fig6

Figure 6. These images demonstrate the modified Pulley Maneuver using Stratafix Symmetric 3/0 for a segment 7 resection. (A) The Stratafix is sutured to the lateral liver edge and anchored to the anterior abdominal wall’s peritoneum close to the midline (well above the costal margin), to provide superior and medial traction. The needle is retained intracorporeal for the duration of surgery; (B) The liver remains suspended due to the traction by the Stratafix pulley system. Only one assistant port is required to provide retraction whilst the hepatotomy deepens along the posterior surface of the liver, adjacent to the inferior vena cava, to isolate the segment 7 inflow pedicle; (C) Once the pedicle is isolated and clamped, ICG is administered systemically and segment 7 is negatively stained. The right triangular ligament is released to mobilize the liver, and the Stratafix needle is pulled in a gentle retrograde direction off from the prior peritoneal anchor point and now sutured to a new pulley site, the left lateral diaphragmatic surface. The left lateral retraction is further enhanced by tilting the patient’s bed position, to maximize the effects of gravity; (D) The ICG demarcation line between the negatively stained segment 7 and segment 6 is now medialized (demarcated by the dotted line); (E) Parenchymal transection can now proceed with ICG-overlay guidance in the anatomical plane. ICG: Indocyanine green.