Technique

Stitch retractor—simple and easy technique to retract brainLokendra Singh MCh1, Nilesh Agrawal MCh⁎

Department of Neurosurgery, Central India Institute of Medical Sciences, Nagpur, India

Received 3 January 2009; accepted 30 January 2009

Abstract Background: Self-retaining brain retractors are commonly used during intracranial surgery, and

Abbreviations: BREEG, electroencephalcerebral perfusion prtomography; SSEP, so

⁎ Corresponding6416.

E-mail address: an1 Senior author.

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they are indispensable during microneurosurgery. There is a common severe complication due to theuse of self-held retractors, that is, formation of a hemorrhagic infarct area in the brain region exposedto traction. All the more, present retractor systems are fixed and rigid and obstruct surgeons duringsurgery. Sometimes these retractors create glare in the microscope that distracts the surgeon. Wehereby propose a simple and easy method of retraction of brain especially the temporal lobe usingthe transsylvian approach and vermis using the transvermian approach.Methods: This is retrospective analysis of 47 patients in 4 years in which we have used our stitchretractor. We have analyzed their outcome, postoperative scan, and ease of performing surgery.Results: In 47 patients, there was only 1 postoperative contusion, and the longest period it was keptfor is 6 hours. The other advantage was that it does not obstruct in any way while doing dissectionsand surgery. There was no glare while operating under a microscope.Conclusion: We hereby propose a simple and easy method of retraction of brain especially thetemporal lobe using the transsylvian approach and vermis using the transvermian approach. It isminimally traumatic, reducing insult to the brain. It allows the surgeon to dissect without anyobstruction and glare in the way. The biggest advantage of the present stitch retractor is that it is verycheap and simple to use.© 2010 Elsevier Inc. All rights reserved.

Keywords: Stitch retractor; Sylvian fissure; Transsylvian approach; Transvermian approach; Temporal lobe; Brain retraction pressure; Self-retainingbrain retractors

1. Introduction

Walter Dandy once wrote while discussing operativetechnique that “it is evident edema is directly proportional tothe amount of insult to the brain during the operation.Gentleness in touching the brain, in traction, in sponging, theuse of sharp instruments instead of blunt force in cleavage,are all important in lowering the amount of cerebral edema”[5]. A retractor is an instrument used during surgery for,

P, brain retraction pressure; CBF, cerebral blood flow;ogram; MAP, mean arterial pressure; rCPP, regionalessure; SPECT, single photon emission computedmatosensory evoked potentialauthor. Tel.: +91 09 970 186 265; fax: +91 0712 223

ileshr@yahoo.co.in (N. Agrawal).

nt matter © 2010 Elsevier Inc. All rights reserved.009.01.031

URGERY 73[2]:123–127, FEBRUARY 2010

among other things, holding back structures adjacent to theimmediate operative field. During surgery for aneurysms, forlesions located in skull base and sellar- suprasellar tumorwhere the sylvian fissure is opened, retraction of temporallobe is required to gain adequate surgical exposure.

At present, many good retractor systems are available.Each system has its own advantages. It is seen that theseretractors may cause contusions in the underlying brain.Andrews and Bringas [2] and Andrews and Muto [3] in theirstudy pointed out that approximately 10% of major cranialbase tumors and 5% of intracranial aneurysm surgeries havebrain retraction injuries. There may even be chances thatretraction-related postoperative hematoma can be fatal [11].Present retractor systems are fixed and rigid, and they alsotend to obstruct surgeons' way at times. These retractors mayalso create glare in the microscope and distract the surgeon.There are various attempts to avoid complications of these

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TECHNIQUE

LOKENDRA SINGH AND NILESH AGRAWAL STITCH RETRACTOR—SIMPLE AND EASY TECHNIQUE TO RETRACT BRAIN

with use of sponge pieces as retractors [4], soft microballoonpaddy [12], spoon retractor 10, malleable retractor [6], andso on. We have been using this simple and easy method ofretraction of brain especially the temporal lobe and cuthalves of vermis using the transvermian approach whiledoing surgery.

1.1. Technique

In our technique, after making the craniotomy, brainprotection is extremely important during arachnoidaldissection and brain separation to create a surgical corridor.Once the sylvian fissure is opened, then 4'0 silk onatraumatic needle is taken to pass through the arachnoid ofsylvian fissure side of the temporal lobe, which is usuallythickened there. After taking the suture, it is tied to skin ortemporalis muscle, and the temporal lobe is retracted verygently as shown in Fig. 1. In this way, even withoutproducing retraction, the temporal lobe can be kept awayfrom the operating field to facilitate surgical dissection.

We have also found it quite useful in the intra fourthventricular tumor surgeries requiring transvermian approach.Using this technique, both halves of the vermis can be keptretracted. It is particularly useful in children where retractioncan be quite dangerous to the patient. In Fig. 2, a similarretraction method is shown while doing tumor dissection.Sometimes, to facilitate the suture to stay at the arachnoidwhere it is thin, it can be coagulated in a little area by using

Fig. 1. A: Preoperative scan suggestive of suprasellar lesion. B: Four-vessel angioafter sylvian fissure dissection. D: Dissection in progress after temporal lobe is beinwith stitch retractor in situ without any evidence of temporal lobe contusion. F: P

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bipolar current at low settings so that the arachnoid becomesthick (Fig. 3).

1.2. Advantages

There are plenty of advantages in the above-describedsystem. The foremost is that there are no chances ofpostoperative contusion or hematoma. This system has theadvantage that it can be kept in use for prolonged timewithout any trauma. The authors have used this retractortechnique since the last 4 years in 47 patients with only 1postoperative confusion, and the longest period it was keptfor is 6 hours. The other advantage is that it does not obstructin any way while doing dissections and surgery. There is noglare while operating under microscope. The biggestadvantage is that it is very cheap, and costs almost nothing;thus, it fulfills the criteria of a good retractor havingproperties of simple function, wide view, and safety.

1.3. Drawback

When the brain is very full and angry, retraction achievedby this is not enough, so the traditionally used retractorsystems are required. In some cases where sylvian fissure isnot opened properly or the temporal lobe is lacerated, itcannot be used. It has limited usefulness in the sense that itcan be used only for the temporal lobe and transvermianapproaches for fourth ventricular surgeries.

gram suggestive of ICA aneurysm. C: Stitch being taken from the arachnoidg retracted away with stitch retractor. E: Clipping and excision of aneurysmostoperative scan.

ORLD NEUROSURGERY DOI:10.1016/J.SURNEU.2009.01.031

Fig. 2. A: Preoperative scan suggestive of vermian SOL. B: Stitch retractor in situ after vermian split for transvermian approach. C: Tumor dissection in progressafter cut halves of vermis are retracted with stitch retractor. D: Excision of tumor with stitch retractor in situ without any evidence of contusion. E: Postoperativescan.

Fig. 3. A: Four-vessel angiogram suggestive of ICA aneurysm. B: Stitch being taken from the arachnoid after sylvian fissure dissection. C: Dissection in progressafter temporal lobe is being retracted away with stitch retractor. D: Another stitch retractor used while clipping of aneurysm in situ without any evidence oftemporal lobe contusion. E: Nicely exposed aneurysm with both stitch retractors in situ.

TECHNIQUE

LOKENDRA SINGH AND NILESH AGRAWAL STITCH RETRACTOR—SIMPLE AND EASY TECHNIQUE TO RETRACT BRAIN

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TECHNIQUE

LOKENDRA SINGH AND NILESH AGRAWAL STITCH RETRACTOR—SIMPLE AND EASY TECHNIQUE TO RETRACT BRAIN

2. Discussion

After the skull is opened, the cerebral perfusion pressurein the area where the brain is retracted can be calculated bythe formula rCPP = MAP − BRP. Where rCPP is themeasured regional cerebral perfusion pressure (in mm HG),and BRP is the measured brain retraction pressure (in mmHG) [1]. Retraction pressure recorded is equal over the fullarea of contact, providing the more meaningful measurementrather than simply at one point on the retractor. Horimotoand Tsujimura [9] by means of technetium-99m–labeledhexamethyl-propyleneamine oxime SPECT, the regionalCBF in the frontotemporal region of the operated side wasstudied in 6 patients using retraction and 6 patients withoutnonretractors. There was reduction in regional CBF in thefrontotemporal region of the operated side in 3 patients.

Hongo et al [8] pointed out that it is very difficult for thesurgeon to accurately gauge the amount of pressure actuallyapplied to the brain during retraction. The injury caused bysuch retraction can be focal or generalized depending on theexcessive pressure applied or the inappropriate distributionof the pressure. Even strain gauge or gauges attached to theblade has been used [8], but this also has limited use exceptto distribute force on brain evenly.

The current popular system that is in use—Leyla retractor(Aesculap, Germany), introduced by Yasergil [14]—remains the popular self-retaining retractor. An importantproblem faced by the surgeon with this retractor system isrelated to adjustment. It is very difficult to tighten the armsufficiently to prevent drifting and even secure mountingdevice at the craniotomy site [7,13]. Sugita et al [13] reportedthat both the adjustment knob and extreme length of flexiblearm tend to protrude and interfere with the surgeon's hand.

Andrews and Bringas [2] in their study pointed out thatapproximately 10% of major cranial base tumors and 5% ofintracranial aneurysm surgeries have brain retraction injuries.There may even be chances that postoperative hematoma canbe fatal to the patient. All the present retractor systems are fixedand rigid, and they also tend to obstruct surgeons way at time asobserved by Sugita et al [13]. Sometimes these retractors createglare in the microscope that distracts the surgeon. There arevarious variables that influence the vulnerability of the brain todifferent degrees of retraction during surgery, including thepresence of subarachnoid hemorrhage, depth of anesthesia,blood oxygen and carbon dioxide levels, and the region of thebrain retracted [3].

Various electrophysiological studies like EEG and SSEPare being done for detection of imminent brain damage,which is affected by the depth of anesthesia. To documentthe monitoring of BRP and cortical activity, a device hasbeen developed—brain retraction sensor, which was patent-ed (United States patent 6916294).This system has theadvantage to improve the accuracy and fidelity of measuringintracranial pressure due to retraction. The use of spongepieces as retractors [4], soft microballoon paddy [12], spoonretractor [10], and malleable retractor [6] has been tried.

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However, in the case of soft microballoon paddy andmalleable retractor, the fixed retractors are still applied.

All of these studies and devices were invented because ofthe problems that were created by the retractor systems. Onthe other hand, it is extremely difficult for the operatingsurgeon to operate without using retraction. In spinal tumorsurgeries, dura and arachoid are often retracted with the helpof stitches, a very similar principle applied while using thisretraction method during our surgery.

Our system allows surgeon to retract the temporal lobewith very little chance of postoperative contusion orhematoma. Continuous retraction to the brain as comparedto intermittent retraction is more traumatic to brain [15], butwith stitch retractor, continuous retraction is possible. Thisstitch retractor has the advantage of being kept in use forprolonged time without any damage to the brain secondaryto ischemia. The other advantage is that it does not obstructin any way while doing dissections and surgery as was theproblem observed with present retractor systems by Sugitaet al [13]. Another advantage is that there is no glare whileoperating under microscope. The biggest advantage is that itis very cheap, and it costs almost nothing. In our experiencewith 47 patients, only 1 patient had postoperative hematoma.We have used this stitch retractor in 8 posterior fossa tumorswithout any complications.

As already mentioned, our retractor is not so useful whenthe brain if full, angry, and traumatized. Its usefulness istested in our center for transsylvian approaches andtransvermian approach for fourth ventricular operativeprocedures. We feel that this stitch retractor, which ischeap, simple to use, minimally traumatic, and innovative,will be extremely useful to the surgeons.

3. Conclusion

The present retractor system is a simple and easy way forretraction because it is minimally traumatic, reducing the insultto the brain. It allows the surgeon to do dissection without anyobstruction and glare in the way for prolonged periods. Thebiggest advantage of the present stitch retractor is that it is verycheap, simple to use, and does not cost to the patient.

Acknowledgments

The authors acknowledge Dr G. M. Taori, Director ofCIIMS Institute, for allowing us to prepare and send thismanuscript. The authors also acknowledge Dr PrashantAgrawal for editing this manuscript andMr Gopal Jadhav forproviding high quality images.

References

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LOKENDRA SINGH AND NILESH AGRAWAL STITCH RETRACTOR—SIMPLE AND EASY TECHNIQUE TO RETRACT BRAIN

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