Issues and Innovations in Laparoscopic Retraction

1. Engineering Research Center for Computer Integrated Surgical Systems and Technology 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.

2. Engineering Research Center for Computer Integrated Surgical Systems and Technology 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

3. Engineering Research Center for Computer Integrated Surgical Systems and Technology 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

4. Engineering Research Center for Computer Integrated Surgical Systems and Technology 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

5. Engineering Research Center for Computer Integrated Surgical Systems and Technology 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

6. Engineering Research Center for Computer Integrated Surgical Systems and Technology 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

7. Engineering Research Center for Computer Integrated Surgical Systems and Technology Case Report and Review of Retraction Injuries CT scan – 3.8cm x 2.6cm hypodense mass

8. Engineering Research Center for Computer Integrated Surgical Systems and Technology 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

9. Engineering Research Center for Computer Integrated Surgical Systems and Technology Case Report and Review of Retraction Injuries

10. Engineering Research Center for Computer Integrated Surgical Systems and Technology 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)

11. Engineering Research Center for Computer Integrated Surgical Systems and Technology PEER and Endoholder System PEER Two telescoping blades Fully rotatable with locking ratchet handle Endoholder Base rod Flesible extension arm Precision clam Table attachment

12. Engineering Research Center for Computer Integrated Surgical Systems and Technology PEER and Endoholder System

13. Engineering Research Center for Computer Integrated Surgical Systems and Technology PEER and Endoholder System itjofisadoijtaoj aoisjd sd itjofisadoijtaoj aoisjd sd

14. Engineering Research Center for Computer Integrated Surgical Systems and Technology 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

15. Engineering Research Center for Computer Integrated Surgical Systems and Technology 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

16. Engineering Research Center for Computer Integrated Surgical Systems and Technology 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

17. Engineering Research Center for Computer Integrated Surgical Systems and Technology 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 Testing how notes displayTesting how notes display