U.S. patent number 3,710,783 [Application Number 05/105,340] was granted by the patent office on 1973-01-16 for thoracic inlet rib retractor.
Invention is credited to Mario Enrique Jascalevich.
United States Patent |
3,710,783 |
Jascalevich |
January 16, 1973 |
THORACIC INLET RIB RETRACTOR
Abstract
A rib retracting instrument for mounting on a surgical table
employs a rigid, elongated boom member provided with swivel means
at the top of the boom member. The swivel means is rotatable about
a first axis parallel to the length of the boom member and about a
second axis which is perpendicular to the first axis. A manually
operable retracting member is connected to the swivel means to
rotate therewith in all planes. The retracting member extends
through the swivel means for linear movement with respect thereto,
the retracting member being adjustable to self-retained
position.
Inventors: |
Jascalevich; Mario Enrique
(West New York, NJ) |
Family
ID: |
22305266 |
Appl.
No.: |
05/105,340 |
Filed: |
January 11, 1971 |
Current U.S.
Class: |
600/228; 403/361;
254/98; 403/131; 403/353; 5/658; 403/90; 403/118; 403/258;
600/234 |
Current CPC
Class: |
A61B
17/02 (20130101); Y10T 403/32598 (20150115); F16B
2200/403 (20180801); Y10T 403/32311 (20150115); Y10T
403/32704 (20150115); Y10T 403/7015 (20150115); F16B
2200/10 (20180801) |
Current International
Class: |
A61B
17/02 (20060101); A61b 017/02 (); B66f 003/08 ();
B25g 003/38 () |
Field of
Search: |
;128/20 ;254/98 ;269/328
;287/14,91,100 |
References Cited
[Referenced By]
U.S. Patent Documents
Foreign Patent Documents
|
|
|
|
|
|
|
625,978 |
|
May 1927 |
|
FR |
|
1,235,135 |
|
May 1959 |
|
FR |
|
Primary Examiner: Pace; Channing L.
Claims
I claim:
1. A thoracic inlet rib retractor comprising an elongated boom
member, means at one end thereof adapted for connecting the boom
member to a surgical table, swivel means at the opposite end of the
boom member for rotation about a first axis parallel to the length
of the boom member and for rotation about a second axis
perpendicular to the first axis, and a screw member having a handle
at one end thereof, the swivel means having a threaded bore, the
screw member extending through and in mating engagement with the
threaded bore.
2. A thoracic inlet rib retractor according to claim 1 including a
rigid extension member connected to the other end of the screw
member, the extension member being connected to the screw member by
means allowing the extension member to rotate about its
longitudinal axis.
3. A thoracic inlet rib retractor according to claim 2 including a
rigid blade supporting member rotatable with the extension member,
the blade supporting member and the extension member having
cooperable means for the releasable connection of the blade
supporting member to the extension, the blade supporting member
having means at the outer end for the connection of a retractor
blade thereto.
4. A thoracic inlet rib retractor according to claim 1 wherein the
boom member comprises a first vertically extending portion and a
second vertically extending portion laterally offset with respect
to the first portion, the upper end of the first portion being
connected to the lower end of the second portion by an intermediate
horizontally extending portion, the swivel means being located at
the top of the second portion.
5. A thoracic inlet rib retractor according to claim 1 wherein the
means at said one end of the boom member for connecting the boom
member to a surgical table includes means for adjusting and
releasably securing the boom member to adjust the position of the
swivel means above a surgical table.
6. A thoracic inlet rib retractor according to claim 1 wherein the
swivel means comprises a bifurcated member having a pair of spaced
arms and a downwardly extending base portion having an internal
bore, said one end of the boom member being positioned within the
bore, the base portion being connected to the boom member to allow
the bifurcated member to rotate about the axis provided by the boom
member, a cross member extending between and pivotally connected to
said arms, the screw member extending through the cross member.
7. A thoracic inlet rib retractor according to claim 6 including a
rigid extension member connected to the other end of the screw
member, the extension member being connected to the screw member by
means allowing the extension member to rotate about its
longitudinal axis.
8. A thoracic inlet rib retractor according to claim 7 including a
rigid blade supporting member rotatable with the extension member,
the blade supporting member and the extension member having
cooperable means for the releasable connection of the blade
supporting member to the extension, the blade supporting member
having means at the outer end for the connection of a retractor
blade thereto.
9. A thoracic inlet rib retractor according to claim 6 wherein the
boom member comprises a first vertically extending portion and a
second vertically extending portion laterally offset with respect
to the first portion, the upper end of the first portion being
connected to the lower end of the second portion by an intermediate
horizontally extending portion, the bifurcated member being located
at the top of the second portion.
10. A thoracic inlet rib retractor according to claim 9 wherein the
means at said one end of the boom member for connecting the boom
member to a surgical table includes means for adjusting and
releasably securing the boom member to adjust the position of the
bifurcated member above a surgical table.
11. A thoracic inlet rib retractor according to claim 1 wherein the
swivel means comprises a socket provided at said one end of the
boom member and a ball within the socket, the screw member
extending through the ball.
12. A thoracic inlet rib retractor according to claim 11 including
a rigid extension member connected to the end of the screw member
opposite the handle coaxially of the screw member, the extension
member being connected to the screw member by means allowing the
extension member to rotate relative to the screw.
13. A thoracic inlet rib retractor according to claim 12 including
a rigid, elongated, blade-supporting member releasably connected at
one end thereof coaxially to the extension member and rotatable
therewith the blade supporting member having means at the other end
for the connection of a retractor blade thereto
14. A thoracic inlet rib retractor according to claim 11 wherein
the boom member comprises a first vertically extending portion and
a second vertically extending portion laterally offset with respect
to the first portion, the upper end of the first portion being
connected to the lower end of the second portion by an intermediate
horizontally extending portion, the ball and socket being located
at the top of the second portion.
15. A thoracic inlet rib retractor according to claim 14 wherein
the means at the lower end of the boom member for connecting the
boom member to a surgical table includes means for adjusting and
releasably securing the boom member to adjust the position of the
ball and socket above a surgical table.
Description
The invention relates to an instrument for retracting the ribs at
the thoracic inlet portion of the anatomy to enlarge the otherwise
confined and restricted area presented to the surgeon who must
operate in the thoraco-abdominal region.
BACKGROUND OF THE INVENTION
A number of serious and delicate surgical operations, which require
a substantial amount of time, are performed within the limited
confines of the thoraco-abdominal region. The space or area within
which the surgeon must work is severely limited by the barrier
provided by the ribs which surround this region.
In the upper right portion of the thoraco-abdominal region there
are the liver, the gall bladder and all of the delicate bile
channels that lie deep beneath the liver and the gall bladder. The
pancreas is in the central portion of this region, this organ lying
deep and posteriorly. In the left upper portion or quadrant are the
spleen, the tail of the pancreas, the stomach and two surgery-prone
parts of the anatomy that are associated with the stomach and which
require delicate surgery; that is, the esophagus and the vagus
nerves. Vagotomies are being perfomed with increasing frequency to
mitigate the effect of ulcers. The esophagus passes through a small
opening in the diaphragm which forms the top or ceiling of the
thoraco-abdominal region, and it is in this area that hernias
sometimes develop to cause diaphragmatic herniations. The repair of
diaphragmatic hernias and vagotomies are two operations which are
extremely difficult to perform because the operative areas are very
deep within the thoraco-abdominal region. Where the patient is
unduly obese, these areas may be so deep that it is too dangerous
to perform the operations. To reach the organs, nerves and areas
referred to above, the patient lies upon his back on the surgical
table in what is termed the anterior position.
To perform surgery upon the kidney and the adrenal gland which lies
on the top of the kidney, the patient must lie upon the surgical
table in what is termed in the lateral position.
To reach the kidney and the adrenal gland it also is sometimes
necessary that the patient lie face down on the surgical table in
what may be termed the posterior position. It is in such position
that access also may be had to the aorta and vena cava, and the
deeply seated splanchnic nerves, which control the functions of
several organs in the abdomen. A splanchnicectomy to cut such
nerves may be required.
In addition, in the recent past it has become possible to graft
entire organs, for example, the pancreas, the liver and many other
organs within the thoraco-abdominal region. For these
time-consuming operations the surgeon is confronted with the
formidable problem caused by the deep approach necessary within an
area encircled or surrounded by the ribs.
In order to expand the opening at the thoracic inlet to enable the
surgeon to operate within the thoraco-abdominal region, the usual
practice has been, and still is, to manually retract the costal
margin or the last ribs at the patient's side or back. An assistant
surgeon holding a Balfour blade or the like, sometimes one blade in
each hand depending upon the kind of operation to be performed,
must pull upon or apply tension to the hand retractors or blades
hooked around the costal margin or end rib or ribs. To
satisfactorily enlarge the opening leading into the
thoracic-abdominal region, it is necessary that the line of
retraction be in an upward direction to lift the costal margin or
the end ribs. Traction to lift frequently must be accompanied by a
vector or component of retraction directed either toward the side
of the table or toward the head of the table, or in both such
directions, thereby requiring lines of retraction in what may be
termed the X and Y directions; that is, the lateral and
longitudinal directions of the horizontal plane, coupled with
retraction in the Z direction or a lifting action in the vertical
plane.
Many of the operations referred to above require several hours. The
assistant surgeon applying retraction manually simply is unable to
apply the necessary retraction continously and with the desired
uniform and constant level of tension. No matter how strong the
assistant surgeon may be, the physical requirements demanded are
beyond human endurance. He becomes fatigued, thereby releasing
tension on the blades upon which he has been pulling. As a result,
the delicate viscera beneath the hooked end of the retractor blade
may be injured, and due to the "shoveling effect," it becomes
necessary at times to remove a perfectly good organ which was not
the objective of the operation. The substantial force of retraction
should be applied solely to the ribs; separation for the delicate
viscera should be accomplished by the gentle hand of the surgeon
rather than by a rigid retractor member or blade. Moreover, in
performing his duty to retract the ribs, the assistant surgeon
cannot avoid presenting some measure of interference to the
operating surgeon.
A number of mechanisms have been proposed to overcome the problems
of physically applying retraction by a person. In one prior art
apparatus, a ring shaped frame is mounted on brackets secured to
each side of the surgical table. The ring shaped frame has a
plurality of retractor blades mounted thereon in a manner to permit
the blades to be moved outwardly in a horizontal plane parallel to
the plane of the table. The frame and the retractor blades mounted
thereon are positioned directly over the patient at the area to be
retracted. The use of this apparatus requires a special technique
for draping the patient, and a preoperative set-up of the
apparatus. The apparatus is not suitable for rib retraction where
the operation requires that the patient lie in the lateral
position. Moreover, the frame is located immediately over the
patient where it obstructs the operative field.
Another apparatus which has been proposed to replace the
application of retraction by an assistant surgeon comprises an arch
shaped assembly having opposite downwardly extending arms connected
to each side of the surgical table and a cross-bar extending
between the arms across the table. A blade support is slideably
mounted on the cross-bar, and a retractor blade is connected to the
support to permit adjustment of the blade in a longitudinal
direction and locking it in retracted position. The necessity to
position the device to extend immediately over the chest of the
patient and to encompass the patient between the device and the
surgical table interferes with the surgeon's operative field. The
device must be mounted on the table only after the patient is upon
the table. Moreover, when it may be necessary to make adjustments
of the position of the blade or blades while the operation is being
performed, an undue amount of time is consumed to change the
position of the blade support along its cross-bar and to adjust the
position of the blade with respect to its support.
In another mechanical device for retracting the costal margin, a
pair of angled shafts are mounted in spaced relation upon a ratchet
bar. Each shaft has a retractor blade connected thereto to engage
opposite sides of the costal margin at its base. The device
operates on the principle that the costal arch possesses a variable
angle, and pressure outward at the base, near the ninth cartilage,
opens up the angle of the arch. The angled shafts on the ratchet
bar are moved apart and secured in their displaced positions to
furnish the lateral, outward pressure at the base. The essential
lifting action is indirect, and therefore of limited extent. Also,
the lifting action is limited by the difference in individuals'
body structures. This device cannot be used where the operation
requires that the patient lie on the table in either posterior or
lateral positions. Also this instrument intrudes to a certain
extent upon the operative field.
In another device, a turret is mounted on the top of a vertically
extending rod having means at its lower end for connection to the
side of a surgical table. The turret is mounted on the rod for
rotation about a single axis only, the longitudinal axis of the
rod. A rigid, manually operable arm extends through the turret and
has a retractor blade hinged to its outer end to permit raising and
lowering of the blade. Only up and down pivoting of the blade with
respect to the end of the arm is permitted by the hinge
arrangement. A slotted bar and pivoted connecting link extend
between the top of the turret and the hinged retractor for locating
the end of the retractor in position, and means is provided at the
turret end of the slotted bar to secure the retractor in such
position. This apparatus, which is designed for the retraction of
the abdominal wall, rather than the costal margin or end ribs, is
rather complicated in construction and expensive to manufacture.
From the functional standpoint, and for the purpose of retracting
ribs at the thoracic inlet, this device would not furnish the
desired line of retraction so essential for the satisfactory
operation of a mechanical device to retract the costal margin and
the end ribs when the patient must be positioned on the table in
the posterior or lateral positions, as well as the anterior
position. Moreover, this device is constructed so that it must
extend over the patient, and therefore interferes with the
surgeon's field of operation.
SUMMARY OF THE INVENTION
In accordance with the invention, a mechanical rib retractor is
provided which comprises a rigid, elongated boom member, means at
the lower end of the boom member to connect it to the side of a
surgical table, and swivel means at the top of the boom member
which is rotatable about a first axis parallel to the length of the
boom member and for rotation about a second axis perpendicular to
the first axis. The swivel means is rotatable in all planes, and in
all combination of such planes. In effect, the swivel means
provides a universal mounting on top of the boom member. A rigid,
manually operable retracting member is connected to the swivel
means for rotation therewith in all planes, and for movement
linearly with respect to the swivel means to adjusted, retained
position. Due to the universal mounting of the linearly movable
retracting member, retraction may be applied in all desired
directions, that is, laterally outward toward the side of the
surgical table (the X direction), longitudinally toward the head of
the table (the Y direction), and upward (the Z direction). The
manually operable member is adapted to have a rib-engaging
retractor blade connected thereto.
Due to the construction of the instrument, the line of retraction
is applied from a point located a substantial distance above the
patient and at the side of the table. Preferably, the point of
retraction is from a high point beyond the side of the table. Only
the retractor blade in engagement with the costal margin or end rib
is in the operative field of the surgeon. Due to the universal
mounting of the linearly movable retracting member, the retractor
blade connected thereto is self-adjustable to each individual's rib
structure. The instrument is suitable for engagement with the
costal margin when the patient is in the anterior position, and the
end ribs at the thoracic inlet when the patient is in the posterior
position or lateral position. The surgery table need not be
initially prepared; it may be prepared at any time, and even during
surgery. No special technique in draping is required; the regular
or usual technique is used. There is not need for a pre-operative
set-up; set-up may be made at any time before or during surgery.
Most important, the instrument of the invention is completely
unobtrusive to the operating team and affords a completely
unobstructed operative field. The device of the invention is
operable by the anesthetist or by a nurse, thereby eliminating the
necessity for an assistant surgeon and the utilization of only his
inadequate physical prowess. As will subsequently appear, the
device of the invention is of simple construction, easy to operate
and inexpensive to manufacture.
The structure of an instrument made in accordance with the
invention, its advantages, and the improved results furnished
thereby will be apparent from the following description of a
preferred embodiment thereof, taken in conjunction with the
accompanying drawings.
BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is an elevational view of a thoracic inlet rib retractor
made in accordance with the invention;
FIG. 2 is an enlarged view of the swivel means and associated
manually operable retracting member taken partly in cross-section,
approximately in the plane of line 2--2 of FIG. 1;
FIG. 3 is a view, partly in cross-section, showing the relationship
of the manually operable retracting member to an extension member,
and the manner in which a blade supporting member may be releasably
connected to the extension member;
FIG. 4 is a cross-section taken approximately in the plane of line
4--4 of FIG. 3;
FIG. 5 is an enlarged partial view of the blade supporting member,
a portion thereof being shown in cross-section to illustrate means
for releasably connecting such member to the extension member;
FIG. 6 is a view taken approximately in the plane of line 6--6 of
FIG. 1 showing in greater detail the means for connecting the lower
end of the instrument's boom member to a surgical table;
FIG. 7 is a view, partly in cross-section, illustrating another
embodiment of the swivel means and its related manually operable
retracting member, this view being taken approximately in the plane
of line 7--7 of FIG. 8;
FIG. 8 is a view taken approximately in the plane of line 8--8 of
FIG. 7;
FIG. 9 is a perspective view of a surgical table having a pair of
instruments made in accordance with the invention connected to the
sides of the table;
FIG. 10 illustrates the function of the instrument of the invention
as it retracts the costal margin, this view, for clarity in
illustration, showing only the patient's rib cage in the anterior
position;
FIG. 11 illustrates the manner of operation of the instrument when
the patient is in the posterior position; and
FIG. 12 shows the manner of operation of the instrument when the
patient is in the lateral position.
DESCRIPTION OF THE PREFERRED EMBODIMENT
Referring to FIGS. 1-6, and in accordance with the invention
generally, the thoracic inlet rib retractor R comprises a rigid,
elongated boom member A, means B at the lower end thereof for
connecting the boom member to a surgical table T (FIG. 9), swivel
means C at the top of the boom member for rotation about a first
axis parallel to the length of the boom member and for rotation
about a second axis perpendicular to the first axis. A rigid,
manually operable retracting member D is connected to the swivel
means C to allow the retracting member to rotate together, or as a
unit, with the swivel means about the first and second axes. The
retracting member D is connected to the swivel means to furnish
linear movement of the retracting member to adjusted, retained
position.
In greater detail, the boom member A is made of a strong rigid
material and has substantial length. For example, the boom member
may be made of stainless steel rod approximately five-eighths inch
in diameter and having an overall length of approximately 32
inches. Although the boom member may be of continuous, linear
length, it is preferred, as illustrated, to make the boom member
with a first vertical portion 20, and a second vertical extending
portion 22 laterally offset from the first portion. An intermediate
horizontally extending portion 24 is connected to the top of the
bottom portion 20 and the bottom of the top portion 22 by screws 26
extended through the vertically extending portions and threaded
into the ends of the horizontally extending portion 24. This
laterally offset arrangement of the portions of the boom member is
preferred because with the instrument R mounted on a surgical table
T, as shown in FIG. 9, it has been found preferable to locate the
connection of the retracting member D to the swivel means C at a
point laterally outward of the side of the table, as well as at a
substantial distance above the plane of the table. By such location
of the point of connection P of the retracting member D to the
swivel means C, suitable lines of retraction are afforded for any
required position of the patient--anterior, lateral or posterior,
and the operative field is unobstructed.
Any suitable means B may be used to releasably connect the
instrument R to the side of a surgical table. The means B is
constructed for the adjustable connection thereto of the boom
member to locate the swivel means C at the desired distance above
the surgical table.
As shown in FIGS. 1 and 6, the means B comprises two segments 28
and 30 secured to one another at a right angle by a plurality of
screws 32 extended through counter-sunk bores in the segment 28 and
threaded into the segment 30. The segment 28 is provided with a
vertical hole or bore 34 through which the portion 20 of the boom
member is extended. The boom portion 20 is provided with a flat
side 36 for engagement by the end of a hand actuated set screw 38.
The vertical position of the swivel means C is adjusted by
loosening the set screw, raising or lowering the boom member A, and
tightening the set screw.
As shown in FIG. 1, the segment 30 of the mounting means or bracket
B is provided with an opening 40 extended therethrough having a
shape or contour to permit the bracket to be slipped over a side
bar 42 on the surgical table (FIG. 9) in mating engagement
therewith, following which the connecting means or bracket is
releasably secured in place by a set screw 44 having a knob at the
outer end thereof. To permit the bracket to be mounted on either
side of a surgical table, the segment 30 is provided with threaded
openings 46 on the top and bottom sides so that the set screw 44
may be threaded into either side for engagement with the side bar
42. While this arrangement permits mounting a single instrument on
either side of the surgical table, it is preferred that the table
be equipped with two instruments R, one on each side of the table
as shown in FIG. 9, to permit the second instrument to be used if
necessary without any loss of time to remove the single instrument
from one side of the table and mounting it on the other side. It
will be understood that for certain kinds of operations it is
desirable that retraction be applied from both sides. For ease of
manufacture, the segment 30 is made of three plates secured to one
another by screws 48 (FIG. 6) extended through aligned tapped holes
in the areas above and below the opening 40.
As illustrated in FIGS. 1 and 2, the swivel means C is mounted on
the top of the boom member A for rotation in all planes. In this
embodiment of the invention, the swivel means comprises a
bifurcated member 50 having a pair of spaced arms 52 and an
integral downwardly extending base portion 54. As shown in FIG. 2,
the base portion is provided with a central bore 56 within which
the upper end of the boom member A is positioned with a slight
amount of clearance. The bifurcated member 50 is connected to the
boom member so that the member is rotatable about the longitudinal
axis of the boom member. As shown, the boom member is made with an
annular groove 58 and the wall of the base portion 54 has tapped
holes extending through opposite sides thereof in alignment with
the groove 58. Pivot pins in the form of screws 60 are extended
through the tapped holes with the ends of the screws within the
groove. This manner of connection of the parts secures the
bifurcated member to the top of the boom member and allows the
bifurcated member to rotate about the longitudinal axis of the boom
member. A cross member 62 is positioned between the spaced arms 52
and is pivotally connected to the arms by opposite end threaded
pivot pins 64 extended through countersunk holes in the arms and
threaded into the cross member. The cross member is rotatable about
the axis provided by the opposite pivot pins 64, such axis of
rotation being perpendicular to the longitudinal axis of rotation
of the bifurcated member 50 about the boom member.
The manually operable retracting member D is connected to and
extends through the swivel means C for rotation as a unit with the
swivel means and for primary linear movement with respect to the
swivel means. As shown in FIG. 1 and 2, the manually operable
retracting member comprises a screw member 66 having a handle 68 at
its outer end. The screw member extends through the cross member 62
which is provided with an internal, matingly threaded bore. The
screw member is made of strong, rigid rod stock, for example,
one-half inch in diameter, and preferably with a thread pitch of
approximately 20 threads per inch to permit fine linear,
self-retained adjustment of the screw member with respect to the
swivel means.
To eliminate torque which would be imparted to a rib-engaging
retractor blade connected to the screw member, the inner end of the
screw member 66 has a rigid extension member 70 connected thereto
by means allowing the extension member to rotate about its
longitudinal axis, also around the longitudinal axis of the screw
member. As best shown in FIG. 3, a hub 72 is provided with a bore
through which a pivot pin 74 having a threaded end is extended and
threaded into the lower end of the screw member 66 for the
rotatable connection of the hub to the screw member. The hub is
provided with a larger counter-bore 76 extending into its opposite
end to accommodate the head of the pivot pin, a washer under the
head, and to receive the end of the extension member 70. The end of
the extension member is provided with a recess 78 to accommodate
the head of the pivot pin 74 and the washer. The extension member
is fixed to the rotatable hub by a set screw 80 whereby the
extension member is rotatable about the longitudinal axis of
rotation provided by the pivot pin 74.
A retractor blade E, such as a Balfour blade or the like, may be
directly connected to the extension member 70. It is preferred,
however, to provide an intermediate blade supporting member F
between the retractor blade and the screw member's rotatable
extension 70. By using an intermediate blade support member, only
such member and the retractor blade E require sterilization. The
blade supporting member F, also the retractor blade, may be made of
rigid, stainless steel stock. It is sometimes desirable to X-ray
the patient during the operation. The retractor blade E may be made
of rigid, transparent, plastic material to allow X-raying.
As shown in FIGS. 3, 4 and 5, the blade supporting member F is made
of flat stock so that the underside thereof will lie against an
adjacent flat side 82 of the extension member 70 for rotation
therewith. The blade supporting member is releasably connected to
the extension member. Suitable releasable connection means may
comprise, as shown, a pair of longitudinally spaced screws 84
threaded into the extension member 70 with the heads of the screws
spaced above the surface 82 a sufficient amount to allow the
thickness of the member F to be positioned under the heads with a
slight amount of clearance. As shown in FIG. 3, the blade
supporting member F is provided with spaced slots 86 therethrough
each formed at one end with an opening sufficiently large to clear
the head of the screw and with a longitudinally extending portion
slightly wider than the shank of the screw to thereby allow the
member F to be moved to the position shown in FIG. 3, where the
member F is held in place. The member F is removed by sliding it
toward the enlarged portions of the slots and lifting it away.
To assure that the blade supporting member F is held in place, such
member is provided with a resiliently mounted connector 88
cooperable with the shank of one of the screws 84. As shown in FIG.
5, such connector may take the form of a spring mounted ball
plunger housed within the central bore of an externally threaded
housing screwed into a threaded bore extended through one side of
the blade supporting member F. A part 90 is threaded through the
opposite side of the member so that the nose thereof extends
slightly into the necked down portion of the slot 86 opposite to
and in alignment with the spring mounted ball plunger. The end of
the blade supporting member F is provided with a hook 92 over which
the apertured end 94 of a suitable retractor blade E, such as a
Balfour blade, may be connected, as shown in FIGS. 10, 11 and
12.
Due to the described connection of the extension member 70 to the
screw member 66, the connection of the blade supporting member F to
the extension member, and the connection of the blade E to the
member F, the blade is movable linearly along the longitudinal axis
provided by the rigid screw member, extension member and blade
supporting member. Also, the articulated connection of the blade to
the rotatable blade supporting member facilitates hooking its
curved end about the costal margin or rib initially, following
which straight line retraction is furnished by turning the handle
68 of the screw member (righthand thread) in counter-clockwise
direction.
Instead of the swivel means constructed as hereinbefore described,
swivel means C' as shown in FIGS. 7 and 8 may be provided at the
top of the boom member A to furnish a universal mounting for the
linearly movable, manually operable retracting member D. A ball 96
is provided with a threaded bore therethrough, the screw member 66
being threaded in and extending through the bore. As shown, and for
convenience and ease of manufacture, it is preferred that the
socket 98 for the ball be furnished by a socket member 100 welded
at 102 to the top of the boom member and a pair of plates. The
socket member preferably is angled and made of flat stock. A hole
104 is formed in the member having a diameter slightly larger than
the diameter of the ball. The ball 96 is held in place by a pair of
apertured plates 106 fastened by screws 108 to each side of the
socket member 100. As illustrated, the plates 106 are each provided
with an opening 110 in alignment with the hole 104. The periphery
of each opening 110 is curved in conformity with the curvature of
the ball to furnish a slight amount of clearance. As shown, the
ball is retained in the socket because the diameter of the outer
peripheral edge 111 of each opening 110 is smaller than the
diameter of the ball; the location of the apertured plates 106 in
the assembly prevents the ball from leaving the socket.
Functionally, the arrangement shown in FIGS. 7 and 8 furnishes the
same kind of universal mounting for the manually operable
retracting screw 66 as hereinbefore described in connection with
FIGS. 1-6. By turning the screw member (righthand thread) in
counter-clockwise direction, the screw member is moved linearly
with respect to the ball in retracting direction. The previously
described arrangement may be used to eliminate the application of
torque upon the retractor blade E connected to the screw member.
Rotation of the screw member in clockwise direction releases the
tension being applied by the retractor blade when hooked about the
costal margin or an end rib at the thoracic inlet.
To retract the costal margin, designated 112, on the left side of
the patient as shown in FIG. 10, only one retractor R mounted on
the left side of the table oriented from the head of the table, as
shown in FIG. 9, need be used. Actually, though the surgeon may be
operating upon an organ on the patient's left side, it is preferred
that retraction be applied to both sides of the costal margin,
whereby an instrument R would be mounted on each side of the table.
Retraction is shown only on one side in FIG. 10 to illustrate the
accordion effect, or the manner in which the ribs are moved
together, when the costal margin is retracted.
After the incision or incisions have been made to expose the costal
margin and the thoraco-abdominal region, and the height of the
point P (FIG. 9) has been adjusted to the individual patient's body
structure by raising or lowering the boom member A by the
releasable connection furnished by the set screw 38, the blade E
having its aperture 94 hooked on the hook 92 of the blade support
member F has its opposite end hooked around the costal margin 112.
By turning the handle 68 of the screw 66 in the proper direction,
tension is applied along the line of retraction Lz as shown in FIG.
10. Due to the location of the point of connection P of the screw
member to the swivel means, C or C', the lifting action along the
line of retraction Lz is accompanied by a line of retraction Lx
directed laterally toward the side of the surgical table and a line
of retraction Ly directed longitudinally toward the head of the
table. As a result, retraction in all directions is furnished to
best enlarge the thoracic inlet to enable the surgeon to operate
under optimum conditions. If additional tension or retraction is
needed, the anesthetist at the head of the table or a nurse simply
grasps the handle 68 and makes an addition turn or turns on the
screw member, thereby placing additional tension on the retractor
blade E and the costal margin 112 about which the blade is hooked.
The screw member 66 remains in adjusted position until the handle
68 is turned.
As will be evident from FIG. 10, only the retractor blade E is in
the surgeon's field of operation. The primary line of retraction is
in the direction of Lz, which is at a substantial inclination or
angle from the horizontal plane; lifting of the costal margin is
accomplished from the relatively high and remote point P. Due to
the articulated connection of the retractor blade E to the blade
supporting member F, and the absence of torque upon the blade
supporting member, the curved end of the retractor blade about the
costal margin initially adjusts itself to the individual patient's
body structure following which retraction is applied linearly. The
mounting of the instrument upon the surgical table, and the
adjustment of the height of the swivel means, and the point P,
above the table are so simple and readily accomplished that the
instrument may be made ready for use within a minimum amount of
time, and at any time including during the operation.
With the patient in the posterior position as shown in FIG. 11, a
retractor blade E connected to the end of the instrument has its
free end hooked around the end rib 114 at the thoracic inlet as
shown. This view shows but one retractor blade, and therefore one
instrument is used to retract the ribs on the patient's right side.
The showing of one retractor blade illustrates the accordion effect
imparted to the ribs when retraction is applied by the instrument.
It will be understood that if the operation requires retraction on
both sides, a pair of instruments would be used, one on each side
of the table. The manner of use and operation of the instrument of
the invention is the same as above described with regard to the
anterior position. When the patient is in the posterior position,
it is desirable that the lifting action along the line of
retraction Lz be accompanied by a substantial component of
retraction longitudinally toward the head of the table, or in the
direction Ly. As indicated in FIG. 11, substantial retraction in
the longitudinal direction also is furnished by the instrument by
virtue of the high and laterally offset location of the connection
P of the manually operable retracting member D to the swivel means
C or C'. In the posterior position, the only element in the
surgeon's operative field is the retractor blade.
Where the operation requires that the patient be in the lateral
position upon the surgical table, only one instrument R is needed.
The instrument is mounted on the left or right side of the table
depending upon which side of the thoracic rib inlet must be
retracted. As shown in FIG. 12, wherein the patient lies on the
table on his left side, and retraction is applied to the patient's
right side, the line of retraction Lz to lift is accompanied by the
desirable substantial components of retraction in the direction Lx
directed toward the side of the table and the direction Ly directed
longitudinally toward the head of the table. The manner of use and
operation of the instrument is the same as hereinbefore described
in connection with the anterior position as shown in FIG. 10.
It is believed that the advantages and improved results furnished
by the thoracic inlet rib retractor of the invention will be
apparent from the foregoing detailed description thereof. Various
changes and modifications may be made without departing from the
spirit and scope of the invention as sought to be defined in the
following claims.
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