JOURNAL OF GYNECOLOGIC SURGERYMary Ann Liebert, Inc., Publishers

Self-Retaining Retractor for Vaginal OperationsJAVIER F. MAGRINA, M.D.

ABSTRACT

A self-retaining retractor designed for the performance of vaginal operations reduces thephysical effort by the assistant, improves the assistant's efficiency, and provides adequate,continuous exposure. In most instances, it eliminates the need for a second assistant. Theretractor is composed of a vaginal ring, five retractor blades, four ratchets, and twoaccompanying bars to secure it in position. The mechanism ofself-retraction is achieved by thepushing tension of the retracted tissues on the blades. It is most adequate for educationalpurposes, since the teaching surgeon, acting as assistant, is not obligated to hold retractingblades and can participate more freely in directing the procedure. The surgeon is providedwith continuous adequate exposure regardless of the degree of expertise of the assistants. (JGYNECOL SURG 7:33,1991)

INTRODUCTION

Self-retaining retraction in abdominal surgery has been used for some time. Among its advantagesare continuous adequate exposure, reduced number of assistants, decreased physical effort, and increased

efficiency of assistants because of concentration on the procedure instead of on the retraction. The Bookwalterabdominal retractor (Codman & Shurtleff, Inc., Randolph, MA), because of its versatility in bladepositioning, provides excellent exposure for abdominal and pelvic operations.

PRINCIPLES AND PROCEDURE

Traditionally, vaginal surgery has been performed with the help of two assistants, whose principal functionis to provide exposure and whose lesser role is to participate in the procedure. Self-retaining retraction has notbeen used in vaginal surgery because of the lack of adequate instrumentation. A self-retaining retractor(Magrina-Bookwalter retractor, Codman & Shurtleff, Inc., Randolph, MA) (Fig. 1) designed for theperformance of vaginal surgery is presented. It uses a principle of self-retraction similar to that of theabdominal Bookwalter retractor. The use of this retractor reduces the physical effort by the assistant, improvesthe assistant's efficiency, and provides adequate, continuous exposure. In most instances, it eliminates theneed for a second assistant.

The retractor is composed of one vertical post, one horizontal flex bar, one post coupling, one ovoid ring,five retractor blades, and four ratchets. The vertical post is attached to the operating table side rail at a levelabove the umbilicus of the patient. It also can be attached to the side rail of the dropping part of the operatingtable. The right side rail is preferable for right-handed surgeons, the left side rail for left-handed surgeons. Thehorizontal bar is attached to the vertical post by a post coupling at the desired height and angulation. The ringis then attached to the opposite end of the horizontal bar at the 11 o'clock position (Fig. 2).

Section of Gynecologic Surgery, Mayo Clinic Scottsdale, Scottsdale, Arizona.Copyright © 1990 Mayo Foundation.

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FIG. 1. Self-retaining retractor for vaginal surgery.

The ovoid ring has an angulation of 20 degrees, a broad base, and a narrower upper section. The broadersection is placed inferiorly. The angulation is positioned at the level of the posterior vaginal wall.

Five retracting blades are provided: one small and one large Deaver, two lateral blades, and a posteriorblade. The blades are attached to the ring by ratchets. Tilt ratchets are used for the lateral blades, and straightratchets are used for the anterior and posterior blades. The pushing effect of the retracted tissues helps keep theblades in position.

The Deaver blades are used at the 12 o'clock position. The large Deaver is designed to be used for retractionof the bladder after the anterior cul-de-sac has been entered. The small Deaver is used preferably in theremaining situations.

The lateral blades are placed at the 4 and 8 o'clock positions in the ring. They are attached to the ring by thetilt ratchets.

The posterior blade is attached to the ring at the 6 o'clock position. It is designed to be positioned in theperitoneal cavity after the posterior cul-de-sac has been entered (Fig. 3).

It is most important to position the patient properly to optimize the use and benefits of the retractor. The highlithotomy stirrups are given a 5-10 degree inclination toward the head of the patient. The top curved end of thestirrup is deviated 45 degrees toward the head of the patient (Fig. 4). This position not only provides optimaluse of the retractor but also facilitates the work of the assistants.

APPLICATIONS

Procedures for which the retractor has been found useful include, but are not limited to, vaginalhysterectomy, anterior and posterior repair, conization, cervical cerclage, repair of vesicovaginal and

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FIG. 2. The horizontal bar is attached to the vertical post, which is located to the patient's right. The ovoid ring isattached to the horizontal bar at the 11 o'clock position. The angulation of the ring is positioned at the level of the posteriorvaginal wall.

rectovaginal fistulas, repair of vault prolapse, local excision of the vagina, vaginal tubal ligation, repair ofpostpartum cervical or vaginal lacerations, and treatment of posthysterectomy cuff bleeding.

The standard position of the blades is used for the performance of vaginal hysterectomy, conization,cervical cerclage, repair of postpartum cervical lacerations, treatment of posthysterectomy cuff bleeding,repair of vaginal vault prolapse, and vaginal tubal ligation. The lateral blades at the 4 and 8 o'clock positions,

FIG. 3. The anterior Deaver, lateral, and posterior blades are positioned for the performance of a vaginal hysterectomy.Two double-toothed tenaculums are applied to the cervix for traction.

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FIG. 4. Optimal position of the high stirrups.

are placed first. Short lateral blades are available for patients with marked uterine prolapse. The anterior blade(small Deaver) is placed next at the 12 o'clock position. The posterior blade is then placed at the 6 o'clockposition. The small Deaver blade is replaced by the large Deaver blade after the peritoneal cavity has beenentered.

The position and number of blades used for other vaginal operations depend on the area to be exposed.The mechanism of self-retraction is achieved by the pushing tension of the retracted tissues on the blades,

which are secured in position by the ratchets on the ring. This eliminates the need for hand-held retraction.Self-retracting is most helpful for educational purposes. The teaching surgeon, acting as first assistant, is

not obligated to hold retractor blades and can participate more freely in directing the procedure. The learningresident (second assistant, if available) is able to concentrate more on the operation than on retraction. Thesurgeon performing the procedure is provided with adequate continuous exposure regardless of the degree ofexpertise of the assistants. Surgeons already familiar with the principles of self-retention governing the use ofthe abdominal Bookwalter retractor will have no difficulty in learning how to use the Magrina-Bookwalterretractor. With increased experience, the surgeon can position the retractor in a very short time. A trainedscrub nurse can facilitate the task by passing preassembled components in an orderly fashion.

Address reprint requests to:Javier F. Magrina, M.D.

Mayo Clinic Scottsdale13400 East Shea Boulevard

Scottsdale, AZ 85259