`The “Tuck-away” liver retraction technique: A Safe, Cost-effective Strategy for Hiatal Exposure During Pediatric Laparoscopy

Introduction: Effective liver retraction is a crucial step in laparoscopic hiatal surgery, providing optimal exposure of the esophageal hiatus and esophagogastric junction. Various techniques have been developed to achieve adequate visualization, but many are associated with potential complications, including significant postoperative elevations in liver enzymes and more severe hepatic injuries such as lacerations, bleeding, and even liver necrosis. The “tuck-away liver retraction” technique, which involves tucking the left lobe of the liver through a window in the falciform ligament, has been described as a safe alternative in single-port laparoscopic surgery. However, its application in standard laparoscopic procedures has not been extensively studied. Methods: A retrospective review was conducted on 82 pediatric patients who underwent laparoscopic surgery for hiatal pathologies between January 2018 and December 2023. The “tuck-away” liver retraction technique was employed in 9 cases where traditional retraction methods were insufficient due to large liver size or limited working space. Data on patient demographics, operative time, intraoperative complications, and postoperative liver enzyme levels were collected and analyzed.Results: The “tuck-away” liver retraction technique was successfully performed in 9 out of 10 cases (90%). The mean operative time for the liver retraction procedure was 18±3.8 minutes. Minor liver abrasions were observed in 3 cases (33.3%), managed effectively with cauterization. No major liver injuries, subcapsular hematomas, or significant postoperative liver enzyme elevations were reported, demonstrating the technique’s safety and feasibility.Conclusion: The “tuck-away” liver retraction technique is a viable and safe alternative for liver retraction in laparoscopic hiatal surgery, particularly in challenging cases involving large livers or limited working space. Although technically demanding, this method offers excellent exposure with minimal risk of liver injury. Further studies with larger sample sizes are recommended to validate these findings and refine the technique’s application.