Hiatal sling liver retraction technique in bariatric and upper gastrointestinal surgeries - Our 15 year experience with 1874 surgeries.

Introduction: Liver retraction is an important aspect when performing minimal access surgeries, especially bariatric and upper gastrointestinal (GI) surgeries. Various liver retraction methods are available and have been tried. Here, we present our experience with our indigenous hiatal sling technique for liver retraction and compare it with Nathanson liver retractor which is a popular and commonly used liver retraction method.

Patients and methods: This is a retrospective observational study of 1874 patients who underwent bariatric and upper GI surgeries over the last 15 years since September 2009. A secondary study was conducted amongst the two groups of patients who underwent upper GI and bariatric surgeries using hiatal sling technique and Nathanson retractor system for liver retraction between January 2023 and October 2023. End points measured were time taken, conversions and complication along with liver function tests (LFTs) such as aspartate aminotransferase (AST) and alanine transaminase measured between the two groups pre- and postoperatively day 0, day 1, day 3 and day 7.

Results: In our series of 1874 patients, hiatal sling liver traction was possible without any difficulties in all except 2 patients with no associated liver injury and with adequate exposure. In the comparative study, patients in the hiatal sling group (Group B) had significantly lesser elevation in LFTs as compared to the patients in the Nathanson liver retraction group (Group A), with no adverse events in both the groups.

Conclusion: Hiatal sling technique for liver retraction is an effective technique which provides adequate exposure of the hiatus and causes lesser liver insult compared to rigid liver retraction system like Nathanson liver retraction system. Hiatal sling does not interfere with surgeons' field causing less errors during surgery and thus making it more ergonomic friendly.