Issues and Innovations in Laparoscopic Retraction

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Issues and Innovations in Laparoscopic Retraction

• Liver Hematoma after Laparoscopic Nissen
  Fundoplication A Case Report and Review of
  Retraction Injuries
• Surgical Laparoscopy, Endoscopy, and Percutaneous
  Techniques. 10(3)178-181
• Pasenau, Jeffery MD, et. al. 2000
• Instrumentation for Laparoscopic Renal
  Surgery-Padron Endoscopic Exposing Retractor
  (PEER) and Endoholder Point of Technique
• Surgical Laparoscopy, Endoscopy, and Percutaneous
  Techniques. 15(1)18-21
• Rehman, Jami MD, et. al. 2005.
• An Articulating Retractor Holder to Facilitate
  Laparoscopic Adrenalectomy and Nephrectomy
• Journal of Urology. 188(1)198-199
• Paulter, Stephen E., et. al. 2001.

Presented by Jennifer Horwat Spring 2005
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Smart Organ Retractor ProjectMentors Greg
Fischer and Mark Talamini, MDPartners Sunipa
Saha and John Yu

• Developing manual and laparoscopic retractors
  with both force and ischemia sensors on each
• Conducting experiments with both retractors to
  relate force and ischemia over time
• Improving current system with a pattern of
  sensors and a full calibration to standard
  pulse-oxidation values

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Paper Selection

• Liver Hematoma after Laparoscopic Nissen
  Fundoplication A Case Report and Review of
  Retraction Injuries
• Instrumentation for Laparoscopic Renal
  Surgery-Padron Endoscopic Exposing Retractor
  (PEER) and Endoholder Point of Technique
• An Articulating Retractor Holder to Facilitate
  Laparoscopic Adrenalectomy and Nephrectomy

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Summary of Problem

• Technical difficulties of laparoscopic surgery
• Reduced haptic feedback
• Loss of 3-D visualization
• Constricted field of view
• Narrowness of instruments
• Often results in application of excessive force
  on the retracted tissue

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Key Results

• Recognition of retraction as a significant source
  of morbidity in laparoscopic surgery
• Visual observation of tissue to monitor ischemia
• Successful use of mechanical systems to maintain
  constant force and retractor position

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Case Report and Review of Retraction Injuries

• Patient-55 year old woman with history of GERD
• Grade 2 esophagitis established with endoscopy
• Abnormal 24-hour pH monitoring
• Obese (165 cm, 80 kg)
• Left lobe of liver retracted by
• epigastric 5mm trocar during procedure
• Patient returned one week after
• discharge with epigastric abdominal pain

http//www.peterjurek.com/rbv_site/web_pages/troca
r.html
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Case Report and Review of Retraction Injuries

• CT scan 3.8cm x 2.6cm hypodense mass

Pasenau, et al (2000)
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Case Report and Review of Retraction Injuries

• Observations
• Technical difficulty of obtaining adequate
  exposure
• Distraction of assistant
• Aggressive retraction may lead to change in liver
  color, a possible indicaiton of ischemia
• Recommendations
• Monitor color of liver throughout procedure
• Careful evaluation of position of retractor at
  intervals

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Case Report and Review of Retraction Injuries

• Safe retraction depends on
• Type of retractor
• Size of patients left lobe
• Amount of force applied on retractor

Pasenau, et al (2000)
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PEER and Endoholder System

• Problem
• Excessive force inadvertently exerted on anatomic
  structures
• Challenge for assistant to maintain force over
  time
• Goal
• To reduce technical difficulty of laparoscopic
  surgery
• Solution
• Use articulating instrument holder (endoholder)
  and Jarit Padron Endoscopic Exposing Retractor
  (PEER)

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PEER and Endoholder System

• PEER
• Two telescoping blades
• Fully rotatable with locking
• ratchet handle
• Endoholder
• Base rod
• Flesible extension arm
• Precision clam
• Table attachment

Rehman, et al (2005)
Rehman, et al (2005)
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PEER and Endoholder System

• Advantages
• Decreases technical difficulty
• Reduced operative time
• Disadvantages
• No measure
• of force

Rehman, et al (2005)
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PEER and Endoholder System

• Performance
• Provides safe and reliable exposure
• Used in more than 200 cases
• Complications 1 minor liver laceration
• No record of hematoma due to ischemic injury

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Clinical Use of Articulating Retractor Holder

• Articulating retractor held fan retractor
• Durable
• Stable
• Laparoscopic Nephrectomy
• Procedure has prolonged operative time
• Fatigue to human assistants
• Procedure would benefit from mechanical assistance

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Clinical Use of Articulating Retractor Holder

• Results
• 111 laparoscopic cases performed
• Articulating retractor holder used in all right
  liver retraction dissections and approximately
  50 of left spleen dissections
• Each case required only 5 minutes for placement
  of port and insertion of retractor
• No device failures or complications related to
  either the retractor holder or the fan retractor
  used

Pautler, et al (2005)
Pautler, et al (2005)
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Relevance to Project

• Established two main objectives
• 1. Avoid excessive force
• Mechanical assistant does not prevent excessive
  force from being used
• No data and no standard for what constitutes
  excessive force
• Currently no measurement of force on any of the
  laparoscopic tools discussed
• 2. Monitor color of liver during procedure
  necessary
• Internally
• Relative oxygenation level
• Field of view issues solved with ischemic sensors

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Possible Next Steps

• Combine the observations and work of the three
  papers discussed
• Observe color changes in tissue through pulse
  oxidation with a mechanical assistant holding
  retractor
• Establish guidelines for force over time to avoid
  ischemia and develop alert for high risk
  conditions