Table Mounted Retractor System for Vaginal Hysterectomy

INTRODUCTION: Despite being the recommended route, the vaginal approach to hysterectomy has seen a decline over the years. One possible contributing factor for this is the reliance on assistants to provide adequate exposure, which can present difficulties in terms of ergonomics, consistency, and reliability. A proposed solution to this common difficulty is the use of a table-mounted retractor system. Two such systems have been described, the vaginal Magrina-Bookwalter and the Martin's Arms. Both have the advantages of stable, non-fatigable retraction that is under the complete control of the surgeon, allowing for exposure that is not dependent on the ability or experience of one's assistant. OBJECTIVE: The objectives of this video are to describe the setup and optimization of the Martin’s Arms for vaginal surgery, particularly vaginal hysterectomy, and to discuss ways to improve surgeon and learner experience using the retractor system. METHODS: The video describes the proper setup for the system, including location of brackets and position of the bed, and describes the proper locations for each arm. The arms can in turn be positioned with a wide range of motion and can hold any surgical instrument, with examples such as Breisky Navratil retractors and Kocher clamps. Finally, the addition of a table-mounted exoscope is easily integrated into this system and can augment learner and staff participation in the case. RESULTS: The exposure achieved by the Martin's Arms is unchanging and under complete control of the surgeon, as seen in the visualization of the adnexal structures in the video. CONCLUSIONS: It is certain that there are multiple reasons the vaginal approach to hysterectomy has declined over the years. To the degree that reliance on assistants for exposure has contributed to this decline, the Martin’s Arms may offer one possible solution by putting full control over exposure in the surgeon’s hands with an easily assembled system that offers retraction that is reproducible, stable, and nonfatigable. This in turn frees both surgeon and learner to observe or teach vaginal surgery instead of being concerned with holding a retractor (Figure 1).