{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,8]],"date-time":"2026-06-08T17:03:10Z","timestamp":1780938190442,"version":"3.54.1"},"reference-count":27,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2026,6,8]],"date-time":"2026-06-08T00:00:00Z","timestamp":1780876800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed metabolic bariatric surgery procedures worldwide. However, conventional LSG generally requires liver retraction for adequate visualization of the operative field. This study aimed to evaluate the feasibility, perioperative safety, and metabolic outcomes of a modified three-port LSG technique performed without the use of a liver retractor. Materials and Methods: This retrospective single-center cohort study included 2000 consecutive individuals with obesity who underwent three-port laparoscopic sleeve gastrectomy between January 2020 and December 2023. All procedures were performed without mechanical liver retraction by two experienced bariatric surgeons. Operative outcomes, postoperative complications, weight loss parameters, metabolic variables, and histopathological findings were evaluated during a 12-month follow-up period. All included patients completed the predefined follow-up schedule. Postoperative complications were classified according to the Clavien\u2013Dindo classification system. Results: The mean operative time, defined as skin-to-skin duration, was 30 \u00b1 15 min, and the median hospital stay was 2.3 days. No conversion to open surgery, additional trocar placement, or rescue liver retractor use was required. The overall complication rate was 9.4%, with most complications classified as Clavien\u2013Dindo grade I\u2013II. Reoperation was required in three patients (0.15%), and no mortality was observed. Significant metabolic improvements were detected following surgery. Mean HbA1c levels decreased from 7.23% preoperatively to 5.67% at 12 months (p &lt; 0.001), while BMI decreased from 42.6 kg\/m2 to 28.7 kg\/m2 (p &lt; 0.001). Excess weight loss and total weight loss at 12 months reached 82.4% and 34.2%, respectively. Diabetes remission was achieved in 65.4% of patients with baseline type 2 diabetes mellitus. Continuous glucose monitoring findings demonstrated reduced postoperative glycemic variability. Conclusions: Three-port laparoscopic sleeve gastrectomy performed without a liver retractor appears to be a feasible and effective surgical approach when performed by experienced bariatric surgeons. The technique was associated with acceptable perioperative safety and favorable metabolic outcomes. However, because of the retrospective single-center design and absence of a conventional comparison group, definitive conclusions regarding superiority or equivalence to standard techniques cannot be established. Prospective multicenter comparative studies are required to validate these findings.<\/jats:p>","DOI":"10.3390\/medicina62061118","type":"journal-article","created":{"date-parts":[[2026,6,8]],"date-time":"2026-06-08T16:25:16Z","timestamp":1780935916000},"page":"1118","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Safety and Metabolic Outcomes of Three-Port Laparoscopic Sleeve Gastrectomy Without Liver Retractor: A 2000-Patient Retrospective Study"],"prefix":"10.3390","volume":"62","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7174-3800","authenticated-orcid":false,"given":"Muzaffer \u00d6nder","family":"\u00d6ner","sequence":"first","affiliation":[{"name":"General Surgery Department, Faculty of Medicine, Ni\u015fanta\u015f\u0131 University, 34398 Istanbul, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8508-196X","authenticated-orcid":false,"given":"F\u0131rat","family":"Aslan","sequence":"additional","affiliation":[{"name":"General Surgery Department, Van Y\u00fcz\u00fcnc\u00fc Y\u0131l University, 65090 Van, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Serhat","family":"Binici","sequence":"additional","affiliation":[{"name":"General Surgery Department, Van Y\u00fcz\u00fcnc\u00fc Y\u0131l University, 65090 Van, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Burhan","family":"Beger","sequence":"additional","affiliation":[{"name":"Pediatric Surgery Department, Van Y\u00fcz\u00fcnc\u00fc Y\u0131l University, 65090 Van, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4932-8758","authenticated-orcid":false,"given":"Orhan","family":"Beger","sequence":"additional","affiliation":[{"name":"Department of Anatomy, Faculty of Medicine, Gaziantep University, 27410 Gaziantep, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,8]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"3013","DOI":"10.1097\/JS9.0000000000000573","article-title":"Effect of laparoscopic sleeve gastrectomy on mobilization of site-specific body adipose depots: A prospective cohort study","volume":"109","author":"Cui","year":"2023","journal-title":"Int. J. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"489","DOI":"10.4103\/jmas.jmas_301_22","article-title":"Effect of laparoscopic sleeve gastrectomy on platelet count and mean platelet volume","volume":"19","author":"Sen","year":"2023","journal-title":"J. Min. Access Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"467","DOI":"10.1007\/s11695-023-06991-8","article-title":"Analysis of Changes in Glucose and Lipid Metabolism in Patients with Clinically Severe Obesity and Type 2 Diabetes Mellitus Undergoing Laparoscopic Sleeve Gastrectomy\u2014Prospective Observational Study","volume":"34","author":"Wysocki","year":"2024","journal-title":"Obes. Surg."},{"key":"ref_4","first-page":"e65613","article-title":"Frequency of Early Complications of Laparoscopic Sleeve Gastrectomy Using Four Ports","volume":"16","author":"Ullah","year":"2024","journal-title":"Cureus"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Belluzzi, A., Sample, J.W., Marrero, K., Tomey, D., Puvvadi, S., Sharma, I., and Ghanem, O.M. (2024). Rare Complications Following Laparoscopic Sleeve Gastrectomy. J. Clin. Med., 13.","DOI":"10.3390\/jcm13154456"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"17181","DOI":"10.1038\/s41598-024-68514-4","article-title":"Comparison of clinical efficacy between modified Kamikawa anastomosis in laparoscopic proximal gastrectomy and Roux-en-Y anastomosis in laparoscopic total gastrectomy","volume":"14","author":"Wu","year":"2024","journal-title":"Sci. Rep."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e03496","DOI":"10.1016\/j.heliyon.2020.e03496","article-title":"The advantages and disadvantages of sleeve gastrectomy; clinical laboratory to bedside review","volume":"6","author":"Kheirvari","year":"2020","journal-title":"Heliyon"},{"key":"ref_8","first-page":"e46956","article-title":"Single Incision Versus Conventional Multiport Laparoscopic Sleeve Gastrectomy: Meta-Analysis and Systematic Review","volume":"15","author":"Ataya","year":"2023","journal-title":"Cureus"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Liu, G., Wang, P., Ran, S., Xue, X., and Meng, H. (2024). Surgical treatment strategies for gastroesophageal reflux after laparoscopic sleeve gastrectomy. Front. Endocrinol., 15.","DOI":"10.3389\/fendo.2024.1463567"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2815","DOI":"10.1210\/jc.2018-00528","article-title":"Hypoglycemia After Gastric Bypass Surgery: Current Concepts and Controversies","volume":"103","author":"Salehi","year":"2018","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Jo, Y.-Y., Kim, S.-M., Lee, D., Kim, Y.-B., Cha, J., and Kwak, H.-J. (2022). Effect of Low or High Pressure Alveolar Recruitment Maneuver on Postoperative Pain and Quality of Recovery in Patients with Obesity Undergoing Laparoscopic Sleeve Gastrectomy. J. Pers. Med., 12.","DOI":"10.3390\/jpm12101550"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"15135","DOI":"10.3748\/wjg.v20.i41.15135","article-title":"Laparoscopic revolution in bariatric surgery","volume":"20","author":"Sundbom","year":"2014","journal-title":"World J. Gastroenterol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"529","DOI":"10.21037\/gs.2016.10.05","article-title":"Innovative solutions in bariatric surgery","volume":"5","author":"Kozlowski","year":"2016","journal-title":"Gland Surg."},{"key":"ref_14","first-page":"e49122","article-title":"The impact of bariatric surgery on weight loss and glycemic control in patients with obesity and type 2 diabetes: A systematic review","volume":"15","author":"Mirghani","year":"2023","journal-title":"Cureus"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1097\/MED.0000000000000277","article-title":"The impact of bariatric surgery on inflammation: Quenching the fire of obesity?","volume":"23","author":"Hafida","year":"2016","journal-title":"Curr. Opin. Endocrinol. Diabetes Obes."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"76","DOI":"10.17476\/jmbs.2023.12.2.76","article-title":"Outcomes and adverse events after bariatric surgery: An updated systematic review and meta-analysis, 2013\u20132023","volume":"12","author":"Kim","year":"2023","journal-title":"J. Metab. Bariatr. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Cornejo-Pareja, I., Molina-Vega, M., G\u00f3mez-P\u00e9rez, A.M., Damas-Fuentes, M., and Tinahones, F.J. (2021). Factors related to weight loss maintenance in the medium\u2013long term after bariatric surgery: A review. J. Clin. Med., 10.","DOI":"10.3390\/jcm10081739"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"100093","DOI":"10.1016\/j.obpill.2023.100093","article-title":"Weight reduction after bariatric surgery\u2014Do results correlate with postoperative visit frequency?","volume":"8","author":"Punjwani","year":"2023","journal-title":"Obes. Pillars"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"4241","DOI":"10.12998\/wjcc.v11.i18.4241","article-title":"Weight loss maintenance after bariatric surgery","volume":"11","author":"Cho","year":"2023","journal-title":"World J. Clin. Cases"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e003642","DOI":"10.1136\/bmjdrc-2023-003642","article-title":"Increased glycemic variability in pregnant women with Roux-en-Y gastric bypass compared with sleeve gastrectomy","volume":"12","author":"Alexiadou","year":"2024","journal-title":"BMJ Open Diabetes Res. Care"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"675","DOI":"10.4093\/dmj.2022.0307","article-title":"Asymptomatic hypoglycemia after metabolic surgery: New insights from perioperative continuous glucose monitoring","volume":"46","author":"Jin","year":"2022","journal-title":"Diabetes Metab. J."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.orcp.2015.07.003","article-title":"Recognition and management of hyperinsulinemic hypoglycemia after bariatric surgery","volume":"10","author":"Malik","year":"2016","journal-title":"Obes. Res. Clin. Pract."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Carbone, F., Migliola, E.N., Bonaventura, A., Vecchi\u00e9, A., De Vuono, S., Ricci, M.A., Vaudo, G., Boni, M., Ministrini, S., and Lupattelli, G. (2021). Circulating levels of sclerostin predict glycemic improvement after sleeve gastrectomy. Nutrients, 13.","DOI":"10.3390\/nu13020623"},{"key":"ref_24","first-page":"e69441","article-title":"Routine Histopathology in Laparoscopic Sleeve Gastrectomy Over 10 Years","volume":"16","author":"Yusufi","year":"2024","journal-title":"Cureus"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1786","DOI":"10.19082\/1786","article-title":"Chronic gastritis in morbidly obese patients with sleeve gastrectomy","volume":"8","author":"Makki","year":"2016","journal-title":"Electron. Physician"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1590\/0102-6720201600s10009","article-title":"Inflammatory disorders associated with Helicobacter pylori in the Roux-en-Y bypass gastric pouch","volume":"29","author":"Chaves","year":"2016","journal-title":"ABCD Arq. Bras. Cir. Dig."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"379","DOI":"10.5152\/tjg.2018.17373","article-title":"Does Helicobacter pylori infection influence the major postoperative complication rate after sleeve gastrectomy? A retrospective cohort study in an endemic region","volume":"29","author":"Serin","year":"2018","journal-title":"Turk. J. Gastroenterol."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/6\/1118\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,8]],"date-time":"2026-06-08T16:56:16Z","timestamp":1780937776000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/6\/1118"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,8]]},"references-count":27,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["medicina62061118"],"URL":"https:\/\/doi.org\/10.3390\/medicina62061118","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,8]]}}}