A Novel Liver Retraction Method Using a Polypropylene Suture in Robotic Gastrectomy for Gastric Cancer: The Subphrenic Pulley Method

Abstract

Introduction

Effective liver retraction is crucial in minimally invasive upper gastrointestinal surgeries, including laparoscopic gastrectomy and robotic gastrectomy (RG) for gastric cancer, to ensure optimal visualization and sufficient working space. Various techniques have been developed to improve the surgical view, simplify procedures, and reduce complications. However, liver enzyme elevation has been a notable concern in these procedures. To address these challenges, we developed the subphrenic pulley (SP) method, a novel liver retraction technique, and evaluated its safety and feasibility in RG.

Methods

We retrospectively analyzed the initial 111 consecutive cases of RG for gastric cancer at a single center between January 2016 and September 2023. The SP method used a 2-0 polypropylene suture with a curved needle, which was placed in the left subphrenic peritoneum, the right side of the esophageal hiatus, and the right subphrenic peritoneum. The suture ends were pulled out from the left upper abdominal wall, achieving ventral and cranial retractions of both the lateral segment and round ligament of the liver.

Results

No case required re-retraction or additional methods, and no case of liver laceration was observed. The incidence of Grade ≥ 3 liver enzyme elevation was 12.6% (14/111) in all cases and 3.5% (3/86) in the subset of cases without aberrant left hepatic artery dissection. Additionally, no patient needed treatment for liver dysfunction.

Conclusion

The SP method is a valuable, simple, and safe liver retraction technique in minimally invasive upper gastrointestinal surgeries, ensuring effective retraction without requiring additional skin incisions.