title: A suture-based liver retraction method for laparoscopic bariatric procedures: results from a large case series.
abstract: BACKGROUND
  Laparoscopic bariatric surgery requires retraction of the left lobe of the liver to provide adequate operative view and working space. Conventional approaches utilize a mechanical retractor and require additional incision(s), and at times an assistant.
  
  
  OBJECTIVE
  This study evaluated the safety and efficacy of a suture-based method of liver retraction in a large series of patients undergoing laparoscopic bariatric surgery. This method eliminates the need for a subxiphoid incision for mechanical retraction of the liver.
  
  
  METHODS
  Two hospitals in the Midwest with a high volume of laparoscopic bariatric cases.
  
  
  METHODS
  Retrospective chart review identified all patients undergoing bariatric surgery for whom suture-based liver retraction was selected. The left lobe of the liver is lifted, and sutures are placed across the right crus of the diaphragm and were either anchored on the abdominal wall or intraperitoneally to provide static retraction of the left lobe of the liver.
  
  
  RESULTS
  In all, 487 cases were identified. Patients had a high rate of morbid obesity (83% with body mass index >40 kg/m(2)) and diabetes (34.3%). The most common bariatric procedures were Roux-en-Y gastric banding (39%) and sleeve gastrectomy (24.6%). Overall, 6 injuries to the liver were noted, only 2 of which were related to the suture-based retraction technique. Both injuries involved minor bleeding and were successfully managed during the procedure. The mean number of incisions required was 4.6.
  
  
  CONCLUSIONS
  Suture-based liver retraction was found to be safe and effective in this large case series of morbidly obese patients. The rate of complications involving the technique was extremely low (.4%).
authors.affiliation: Division of General Surgery, University of Missouri School of Medicine, Columbia, Missouri. Electronic address: radltorre@aol.com.
authors.forename: Roger
authors.initials: R
authors.lastname: de la Torre
authors.affiliation: Bariatric Surgery, Des Peres Hospital, St Louis, Missouri.
authors.forename: J Stephen
authors.initials: JS
authors.lastname: Scott
authors.affiliation: University of Missouri School of Medicine, Columbia, Missouri.
authors.forename: Emily
authors.initials: E
authors.lastname: Cole
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D050110:Bariatric Surgery / Q000379:methods*; D015992:Body Mass Index; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008099:Liver / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D010149:Postoperative Pain / Q000517:prevention & control; D012189:Retrospective Studies; D013536:Suture Techniques / Q000295:instrumentation*; D013537:Sutures; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: Bariatric surgery; Laparoscopic surgery; Liver retraction; Morbid obesity; Postoperative pain; Suture-based retraction