New principle in mechanical abdominal retraction

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NEW PRINCIPLE

IN MECHANICAL RETRACTION * DAVID J. WEXLEK,

Attending

Surgeon, Southside LONG ISLAND,

I

Hospital,

ABDOMINAL

M.D. Bay Shore, N. Y.

NEW YORK

as other considerations necessitate a much smaIIer incision. The probIem of exposure then narrows down essentiaIIy to the probIem of good retraction. ExpeciaIIy is this probIem cf adequate retraction of importance in the smaIIer hospitaIs which in the

T is aImost trite to say that good exposure is the sine qua non of efficient abdomina1 surgery. In war surgery when the routine incision for abdomina1 exploration often extended from ensiform to pubis, exposure was seIdom a problem

FIG. I. The retractor and its component parts. a, Octagonal frame; b, universal joint and clamp; c and d, bIades fixed respectively to the frame and universal joint; e, expanding blade;f, standard bIadder retractor bIade.

which, incidentaIIy, was probably an imaggregate serve a Iarge proportion of our portant factor in the exceIIent resuIts popuIation. obtained in our overseas hospitaIs. In In the Iarger medica centers enough civiIian practice, however, cosmetic as we11 residents or internes are usuaIIy avaiIabIe * Manufactured by Edward Week & Co. 103

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American Journal of Surgery

Wexler-Abdominal

so that in a major operation retractors may be heId by hand. However, certain factors mitigate against the e&iency or even the desirability of hand retraction. The first assistant must not be distracted by the necessity of occasionaNy holding a retractor

FIG. 2. Showing the angulation and mobility available by use of the universal joint.

FIG. 4. Retracto
accessory bJades at-start of cholecystectomy.

or replacing retractors heId by a tiring second assistant. In work of major scope three assistants are often used; here the work is just as apt as not to be impeded by the crowding around the table. The very human element of fatigue on the part of the retractor hoIders is prone to become a problem in preciseIy the pIaces where steady and adequate retraction is most

Retraction

JULY, rgar?

important in Iong drawn out deep abdominal procedures. From the point of view of the downtrodden retractor puIIers, no Iess than that of the operator, a device which would render hours of physica effort unnecessary whire maintaining the

FIG. 3. Illustrating ease of width adjustment of incision.

FIG. 5. Retractor

in cholecystectomy showing cleanIy waIled-off fieId of operation. Note clearly defined anatomical Iandmarks: a, gallbIadder; b, ligature on cystic duct; c, common duct.

adequacy of the exposure would be a priceIes’s gift. Hence, even in our largest medica centers with their plethora of assistants mechanica retraction which could accompIish what hand retraction does would be a definite boon. In the smaIler community hospitals no profusion of assistants is ordinariIy avaiIable. Here the problem of adequate retrac-

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1

Wexler -~-Abdominal

tion has customarily been solved by the use of the available seIf-retaining retractors. The deficiencies of these retractors ;rre too welI known to require extended comment. Having worked in a smaIIer suburban

FIG. 6. Variable

width blade showing normal and expanded positions.

hospital for a number of years under these handicaps, it occurred to the writer that two essentia1 eIements were missing in any of the then avaiIabIe seIf-retaining retractors. The first was that in any of the existing instruments the retraction couId not aIways be made to work preciseIy where the operator intended it to. This was due to the fact that aIthough the handIe couId usually be slid aIong the frame, the bIade being fixed to the handIe at a constant angIe, always exerted its restraining effect in a pIane roughIy perpendicuIar to the handle (and hence, to the anterior abdominal waI1.) Retraction is frequentIy needed, however, at a point so deepIy placed, and so far IateraIIy beneath the incision that no standard bIade can reach it; to do so, the retractor wouId need an awkward, Iong bIade fixed at an acute angIe to the handIe. This feature was soIved by the use of a

Retraction

An~crican Jwrnal

cd Surrwu

IO<

universa1 joint which can be attached anywhere aIong the circumference of an standard octagona frame. Any slotted retractor can be attached to this joint and by tiIting the handIe upward the point of the bIade can be made to reach deep underneath and Iaterally to the incision. The universa1 joint can be IirmIy locked at any point on the frame and the retractor having been pIaced at any desired angle securely locked at the joint (Figs. I and 2.) Figure I b shows the two universal joints in pIace on the octagonal frame a. The ratchet arrangement on the octagonal frame enabIes the wound to be opened and secured at any desired width. (Figs. 3 and 4.) Also shown in Figure I are a sIotted maIIeabIe retractor c which has been found very usefu1, a sIightIy modified Deaver (with sIotted handIe) d and a standard bIadder retractor f. Any of these may be attached either directIy to the frame (as in c) or to the universa1 joint (as in d). The standard Horgan, BIand or BaIfour bIades may be used on the instrument without modification. Figures 4 and 5 show the retractor being used in a choIecystectomy; in Figures _ and 8 its use in a peIvic Iaparotomy is iIIustrated. The second eIement in which standard mechanica retractors were found to be deficient was that no bIade was wide enough to waI1 off adequately the constantIy shifting intestines and keep them away from the fieId of operation. Six inches was found by experiment to be the optima1 width for retraction of this type but a six-inch bIade wouId be totaIIy unwieldy. This diffrcuIty was overcome b,y construction of a new type of blade of standard width which couId by a simpIe movement be expanded to any desired width up to 6 inches. (Figs. re and 6.) The angIe of the bIade to the handIe was designed specificaIIy to make the bIade lie paraIIe1 to the superior border of the sacral promontory, so that in a peIvic Iaparotomy with the handIe Iying ffat on the abdomen, the expanding bIade covering a

IO6

American

FIG.

Journal

of Surgery

Wexler--- -Abdominal

7. Retractor in peIvic laparotomy exceIIent exposure and use of expanding

showing bIade.

Iap pad very effectiveIy seaIs off the intestines. This is cIearIy shown in Figures 7 and 8. This bIade was found to be most usefu1 in other procedures of abdomina1 surgery besides peIvic Iaparotomies; heId by hand it furnishes adequate retraction when working in the IateraI gutters where mechanica retraction with any instrument has been found to be inadequate. It is aIso very usefu1 in gaIIbIadder surgery (Fig. 5) as we11 as Iower abdomina1 procedures such as abdominoperinea1 resection. The two outstanding deficiencies of avaiIabIe seIf-retaining retractors-the inabiIity to pIace the retractor bIade at the desired angIe or depth and the Iack of width of the retractor bIade itseIf-have been compIeteIy corrected by the use of the two new principles herein described, the use of the universa1 joint and the expanding retractor.

Retraction

FIG. 8. Retractor in hysterectomy ease of exposure. a, uterine vesseIs; ligaments; c, ovarian vessels.

showing b, rouncl

SUMMARY

A seIf-retaining abdomina1 retractor embodymg two entireIy new mechanica principIes is described. The retractor possesses the foIIowing advantages : I. By means of a universa1 joint the blades can be heId secureIy at any position, angIe or depth desired. 2. An expanding bIade provides efficient viscera1 retraction to a width of 6 inches. 3. A maIIeabIe retractor and a Deaver bIade sIightIy modified may be used as an integra1 part of the instrument. 4. The standard slotted bIades of existing seIf-retaining retractors may be used interchangeabIy with the instrument. Many thanks are due Dr. So1 Shlimbaum for his suggestions as well as Drs. Charles C. Murphy, Ear1 B. McCoy and Fred Bromberg for their cooperation during the deveIopment of this instrument. Thanks are due also to Dr. Anthony Kohn, the author’s associate, for heIp in the preparation of this article.