title: Review of various liver retraction techniques in single incision laparoscopic surgery for the exposure of hiatus.
abstract: BACKGROUND
  The main aspect of concern for upper GI procedures has been the retraction of the liver especially large left lobes as commonly encountered in Bariatric surgery. Not doing so would compromise the view of the hiatus, hence theoretically reducing the quality of the surgery and increasing the possibility of complications. The aim of this study was to review the various liver retraction techniques in single incision surgery being done at our institute and analyze them.
  
  
  METHODS
  A retrospective study of the various techniques and a subsequent analysis was made based on advantages and disadvantages of each method. Objectively a quantitative measure of hiatal exposure was done using a scoring system based on the grade of exposure after reviewing the surgical videos. From January 2011 to January 2013 total 104 patients underwent single incision surgery with the various liver retraction techniques with following grades of exposure -liver suspension tube technique with naso gastric tubing (2.11) and with corrugated drain (2.09) needlescopic method (1.2), Umbilical tape sling (1.95), crural stitch method (2.5). Needeloscopic method has the best grade of exposure and is the easiest to start with. The average time to create the liver retraction was 2.8 to 8.6 min.There was no procedure related morbidity or mortality.
  
  
  CONCLUSIONS
  The mentioned liver retraction techniques are cost effective and easy to learn. We recommend using these techniques to have a good exposure of hiatus, without compromising the safety of surgery in single incision surgery.
authors.affiliation: Department of Bariatric Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India.
authors.forename: Praveenraj
authors.initials: P
authors.lastname: Palanivelu
authors.affiliation: Department of G.I Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India.
authors.forename: Kedar Pratap
authors.initials: KP
authors.lastname: Patil
authors.affiliation: Department of G.I Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India.
authors.forename: Ramakrishnan
authors.initials: R
authors.lastname: Parthasarathi
authors.affiliation: Department of G.I Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India.
authors.forename: Jaiganesh K
authors.initials: JK
authors.lastname: Viswambharan
authors.affiliation: Department of HPB Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India.
authors.forename: Palanisami
authors.initials: P
authors.lastname: Senthilnathan
authors.affiliation: Department of Bariatric Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India.
authors.forename: Chinnusamy
authors.initials: C
authors.lastname: Palanivelu
keywords: Hiatal exposure; laparoscopic surgery; liver retraction techniques; single incision surgery