Internal Organ Retractors During Minimally Invasive Surgery

One of the major challenges in advanced minimally invasive gastrointestinal and hepatobiliary surgeries is retraction of the organs and maintaining a stable operative field. This is overcome with the advent of internal organ retractors (IOR). In this brief report, we describe the parts of IOR (Aesculap AG, Germany), the usual application technique, and how we modified the application technique. IOR is a novel self-retaining intracorporeal retractor used in laparoscopic surgeries, single incision laparoscopic surgeries, and robotic surgeries to atraumatically grasp the bowel/organs and helps in reproducing the retraction done in open surgery. It is introduced into the abdomen through the laparoscopic trocar with the help of the application forceps. The use of additional trocars to retract the internal organs is avoided with the usage of IOR. The inherent advantages of the IOR are easy reproducibility of the technique, easy maneuverability, and technically easy intraoperative repositioning of the clip. In addition to these advantages, it has been shown that the use of IOR significantly lowers the conversion rate and postoperative pain score. It is also cost-effective as the retraction clip and the applier are reusable, and the silicone ring is very cheap.[1] Internal organ retractor has two parts: Retraction clip with a triangle jaw design to atraumatically grasp the organ to be retracted. Hook needle attached to a latex-free silicone ring—the needle will be attached to a specific point on the abdominal wall at a specific angle to expose the surgical field. IOR can be used to retract the bowel, mesentery, gall bladder, and left/right lobe of the liver. More than one internal organ retractor can also be used for optimum exposure.[2] Standard Assembly and Application of the Retractor The silicone ring with the hook needle is mounted through the ring at the tail end of the retraction clip. The hook needle is placed between the jaws of the retraction clip (to avoid damaging the trocar valve) and introduced with the help of the application forceps through a 12 mm trocar. Once introduced inside the abdomen, the desired organ to be retracted is grasped with the retraction clip, and the needle is hooked onto the abdominal wall with the help of a laparoscopic needle holder at a desired point, which provides adequate retraction. The anchoring needle can be repositioned to a different point on the abdominal wall to provide adequate retraction and exposure without repositioning the clip.[3] Our Technique of IOR Application We modified the assembly of the IOR so that it is ergonomically easier to anchor the hook needle in the abdominal wall at a point closer to the organ to be retracted. After introducing the IOR through the 12 mm trocar, the silicone ring with the needle hook is kept between the jaws of the retractor (instead of passing through the ring in the tail end of the IOR), and then the organ to be retracted is grasped. The hook needle is then anchored to the abdominal wall [Figures 1 and 2]. The distance where the needle has to be anchored in the abdominal wall is limited in pancreatic or hepatobiliary surgeries. This prevents adequate stretch of the elastic silicone ring, and a lax ring provides insufficient retraction. This significant technical issue is circumvented by fixing the silicone ring between the jaws [Video 1].Figure 1: Application of internal organ retractor (IOR) for superior mesenteric artery first approach in robotic pancreaticoduodenectomy. (A) The IOR is introduced through the applier, and the silicone ring is passed between the jaws of the clip before grasping the mesocolon, which is to be retracted. (B) After grasping the mesocolon, the hook needle is held with a Maryland bipolar instrument and pulled for adequate tension for retraction before anchoring to the abdominal wall.Figure 2: Two internal organ retractors are applied, and the mesocolon is retracted for superior mesenteric artery dissection Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.