title: Minimal Invasive Internal Liver Retractor in Conventional and Trans-umbilical Single-Incision Laparoscopic Sleeve Gastrectomy: Video Report.
abstract: BACKGROUND
  Sleeve gastrectomy (SG) is a safe and efficient procedure with comparable results between conventional and single-incision approach in selected patients. However, the critical point in both approaches is the retraction of the hypertrophic and fatty left lobe of the liver which increases technical difficulties and limit the exposure of the hiatus. Traditional liver retractors require an additional sub-xiphoid incision for insertion and cause post-operative pain as well as iatrogenic liver injuries. Various techniques have been described to allow adequate liver retraction through smaller incisions or fewer ports without compromising patient safety. However, some disadvantages of these methods are the need for incision of the liver ligament or diaphragmatic crura puncture rendering the device difficult to reposition.
  
  
  METHODS
  Two morbidly obese patients underwent a SG by conventional laparoscopy and by trans-umbilical single-incision using a novel minimal invasive internal liver retractor: the Versa Lifter Band®.
  
  
  RESULTS
  This soft and flexible internal retractor was fully repositionable and adjustable intraoperatively. The time required to complete the liver retraction was 4 min 12 s in conventional surgery and 5 min 23 s in single-incision approach. Liver retraction was always satisfying resulting in limited intra-operative difficulties without the need of additional retractors/ports or conversion in both patients. No adverse outcomes occurred during the intra and post-operative periods without rise in aspartate aminotransferase and alanine-aminotransferase serum levels.
  
  
  CONCLUSIONS
  In our preliminary experience, this internal liver retractor was easy to handle and provided an effective and safe retraction with good exposure of the surgical field and improved ergonomy in single incision as well as reduced port laparoscopic SG.
authors.affiliation: Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Digestive and Hepato-Pancreato-Biliary Surgery, Liver transplantation; Pitié-Salpêtrière University Hospital, Pierre & Marie Curie University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France. Laurent.genser@gmail.com.|Institute of Cardiometabolism and Nutrition (ICAN), Pitié-Salpêtrière Hospital, Paris, France. Laurent.genser@gmail.com.
authors.forename: Laurent
authors.identifier: http://orcid.org/0000-0001-7635-7813
authors.initials: L
authors.lastname: Genser
authors.affiliation: Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Digestive and Hepato-Pancreato-Biliary Surgery, Liver transplantation; Pitié-Salpêtrière University Hospital, Pierre & Marie Curie University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France. Adriana.torcivia@aphp.fr.
authors.forename: Adriana
authors.initials: A
authors.lastname: Torcivia
authors.affiliation: Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Digestive and Hepato-Pancreato-Biliary Surgery, Liver transplantation; Pitié-Salpêtrière University Hospital, Pierre & Marie Curie University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France. Arnaud.saget@aphp.fr.
authors.forename: Arnaud
authors.initials: A
authors.lastname: Saget
authors.affiliation: Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Digestive and Hepato-Pancreato-Biliary Surgery, Liver transplantation; Pitié-Salpêtrière University Hospital, Pierre & Marie Curie University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France. Jean-christophe.vaillant@aphp.fr.
authors.forename: Jean-Christophe
authors.initials: JC
authors.lastname: Vaillant
authors.affiliation: Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Digestive and Hepato-Pancreato-Biliary Surgery, Liver transplantation; Pitié-Salpêtrière University Hospital, Pierre & Marie Curie University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France. Jean-michel.siksik@aphp.fr.
authors.forename: Jean-Michel
authors.initials: JM
authors.lastname: Siksik
mesh_terms: D000410:Alanine Transaminase / Q000097:blood; D001219:Aspartate Aminotransferases / Q000097:blood; D005743:Gastrectomy / Q000295:instrumentation* / Q000379:methods; D006801:Humans; D010535:Laparoscopy / Q000295:instrumentation* / Q000379:methods; D008099:Liver / Q000601:surgery*; D009767:Obesity, Morbid / Q000097:blood / Q000601:surgery*; D011184:Postoperative Period
chemical_list: D001219:Aspartate Aminotransferases; D000410:Alanine Transaminase
keywords: Bariatric; Liver retractor; Single port; Sleeve; Trans-umbilical