The Israel Retractor
Modification for
Oropharyngeal
Surgery on Patients
of Larger Body
Habitus
INTRODUCTION
METHODS & RESULTS
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.
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.
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.
Andrew M. Vahabzadeh-Hagh, MD1;
Eddie Ramirez, MD1
1UCLA
David Geffen School of Medicine
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).
ABSTRACT
Objectives: 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.
ISRAEL RAKE RETRACTOR
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.
Study Design: How I do it.
Methods: Operational instructions for Israel
retractor modification in oropharyngeal surgery
on patients of larger body habitus.
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.
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.
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.
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.
DISCUSSION
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.
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).
CONCLUSIONS
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.
CONTACT
Andrew M. Vahabzadeh-Hagh
UCLA David Geffen School of Medicine,
Department of Head and Neck Surgery
Email: [email protected]
Website: headandnecksurgery.ucla.edu
REFERENCES
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.
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