Combined suture retraction of the falciform ligament and the left lobe of the liver during laparoscopic total gastrectomy

Abstract

The inferior surface of the liver’s left lobe overlies important structures such as the hepaticoduodenal ligament, the lesser omentum, and the gastroesophageal junction. Exposure of these structures is mandatory during dissection of lymphatic basin when total laparoscopic gastrectomy is performed. This report describes a liver retraction technique using a suture that simultaneously retracts both the falciform ligament and the left lobe of liver. The reported technique involves placement of a suture through the mid pars condensa of the lesser omentum and its retrieval through a single subxyphoid stab wound after one limb has been passed through the avascular segment of the falciform ligament. The end result is a V-shaped formation that maintains the falciform ligament and the left lobe of liver in a retracted cranial and anterior position. In this prospective study, 55 patients (34 men and 20 women) with gastric cancer underwent laparoscopic total gastrectomy using the reported liver retraction technique between August 2008 and November 2009. The mean age of the patients was 59 years (range, 31–86 years), and their mean body mass index (BMI) was 24 kg/m² (range, 18.2–31.9 kg/m²). The mean time required to complete the procedure was 4 min (range, 3–7 min). All the patients had adequate exposure of the dissection field without the need for an additional retraction device. No failures or complications resulted from this pars condensa suture liver retraction technique. The technique of combined falciform and left lobe of the liver retraction using a single suture is a safe, effective, and efficient method for exposing the hepaticoduodenal ligament, lesser omentum, and gastroesophageal junction in patients undergoing total laparoscopic gastrectomy.