 35 (Table


N(%) Procedure

35 (29.1) Lap.gastric bypass

85(70.8) Lap. Sleeve gastrectomy

Lap : laparoscopic ; n : number of patients; RYGB : Roux –

en-Y gastric bypass.

The estimated operative time for the placement of this

liver retractor was 1 minute in all cases. There were

3cases where an additional stone forceps retractor was

used to retract avery largeliver. No conversion to a

conventional liver retractor was required for this case s.

The post operative course was uneventful in all cases.

The wound sit from the stone forcep retractor was barely

noticeable at 2weeks post operatively. There were no

postoperative compli cations at 30days.


A critical requirement in bariatric surgery is exposure of

the hiatus by retraction of the left lobe of the liver.

Traditional liver retractors generally require an

additional port site, increase the risk of infection and

consume operative time to assemble . Many approaches

require additional materials and instruments and increase

operative time. [5,14] Many techniques for liver retraction

have been described in the literature. One such procedure

is known as the Istanbul tec hnique, which is utilized

during single incision laparoscopic surgery(SILS)and

was first describedby Hamzaoglu etal. [7,15] In this

technique, a Penrose drain is prepared with 2silk sutures

tied to each end of the drain. It is then inserted

througha10 -mmtro car of the SILSport and placed below

the lateral segment of theliver, where it serves as a

“hammock” to suspend the liver. Another liver

suspension technique was described by Wooetal. [4,6] and

requires the use of two 4 x4gauze pads, 2–0

polypropylene monof ilament suture,and a70 -mm doubl


Hamdy et al. European Journal of Pharmaceutical and Medical Research


estraight taper needle. The gauze pads are folded and

then threaded using the suture to create a make shift a

traumatic support for the liver suspension. Where as

there is successful a traumatic suspension of the liver,

thes e techniques require additional operative time that

must be spent on manually fashioning the “hammock”

and gauze sutures. A technique of liver retraction that

utilizes a silicone disc is known as the ?-shaped

technique, first described by Saeki et al.[8,9,12] This

technique was primarily utilized during laparoscopic

gastrectomies in patients with gastric cancer for lateral

liver segment retraction.

In this technique, a leaf -shaped silicone is used alo ng

with aloop created using 2 –0 monofilament

polypropylene suture. After performing the necessary

suturing, the silicone disc is introduced into the

abdominal cavity and placed underneath the liver where

traction is applied to the suture, allowing the disc to lift

and suspend the lateral segment of the liver. Once critical

time is needed to fashion the silicone disc before its use

during the surgical procedure. Another technique that

utilizes a percutaneous approach to liver retraction is

described by Giann ietal. [10,16], which utilizes a15 –

cmVerrus needle. After percutaneous insertion into the

subxiphoid area, the needle is covered by a16to18 French

nasogastric or drainage tube. An angle is created at the

covered tip of the needle, allowing for easy liver

retracting. This technique reduces the need for additional

incisions, trocars and retractors, but may not provide

adequate support for retraction and suspension of larger

livers, which are frequently encountered in bariatric

patients. A randomized controlled trial comparing 3

methods of liver retraction for bariatric surgery was

reported in2013 by Goel etal. [3,11]


The goal of this paper is to describe our technique of

percutaneous liver retraction and highlight the fact that

this has been used by us as the only method of liver in

bariatric cases. The stone forceps retractor can be used

safely and efficiently to obtain adequate retraction of the

left lobe of the liver during laparoscopic bariatric

procedures over a wide range of BMIs. We have also

found that the technique is associated with better

cosmesis, shorter operative times and ease of

maneuverability during repositioning if necessary .


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