SHORT REPORT

Use of a Self-retaining Retractor for Minimally InvasiveApproaches to the Aorta

W. Robb, M. C. Barry*, R. Osman, J. ODonnell, D. Logan, A. Ireland andD. Bouchier Hayes

Department of Surgery, Royal College of Surgeons in Ireland and Beaumont Hospital, Dublin, Ireland

Key Words: Minimally invasive surgery.

Introduction

The technique of open repair of abdominal aorticaneurysms and aorto-iliac reconstruction has changedlittle over the past four decades. Endovascularapproaches remain under investigation but are limitedby anatomical considerations and questions regardingefficacy, safety and durability have not yet been fullyanswered. Laparoscopic and laparoscopically assistedtechniques have been investigated, used alone or inconjunction with a minilaparotomy technique.1 Morerecently successful aortic reconstructions using mini-laparotomy incisions of 810 cm without laparoscopyhave been reported.2

This report describes our preliminary experiencewith a minimally invasive approach to aortic surgeryusing a newly developed self-retaining retractor(Ecotracte, Advanced Surgical Concepts, Bray,County Wicklow, Ireland).

The retractor (Fig. 1) is composed of two plasticrings joined by a polythene sheet. The inner ring,placed intra-abdominally, is malleable but expandsfirmly outwards to maintain its circular shape. As thisring is flexible, it may be introduced through a smallincision with a lesser circumference. Its flexibility alsoallows it to be placed precisely around the field ofdissection. The outer ring is a more rigid structure,which remains outside the abdominal cavity and alsohas the added advantage of acting as a woundprotector. Once the intra-abdominal ring is in positionthe plastic sheet is drawn through the outer hoop and

stretched backwards over its outer circumference. Thisdraws the walls of the wound and the abdominalviscera outwards and creates an open wound withstable and wide exposure.

Case 1

A 78-year-old lady with respiratory compromise(FEV1 1.07L) was admitted for assessment of a5.2 cm aneurysm. Spiral CT scan showed a 5.2 cmjuxta-renal aortic aneurysm, unsuitable for endovas-cular repair. The patients respiratory function wasimproved pre-operatively (FEV1 1.39L) with chestphysiotherapy and bronchodilators. At operation an11 cm incision was planned based on CT scan andphysical findings. The small bowel was packed out ofthe field of dissection within the abdomen using moistswabs. The aneurysm neck was then dissected and theiliac arteries isolated. An infra-renal clamp was placedon the aorta and the iliac arteries were controlled withangled clamps. The aneurysm repair then proceededin conventional manner using an 18 mm tube graftanastomosed using an inlay technique (Fig. 2). Post-operatively the patient had an uncomplicated recovery.Duration of ventilation and intensive care unit stay were20 and 36 h, respectively. The nasogastric tube wasremoved on day 2 post-operatively and oral fluids anddiet commenced.

Case 2

A 76-year-old man was admitted for repair of a 5.3 cm

EJVES Extra 7, 5254 (2004)

doi: 10.1016/j.ejvsextra.2004.02.002, available online at http://www.sciencedirect.com on

*Corresponding author. Ms M. C. Barry, Department of Surgery, StVincents University Hospital, Elm Park, Dublin 4, Ireland.

15333167/040052 + 03/0 q 2004 Elsevier Ltd. Open access under CC BY-NC-ND license.

Fig. 1. The retractor is composed of two plastic rings joined by a polythene sheet. The inner ring, placed intra-abdominally, ismalleable but expands firmly outwards to maintain its circular shape. The outer ring is a more rigid structure which remainsoutside the abdominal cavity and also has the added advantage of acting as a wound protector.

Fig. 2. The retractor in place during the operation described in Case 1 illustrating its use as both wound protector andeffective retractor.

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abdominal aortic aneurysm detected at surgery for acaecal carcinoma six weeks earlier. At operation amidline incision (14 cm) was used and the aorticaneurysm repaired in standard fashion using a 24 mmtube graft. The patient was ventilated for 15 h post-operatively and spent 18 h in the intensive care unit.Diet was re-introduced on day 2 post-operatively andthe patient made an uneventful recovery.

Discussion

The development of endovascular and laparoscopictechniques have challenged previously acceptedapproaches to aortic surgery.1 4 Despite initial opti-mistic reports describing comparable and sometimesimproved outcomes following endovascular repair,long-term results regarding safety and durability arenot yet available. Laparoscopic aortic surgery is stillundergoing development and has been shown toreduce intra-operative fluid shifts, decrease post-operative pain and shorten intensive care unit andtotal hospital stay.1 A totally laparoscopic approach isseen as difficult by many without training in advancedlaparoscopic techniques and adds considerably to theduration of cross-clamp time and overall duration ofsurgery. Addition of a mini-laparotomy providesgreater ease of access for performance of the ana-stomoses.1

Recently, the use of a mini-laparotomy alone with-out adjunctive laparoscopy has been advanced as analternative to the laparoscopic approach.5 Turnipseedet al. reported that this technique using a Buckwalterself-retaining retractor preserved the same quality ofoutcome as traditional open repair while significantlyreducing post-operative ileus, time to return to normal

diet, ICU and overall hospital stay. Furthermore, whencompared to laparoscopically aided procedures sig-nificant decreases in cost, procedure and cross-clamptime have been reported.5

The advantages of the technique described in thisreport are the speed with which the retractor can beinserted into the abdominal cavity without therequirement for complex assembly instructions. Fur-thermore, once in place, no further adjustment isrequired and the operation can proceed with the aid ofone assistant. With careful pre-operative planningusing ultrasound to mark the aneurysm, the size of theincision can be reduced to 810 cm. The techniqueinvolves minimal disturbance of small bowel with itsattendant risks of peri-operative fluid loss and post-operative ileus. For the surgeon performing theprocedure only a modification of previously learnedskills is required.

References

1 Alimi YS, Hartung O, Valerio N, Juhan C. Laparoscopicaortoiliac surgery for aneurysm and occlusive disease: whenshould a minilaparotomy be performed? J Vasc Surg 2001; 33:469475.

2 Maloney JD, Hoch JR, Carr SC, Acher CW, Turnipseed WD.Preliminary experience with minilaparotomy aortic surgery. AnnVasc Surg 2000; 14:612.

3 Sternbergh WC, Money SR. Hospital cost of endovascular versusopen repair of abdominal aortic aneurysms: a multicenter study.J Vasc Surg 2000; 31:237244.

4 Clair DG, Gray B, OHara PJ, Ouriel K. An evaluation of thecosts to health care institutions of endovascular aortic aneurysmrepair. J Vasc Surg 2000; 32:148152.

5 Cerveira JJ, Halpern VJ, Faust G, Cohen JR. Minimal incisionabdominal aortic aneurysm repair. J Vasc Surg 1999; 30:977984.

Accepted 19 February 2004

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Use of a Self-retaining Retractor for Minimally Invasive Approaches to the AortaIntroductionCase 1Case 2

DiscussionReferences