Department of Hepatobiliary and Pancreatic Surgery, NHO Kyushu Cancer Center, Fukuoka, Japan.
Department of Gastroenterological Surgery, NHO Kyushu Cancer Center, Fukuoka, Japan.
Asian J Endosc Surg. 2024 Oct;17(4):e13377. doi: 10.1111/ases.13377.
Achieving an adequate surgical plane through optimal traction is crucial for liver parenchymal transection in minimally invasive liver surgery (MILS). MILS is more technically demanding than open liver surgery because of limited instrument mobility and the inability to use the surgeon's hand, potentially leading to iatrogenic injuries. The Pulley maneuver using barbed sutures has been used for laparoscopic hepatectomy; however, the sutures are single-use and may pass through the liver parenchyma, making it uneconomical and inflexible. To address this, we developed a modified pulley maneuver using a barbed with a nonabsorbable polymer clip and metal clip for parenchymal transection in MILS.
Before liver transection, we prepared barbed sutures and attached nonabsorbable polymer and metal clips to the distal end. The metal clip prevented the nonabsorbable polymer clip from slipping, allowing one suture to be reused three times. Before liver transection, the suture was passed through the liver surface twice, with the clips to reduce iatrogenic damage. The sutures were anchored to the diaphragm or peritoneum for optimal liver traction. A laparoscopic or robotic grasper adjusted the suture tension for the appropriate transection plane. In open-pit-shaped resections, the liver is lifted ventrally for deeper access, whereas in wedge-shaped resections, it is elevated in the caudal view. The modified pulley maneuver provides stable liver traction.
The modified pulley maneuver is an economical, simple, and feasible method for enabling stable liver traction, thereby enhancing the versatility and safety of liver parenchymal transection in MILS.
在微创肝外科手术（MILS）中，通过最佳牵引实现足够的手术平面对于肝实质切开至关重要。由于仪器移动性有限且无法使用外科医生的手，MILS 比开放性肝手术更具技术挑战性，这可能导致医源性损伤。使用带倒钩缝线的滑轮操作已用于腹腔镜肝切除术；然而，缝线是一次性使用的，并且可能穿过肝实质，因此不经济且不灵活。为了解决这个问题，我们开发了一种改良的滑轮操作，使用带倒钩的缝线和不可吸收的聚合物夹和金属夹进行 MILS 中的实质切开。
在进行肝切开之前，我们准备了带倒钩的缝线，并将不可吸收的聚合物夹和金属夹连接到缝线的远端。金属夹可防止不可吸收聚合物夹滑动，从而使一根缝线可以重复使用三次。在进行肝切开之前，缝线通过肝表面穿过两次，使用夹子减少医源性损伤。缝线固定在膈肌或腹膜上以获得最佳的肝脏牵引。腹腔镜或机器人抓握器调整缝线张力以获得适当的切开平面。在开腹式切除中，肝脏被提起以获得更深的进入，而在楔形切除中，肝脏被提起以获得尾侧视图。改良的滑轮操作可提供稳定的肝脏牵引。
改良的滑轮操作是一种经济、简单且可行的方法，可实现稳定的肝脏牵引，从而增强 MILS 中肝实质切开的多功能性和安全性。
