When should surgical self-retaining retractors be used?
Use and background of Lone Star retractor instruments and other options
Surgical Retractor instruments are used to hold an incision or wound open while a surgeon works. The retractor could also be used to hold tissues or organs out of the way during a surgery. Newer retractors also have light attachments to aid visibility.
Self-retaining retractors allow hands free operation during a surgery. Self-retaining surgical retractors like the Galaxy II can be small, such as those for eye procedures, or large, such as table mounted retractor systems.
Self-retaining abdominal retractors
Weitlaner and Gelpie Retractors are two of the most commonly used self-retaining retractors for abdominal surgery, but there is also Balfour and Bookwalter Retractors (can be table mounted), as well as Goligher Retractor and Iron Intern. Newer Galaxy II Snowman is now frequently used in hernia, offering a less harsh yet effective tissue retraction.
Self-retaining surgical retractor example
This instructional video demonstrates set up and utilization of the vaginal self-retaining retractor for pelvic surgery. This includes review of all the component parts, step-by-step assembly, and utilization in different surgical scenarios. This retractor can be easily used with an improved understanding of function and set up; this video aims to aid with both. Utilization of a vaginal retractor facilitates surgical exposure of the pelvis. It also allows the surgeon to operate without reliance on variable surgical assistants. Finally, it promotes surgeon ergonomics.
Ergonomics in the operating room
Manual retraction, a task performed to expose the surgical site, poses a high risk for musculoskeletal disorders that affect the hands, arms, shoulders, neck, and back. In recent years, minimally invasive and laparoscopic procedures have led to the development of multifunctional instruments and retractors capable of performing these functions that, in many cases, has eliminated the need for manual retraction.
During surgical procedures that are not performed endoscopically, the use of self-retaining retractors enables the assistant to handle tissue and use exposure techniques that do not require prolonged manual retraction.
Self-retaining retractor benefits
Tissue Retraction in the Perioperative Setting provides an algorithm for perioperative care providers to determine when and under what circumstances manual retraction of tissue is safe and when the use of a self-retaining retractor should be considered.Benefits of surgical self-retaining retractors:
- Surgical retractors free up the hands of an assistant
- Improved access to surgical site
- Single handed adjustments (in newer models)
- Less instrument clutter at the incision
- Light-weight and easy to use (newer models)
- Fewer staff in operating room
- Great visual access for students
There is plenty of evidence that fewer staff in the operating room/theatre has a positive effect by reducing infection risk. By replacing the number of individuals close to the open wound, the risk of contamination both from staff to patient as well as from patient to staff is improved. With Covid-19 now present in our every day lives, of course there is now further benefits to using surgical retractors instead of assistants in very close proximity having to lean in close in often awkward positions to assist for long period of times.
Types of self-retaining retractors
These types of self-retaining retractors have locking mechanisms that keep the blades apart and in place while spreading the edges of the incision and holding other tissue in place, thus freeing the surgeon’s and assistant’s hands for other tasks.
Weitlaner and Gelpie
Two of the most commonly used self-retaining retractors used to be the Weitlaner and Gelpie retractors. These are used to retract skin edges for superficial procedures. Care must be taken not to puncture vital tissues or oneself with the sharp points of these retractors.
Balfour and Bookwalter
The Balfour and the Bookwalter are self-retaining abdominal wall retractors with various deep and shallow blades that can be attached and removed as needed. The Balfour retractor is placed within the incision, spread apart as needed, and locked in place by tightening of a wing nut. The Bookwalter retractor has a single post that attaches to the table’s side rail. This attachment takes some practice to master. A crossbar mounted on the post holds an oval or round ring to which various sizes of Richardson, malleable, and Deaver-like blades may be attached with adjustable, ratcheted “clips.”
Goligher and Iron Intern
The Goligher retractor is used for abdominal operations in the superior regions of the peritoneal cavity, particularly for gallbladder, liver, and stomach procedures. It is easily attached to a crossbar placed onto the head of the OR table. The Iron Intern uses a series of locking arms and joints to position retractors within the abdomen or pelvis.
These types are particularly useful in urology, gynecology, ENT, orthopedics, plastic surgery, and many other procedures that need 360 degrees access and vision.
Older systems with screw or wire mechanism:
- Lone Star retractor system (single use or reusable frames) from 1997
- Wilson retractor
- Seastar retractor
New systems with cam lock mechanism:
- Galaxy II self-retaining retractor (single use frames) use less plastic and can be recycled. Winner of The Queen’s Award for Innovation 2021.
Retractor frames can be re-usable or single use, and are used with single use hooks of different types. The most common hooks are 5mm sharp or blunt hooks or in some cases 12mm blunt hooks for some procedures.
- No sterilisation cost for single use kits
- Pre-packed, sterile kit
- No need for assistant to retract
- Easily adjusted during surgery leading to reduced operating time
- Less staff cost
- Better ergonomics in the workplace
Galaxy II cost savings in USA: A real life example
Single use vs reusable ring retractors
Single use vs re-sterilising
Switching to single-use self-retaining surgical retractors reduces the risk of patient-to-patient cross-contamination as well as saving the time and cost involved in reprocessing. The traditional alternative to single-use kits is reusable instruments, which by their very nature have inherent risks when it comes to infection of patients.
False economy around reusable vs self-retaining retractors
Reusable instruments can be perceived to offer false economies to healthcare practitioners and health institutions as a result of these risks.
There is significant knock-on implications in terms of cost, patient safety and recovery time.
Reusable medical instruments also pose inherent concerns regarding their maintenance, storage and repeated use, all of which are often exacerbated by reprocessing and sterilisation procedures. For surgical self-retaining retractors, it is only the frame that could be reprocessed (not the stay hooks which would always be single use due to infection risk), and with the low cost of the Galaxy II frame (despite being manufactured in the UK), the perceived cost saving in reusable metal retractors are virtually none once purchase cost, manual handling, storage, washing, sterilising and transport has been factored in.
Many surgical instrument failures occur as a result of healthcare practitioners failing to follow manufacturers’ reprocessing and handling instructions.
Common errors include, but are not limited to:
- Lack of sinks to soak, wash and rinse the instruments
- Not having all the manufacturer’s instructions to hand
- Staff not following all the manufacturer’s written instructions
- Not using ultrasonic cleaners properly
- Not thoroughly inspecting instruments prior or post reprocessing
- Not using inspection lamps or lenses
- Assembling hinged instruments in the closed position
- Not storing sterile items in a separate, controlled area
Single-use instruments are designed to be cost-effective, safe and ready to use at the point of care.
Retractor weight is important
Single-use surgical retractors are much lighter than reusable retractors (made of steel).
This is important for self-retaining ring retractors, as they are designed to hold themselves in place without needing to be clipped on to something, held by an assistant (which defeats some of their purpose) or mounted onto a frame or a table.
Re-usable retractors still need single use stay hooks
Re-usable retractors still need single use stay hook to be a complete product to use during surgery. The stay hooks are often priced higher for the re-usable retractors, as they are a disposable item and will bring recurring revenue for the manufacturer.
For Galaxy II® we have made pre-packed kits with frame, stay hooks of choice and catheter clip and light attachment clips that make the entire kit more cost effective.
Better for transport, better for packaging, better for environment, better for surgeon and ultimately, better for the patient.
Question: Can Galaxy II frames be re-sterilised?
Answer: No, they come sterile, and are single use only.
Common hand-held and self-retaining retractors
Common Hand-held Retractors (Manual)
- Senn – is a handheld, double-ended retractor used to retract primarily surface tissue. Often used in plastic surgery, small bone and joint procedures, or thyroidectomy and dissection of neck tissue.
- Army-Navy – Used to retract shallow or superficial incisions. From small wounds to abdominal operations.
- Ribbon (Malleable) – Used to retract deep wounds. May be bent to various shapes to assist in holding back tissue.
- Hohmann – used in orthopedics to expose bone for procedures.
- Farabeuf – general use. It is a handheld retractor that is used in multiple procedures. It may be used in dentistry, wrist and hand procedures, or in hernia repair to name a few. We have seen that Galaxy II Snowman can be successfully used in inguinal hernia to reduce number of staff needed.
- Meyerding – frequently used to hold back tissue and muscle in spinal and neurosurgical procedures such as laminectomy.
- Deaver – used to retract deep abdominal or chest incisions. Used in Cholecystectomy (removal of gallbladder) for retraction of right lobe of liver. Used in Truncal vagotomy (division of the main trunk of the vagus nerve) for retraction of left lobe of liver.
- Richardson – retract abdominal or chest incisions. Used for holding back multiple layers of deep tissue. This is one of the most common general retractors.
Self-Retaining Retractors (Hold their shape and position once set in place)
- Weitlaner – It is a popular instrument, most commonly used in basic plastic surgery, large bone and joint procedures.
- Balfour Abdominal Retractor – Retract wound edges during deep abdominal procedures.
- Finochietto Rib Retractor (rib spreader) – specifically designed to separate ribs in thoracic surgery.
- Hip Retractor system – Millennium surgical has a huge selection of surgical instruments for every specialty. One being the Hip Retractor System. The self retaining hip retractor helps to free assisting personnel while providing excellent exposure during hip arthroplasty and hip fracture surgery.
- Gelpi – retract shallow incisions. Often used in smaller surgical sites. Common in spine surgery.
Galaxy II can successfully replace most self-retaining retractors, and is suitable also for high-demand retraction (3 finger claw holds up to 30N — almost triple the force needed in most surgical applications).