SURGERY


stress incontinence, who have already had failed surgery elsewhere and need specialist input. The sheer number of operations we carry out means that surgical equipment that is both functional and cost effective is essential. This includes surgical retractors, which – although simple devices – can have a significant impact on these kinds of procedures, freeing up the hands of assistants and surgeons, and efficiently clearing the surgical site. However, many single-use disposable instruments like this are expensive.”


Mr Alex Digesu, consultant obstetrician and gynaecologist at Imperial College Healthcare NHS Trust in London, added: “The retractors I used previously were extremely traumatic on the vaginal mucosa, especially for older patients with more fragile tissue. The problem with that is that the more damage you cause to the tissue, the greater the inflammatory response and the greater the pain experienced by the patient, so I needed to find a more suitable alternative.”


Simplifying surgery and helping patients The opportunity to watch during gynaecological and urological surgery showed how cumbersome and awkward disposable retractors were to use, not to mention expensive to buy, and fed into the development of a new retractor. Miss Greenwell and Mr Digesu, along with Mr Wael Agur, a consultant urogynaecologist working in Ayrshire and Arran on the west of Scotland, all contributed to the design process, leading to a lighter, cheaper, uncluttered model that is suitable for a number of surgical disciplines, not just women’s health.


Simple refinements


The first product to come out of these initial encounters was the Galaxy I prototype, launched in 2015 as a lower cost version of existing retractors, retailing at almost half the price. The cost savings were attractive to healthcare providers, and feedback from the surgeons was good, but how else could it be improved? From the surgeons’ perspective it needed to be simpler to use, easier to manoeuvre and lighter weight, as the NHS had a target of reducing plastic waste by 10 per cent. The further improved Galaxy II was then launched in 2018.


Mr Digesu described his involvement in the process: “In those early days, I used the Galaxy prototype product, but also welcomed the opportunity to give feedback on how the retractor could be improved. We didn’t reinvent the wheel but used our experience and that of other surgeons to suggest some modifications that were then included in the design of the Galaxy II. We wanted something lightweight, with a clip for the catheter, and gentler hooks that didn’t cause


FEBRUARY 2021


Figure 2: Cam locks allow easy single- handed positioning


their experience. A series of trials on human cadaveric tissue showed exactly what levels of tension human tissue can withstand, and this guided the tensile strength chosen for the Galaxy II hooks and stays, which can accommodate a level far greater than what could be needed.


Figure 1: The Galaxy II Surgical retractor


Mr Digesu commented: “The stays and hooks on a retractor are incredibly important. The selection supplied with the Galaxy II suit different layers of tissue that might need to be pulled back and all designed to minimise trauma. While not all the options are applicable to vaginal surgery, other surgical specialties that operate on regions with more anatomical layers benefit enormously from this. “However, for me the game-changer on the whole retractor design was the cam lock (Figure 2), just a simple clip lock that has made our lives so much easier. The design makes it far easier to optimise the retractor shape for different procedures, and to modify it for each individual patient; patients are all different sizes so being able to place the retractor accordingly is very useful.” Mr Agur agreed: “The hooks supplied with other retractors are available in sharp or blunt varieties but I have found problems with both – the sharp hooks caused too much tearing and the damaged areas needed suturing, whereas the blunt hooks didn’t hold the tissue well.


Figure 3: The Galaxy II Make kit


so much damage to the tissues.” Further input also suggested that additional changes were necessary to allow the retractor to sit correctly and avoid getting in the way of a colleague operating laparoscopically alongside. It was clear from observation that this just needed a square counterpart to complement the snowman shape design.


Strong, lightweight and better for the patient


The design process resulted in a product that addressed the needs of the contributing surgeons, improving efficiency and reducing the number of people needed in the operating room (Figure 1). New hooks were also specially developed, and the elasticity of the cord was increased to enable more tension to be applied without tearing the tissue.


However, exactly how strong the Galaxy II needed to be was a challenge for the team, as surgeons don’t measure how many Newtons of force human tissue can take if you pull it with a sharp hook, they use


“In contrast, the hooks with the Galaxy II are pointed enough but not too sharp; I have found they provide just the right balance between adequately retracting the tissues and avoiding unnecessary trauma. Having a place for the urinary catheter is another big advantage for me, and the locking mechanism is much finer than alternatives.”


Taking the pressure off staff and training the next generation A further advantage of the improved self-retaining retractor is its suitability for teaching. Mr Digesu explained: “Having a retractor is very important during my educational courses. Historically, surgical trainees and students would assist in the operation by standing next to the surgeon and manually retracting the tissue. However, I am now able to use the retractor instead, which means that trainees and students can observe from directly behind me, giving them the best view for learning the anatomical structures and surgical steps.” Mr Agur has also seen benefits when teaching: “It is far more important for a trainee to really use every opportunity they have to learn how to do a procedure. The use of a self-retaining retractor makes the field clear and accessible, with no hands in the way, and frees up assistants to perform important steps of the procedure themselves. In that respect, I have found the Galaxy II retractor vital for teaching vaginal surgery.”


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