Ports minimization with mini-port and liver flexible retractor: an ergonomic and aesthetic alternative for single port in laparoscopic gastric bypass.

BACKGROUND The laparoscopic access, with its classically known benefits, pushed implementation in other components, better ergonomy and aesthetic aspect. AIM To minimize the number and diameter of traditional portals using miniport and flexible liver retractor on bariatric surgery. METHOD This prospective study was used in patients with less than 45 kg/m2, with peripheral fat, normal umbilicus implantation, without previous abdominoplasties. Were used one 30° optical device with 5 mm in diameter, four accesses (one mini of 3 mm to the left hand of the surgeon, one of 5 mm to the right hand alternating with optics, one of 12 mm for umbilical for surgical maneuvers as dissection, clipping, in/out of gauze, and one portal of 5 mm for the assistant surgeon), resulting in a total of 25 mm linear incision; additionally, one flexible liver retractor (covered with a nelaton probe to protect the liver parenchyma, anchored in the right diaphragmatic pillar and going out through the surgeon left portal) to visualize the esophagogastric angle. RESULTS In selected patients (48 operations), gastric bypass was performed at a similar time to the procedures with larger diameters (5 or 6 portals and 10 mm optics, with sum of linear incision of 42 mm) including oversuture line on excluded stomach, gastric tube and mesenteric closing. The non sutured portal of 3 mm and the two of 5 mm with subdermal sutures, were hardly visible in the folds of the skin; the one of 12 mm was buried inside the umbilicus or in the abdominoplasty incision. CONCLUSION Minimizing portals is safe, effective, good ergonomic alternative with satisfactory aesthetic profile without need for specific instruments, new learning curve and limited movement of the instruments, as required by the single port.