The Israel Retractor Modification for Oropharyngeal Surgery on Patients of Larger Body Habitus

Andrew M. Vahabzadeh-Hagh, MD1; Eddie Ramirez, MD1

1UCLA David Geffen School of Medicine

CONTACT

Andrew M. Vahabzadeh-Hagh

UCLA David Geffen School of Medicine,

Department of Head and Neck Surgery

Email: AVahabzadehHagh@mednet.ucla.edu

Website: headandnecksurgery.ucla.edu

ABSTRACTObjectives: Elective oropharyngeal surgery including tonsillectomy and uvulopalatopharyngoplasty performed for obstructive sleep apnea increasingly is performed on patients of upper tier body habitus. The use of the Crowe-Davis retractor in such patients may be complicated by a large barrel chest making it difficult to anchor the retractor to the Mayo stand. Here we present a simple modification using the Israel Retractor to facilitate such surgeries.

Study Design: How I do it.

Methods: Operational instructions for Israel retractor modification in oropharyngeal surgery on patients of larger body habitus.

Results: The Israel retractor provides an extension of to the Crowe-Davis retractor. The Crowe-Davis is able to anchor to the Israel retractor, whose fingers articulate well for suspension on the Mayo Stand. This extension allows ease of positioning and suspension of patients with larger body habitus in oropharyngeal surgery.

Conclusions: Use of the Israel retractor as an extension of the Crowe-Davis retractor handle provides an easy, quick, and reliable method for placing patients of larger body habitus into suspension.

INTRODUCTION

DISCUSSION

METHODS & RESULTS

ISRAEL RAKE RETRACTOR

CONCLUSIONS

REFERENCES

The setup begins the same for a standard oropharyngeal surgery case such as is

performed with a tonsillectomy. The patient is intubated with the appropriate sized

oral RAE endotracheal tube, or in larger patients, a standard endotracheal tube is

preferred and less likely to become dislodged from the airway inadvertently during

surgery. The head of the bed is rotated 90 degrees counter clockwise. A small

gelatinous shoulder roll is placed. The Crowe-Davis retractor is inserted into the

mouth in a closed position apposing against the upper incisors. The retractor is

opened retracting the tongue and endotracheal tube caudally. In a normal sized

patient the Mayo stand is then brought above the patients chest, the Crowe-Davis

retractor suspension arm is hooked onto the edge of the Mayo stand and the

Mayo stand is slowly elevated to improve visualization of the patients oropharynx.

In obese, barrel, or large chested patients, the Mayo can be brought over the

patient’s chest, but will be so high in order to clear the chest, that the suspension

arm can no longer articulate with its edge. Here, we hook the Crowe-Davis

suspension arm into the tear-drop handle of the Israel retractor and then use the

bunt prongs to suspend from the Mayo stand. This allows for suspension that

accommodates the large chested or obese patient while ensuring that no pressure

is placed on the patients chest during surgery.

With increasing demand for oropharyngeal surgery in a population of increasing body habitus, the challenge of obtaining the perfect view in oropharyngeal surgery will always remain and only get more difficult. Use of the Israel retractor to overcome the difficulties with suspending the Crow—Davis retractor on an external support such as the Mayo stand will help us adjust to this changing climate.

Companies have recognized this problem and have sought to develop devices specific for this purpose (Figure 4). However, in multidisciplinary operating rooms or surgery centers, the tool for this job might already be available. For this, keep the Israel retractor in mind. Alternatives to this technique might include using a different external support structure than the Mayo stand which may not need to be directly over the point of maximum protrusion of the patients chest. If none of these options are available, one may consider stacking OR towels on the patients chest under the Crowe-Davis suspension arm to at least provide some mild degree of suspension.

The surgical Israel Rake Retractor, also known as the Volkman retractor, is a

retractor used for retraction of superficial wound edges or for deeper adipose

layers as in abdominal surgery. It can have 2-6 prongs that may be sharp or blunt.

Importantly the handle incorporates a teardrop or round opening. This opening in

the handle of the Israel retractor is able to accommodate the suspension arm of

the Crowe-Davis mouth retractor, probably the most common tool used to expose

the tonsil, superior base of tongue, and lateral pharynx for oropharyngeal surgery

or transoral robotic surgery. We utilized this feature to function as an extension of

the Crowe-Davis suspension arm to allow suspension on a Mayo stand positioned

exceptionally high to overcome an obese, barrel, or large-chested patient.

MATERIALS:

The main instruments we utilized for oropharyngeal surgery include the standard

Crowe-Davis mouth retractor and an Israel Rake Retractor (Volkman retractor).

Specifically we use the Israel retractor with 4 blunt prongs and a tear-drop handle.

In oropharyngeal surgery as with any surgery exposure and visualization is key. In

times when the ability to suspend the Crow—Davis retractor secondary to large

body habitus, consider use of the Israel or Volkman retractor.

Obstructive sleep apnea (OSA) is becoming an evermore common sleep disorder

comprised of repetitive upper airway collapse during sleep. Intermittent

hypoxemia, sympathetic surges, and sleep arousals. 10-25% of adults have OSA

with upwards of 10% having moderate to severe OSA. If OSA goes untreated,

one’s quality of life will suffer and the 15-year mortality is increased by 30%. The

gold standard treatment of OSA is non-invasive positive pressure, such as CPAP,

however 30-50% of patients with OSA do not tolerate CPAP and another 10-20%

refuse to even try it. For appropriately selected patients that do not tolerate CPAP,

surgical procedures aimed to open obstructed regions may be an option (Toh

2014). Trends in obesity and OSA are only increasing (Figure 1A, B – Lancet

2016, Franklin 2015). As such the need for oropharyngeal surgery in patients of

larger body habitus will rise.

At the turn of the 19th century an assistant of Harvey Cushing, Professor Crowe and Cushing’s anesthetist, Davis, devised the Crow—Davis mouth retractor; an open frame mouth gag designed to anchor or suspend to an external support. This device would become the mainstay or providing exposure in modern day oropharyngeal and even transoral robotic surgery. However, at the time of its engineering, patient’s habitus was quite different.

PROBLEM: Inability to suspend Crowe-Davis retractor on an external support (Mayo stand) because of obese, barrel, or large-chested patients causing a large gap between the suspension handle of the Crowe-Davis retractor and the Mayo stand.

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Figure 1. Obesity and Obstructive Sleep Apnea Trends. Obesity, severe and even morbid

obesity has been on the incline overtime as demonstrated by the NCD Risk Factor

Collaboration (NCD-RisC) 5. If the current trends continue, 18% of men and 21% of

women globally will be obese with 6 and 9% being severely obese respectively. Left:

trends in obesity (Adapted from Lancet 2016). Right: Trends in OSA (Adapted from

Franklin 2015).

Figure 2. Israel rake retractor / Volkman retractor. Left to Right – different profile views of

the retractor. Tear drop handle is located superiorly. 4 blunt prong end is demonstrated

inferiorly.

Figure 3. Crowe-Davis

retractor suspended on

Mayo stand using Israel

retractor technique.

Suspension arm of

Crow—Davis retractor is

placed in tear-drop handle

of Israel retractor. Blunt

prongs of Israel retractor

are then hooked onto

edge of Mayo stand which

is then raised to place the

patient in adequate

suspension and improve

oropharyngeal

visualization.

Figure 4. Advertisement

for the ’Dedo Extension’.

Available for sale from the

CANT Corporation <

www.jrcant.com>. No

financial interest,

disclosures, or conflicts of

interest to disclose. Very

similarly this device

mimics that which the

Israel retractor can be

used for as demonstrated

here. With perhaps the

advantage of a more

universal articulating arm

(blunt prongs).