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[Retraction-associated liver injuries in laparoscopic sleeve gastrectomy: incidence, retraction methods and role of
L I Vardaev1,2, R V Ipatkin2, K E Mironov1,2
1Russian University of Medicine, Moscow, Russia.
Objective:
To assess the incidence and characteristics of retraction-associated liver injuries in laparoscopic sleeve gastrectomy (LSG), different liver retraction techniques and impact of the third assistant on reducing the risk of hepatic injury.
Material And Methods:
We reviewed literature data (2010-2025) and retrospectively analyzed 1089 consecutive LSG procedures. In early phase, rigid retractors, including the Nathanson retractor (n=20), were used. The main cohort consisted of more than 700 procedures performed with a six-port technique and dynamic atraumatic liver retraction by a dedicated third assistant. Additional 150 surgeries were performed by a stable unchanged surgical team.
Results:
The Nathanson retractor resulted in liver injury in 15% of cases, including capsular tears with bleeding (10%) and segmental ischemia with 8-10-fold elevation of liver enzymes (5%). In six-port technique with the third assistant, the incidence of liver injury was 0.57%. All cases occurred at temporary replacement of experienced assistant. There were no hepatic injuries after 150 consecutive procedures performed by a stable team.
Conclusion:
Rigid liver retraction-particularly with the Nathanson retractor - is a significant modifiable risk factor for hepatic injury during LSG. The six-port approach, dynamic atraumatic retraction, and inclusion of a dedicated third assistant reduce complication rates. Surgical team stability is a critical determinant of procedural safety.
