Traction method with pulley maneuver in minimally invasive hepatobiliary pancreatic surgery: how I do it differently?

BACKGROUND: Achieving optimal traction and exposure in minimally invasive hepatobiliary and pancreatic surgery remains a significant challenge, often necessitating additional ports or assistants. This article describes novel traction techniques utilizing the Stratafix® symmetric barbed suture, repurposed from its original wound closure design, to enhance surgical efficiency and control. METHODS: We detail the "Pulley maneuver," a versatile approach for various hepatobiliary and pancreatic procedures. Key modifications include a "Sling pulley maneuver with Endo-loop" for pancreatic elevation during distal pancreatectomy, a "traction of vascular structure with vessel loop" for precise hilar lymph node dissection, and a "traction of gallbladder" technique to provide an additional "hand" in robotic single-site cholecystectomy. The Stratafix suture's unique symmetrical anchors offer superior tissue-holding strength, allowing for dynamic, multi-directional tension adjustments without knot tying. RESULTS: This repurposing offers a simple, effective, and reproducible solution to exposure challenges. It enhances surgical ergonomics through stable, hands-free retraction, improves visualization of critical structures, and potentially reduces the need for additional trocars or assistants. The ability to create adjustable traction points with minimal equipment is a significant advantage in complex cases. CONCLUSION: The "Pulley maneuver" using the Stratafix symmetric barbed suture represents a valuable technical variation in minimally invasive hepatobiliary and pancreatic surgery. Its versatility, ease of application, and superior tissue-holding capabilities make it an essential tool for optimizing the surgical field, ultimately enhancing patient safety and surgical outcomes.