Buscar en
Cirugía Española (English Edition)
Toda la web
Inicio Cirugía Española (English Edition) Use of Alexis Retractor in Thyroid and Parathyroid Surgery
Journal Information
Vol. 97. Issue 1.
Pages 46-49 (January 2019)
Visits
1913
Vol. 97. Issue 1.
Pages 46-49 (January 2019)
Innovation in Surgical Technique
DOI: 10.1016/j.cireng.2018.12.002
Full text access
Use of Alexis Retractor in Thyroid and Parathyroid Surgery
Uso de retractor Alexis en cirugía de tiroides y paratiroides
Visits
...
Yolanda Lois-Ortegaa,
Corresponding author
yloisortega@gmail.com

Corresponding author.
, Fernando García-Curdib, Simón Brotons-Durbánc, Juan Bosco Vendrell-Marquésc
a Servicio de Otorrinolaringología, Hospital Ernest Lluch Martín, Calatayud (Zaragoza), Spain
b Servicio de Otorrinolaringología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
c Servicio de Otorrinolaringología, Fundación Instituto Valenciano de Oncología, Valencia, Spain
Related content
Cir Esp. 2019;97:358-910.1016/j.cireng.2019.05.014
Melody Baeza Murcia, Joana A. Miguel Perelló, Benito Flores Pastor, José Luis Aguayo Albasini
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (4)
Show moreShow less
Abstract

In thyroid and parathyroid surgical procedures, good visibility of the thyroid gland is essential. This is traditionally achieved by means of traction sutures of the dermo-plastysmal flaps to the drapes of the operative field, producing tension and even damage to the skin. The Alexis® retractor ring improves exposure and facilitates stable access to the thyroid, protecting the skin from injury during the intervention.

Keywords:
Alexis ring retractor
Thyroidectomy
Retractor
Traction
Resumen

En los procedimientos quirúrgicos de tiroides y paratiroides es indispensable una buena exposición de la glándula tiroidea, lo cual se realiza habitualmente mediante suturas de tracción de los colgajos dermoplatismales a los paños del campo operatorio, lo que produce tensión e incluso daños en la piel. El anillo retractor Alexis® mejora la exposición y facilita el acceso a la celda tiroidea de forma estable, protegiendo la piel de lesiones durante la intervención.

Palabras clave:
Anillo retractor Alexis
Tiroidectomía
Retractor
Tracción
Full Text
Introduction

Thyroid and parathyroid surgery requires good exposure of the glands, for which an incision must be made to provide access to the superior and inferior thyroid poles.1 Meanwhile, the incision should be as small as possible so that the scar is not unsightly in such a visible body area and, in certain cultures, a mark in this area can be a social stigma.

Exposure of the gland during thyroidectomy can be maintained with different methods. One of the most frequently used techniques is the fixation of the upper and lower flaps to the operative field with silk sutures, which can leave marks on the skin of the chin. Another common method is the use of an automatic separator between the two flaps.2

The Alexis® retractor (Alexis® O Wound Retractor/Protector, Applied Medical Technology, Modesto, CA, USA) is a device designed to provide stable atraumatic exposure, while protecting the flap skin from damage during surgery.3 The device is widely used in different surgical specialties for a multitude of procedures, especially in abdominal, pelvic, thoracic and urological surgery.3,4 Our hospital has recently begun performing thyroid and parathyroid surgery using this device.

Technique

The different steps in the procedure are similar to conventional thyroid surgery, except in the manner of maintaining field exposure. A 4–5cm transverse incision is made, depending on the size of the thyroid and the condition being treated, involving the skin, the subcutaneous cellular tissue and the platysma.

After releasing the subplatysmal flap above, below and laterally, the Alexis® retractor is positioned, which consists of 2 semi-rigid rings joined by a flexible polymer membrane (Fig. 1). From among the different ring diameter sizes, the manufacturer recommends size “XS” (4cm in diameter) in thyroid surgery, requiring a minimal incision, although operations for large goiters may require size “S” (6cm in diameter). The green ring is inserted under the flap and the white ring is rolled over the membrane until the 2 rings are adjacent5 (Fig. 2). Once in position, static circumferential vision is achieved, providing good access to both thyroid lobes (Fig. 3). Its placement does not prevent the use of instruments by the assistant, such as Farabeuf, Mathieu or Langenbeck separators to improve access in certain areas.

Fig. 1.

(A) Alexis® retractor device, size XS (4cm in diameter), comprised of 2 flexible rings joined by a polymer membrane; (B) Alexis® retractor device, unrolled before placement.

(0.2MB).
Fig. 2.

Placement of the Alexis® retractor device in the surgical field, rolling it over the plastic membrane.

(0.06MB).
Fig. 3.

Alexis® retractor placed in the incision, exposing the superficial cervical fascia and infrahyoid muscles.

(0.13MB).

After placement of the retractor, the infrahyoid muscles are separated to access the thyroid gland. Thereafter, the surgical times depend on the type of procedure performed. In our hospital, the device has been used in lobectomies, total thyroidectomies and parathyroid surgery (Fig. 4).

Fig. 4.

Photograph during right lobectomy showing the right hemithyroid connected to the isthmus.

(0.13MB).

After performing the corresponding surgical procedure and hemostasis of the surgical bed, the Alexis® retractor is removed by pulling the inner ring. One or two Jost–Redon drain tubes are inserted, the strap muscles are approximated and the incision is sutured.

Discussion

Although recent studies have been published about the use of the Alexis® retractor in surgical procedures of the head and neck, such as oral and maxillofacial surgery,6 transoral robotic surgery7 and orbital surgery,4 there are no reports in the literature describing the use of this device in thyroid surgery.

In a period of 2 months, a total of 13 interventions were performed in patients with thyroid or parathyroid disease using the Alexis® retractor device, specifically in 11 women and 2 men, aged between 43 and 68 years. In 12 of the interventions, the “XS” size retractor was used: 4 total thyroidectomies (2 for multinodular goiter and 2 for papillary carcinoma); 6 lobectomies for multinodular goiter; and 2 parathyroidectomies for parathyroid adenomas. Total thyroidectomy was performed with an “S” size retractor in a large goiter.

The authors consider that this technique offers some advantages over traction sutures. The main ones are the greater visibility and easier illumination of the thyroid gland and better access to the superior thyroid pedicles, avoiding the need to extend the incision on certain occasions. Insertion of the device is easy and fast, and the homogenous tension created favors hemostasis of the skin, which maintains its moisture3 and protects it from possible burns or tears during the intervention. Its use also avoids skin damage caused by the tension of traditional traction sutures.5 It does not interfere with the use of instruments and reduces the need for the assistant to use handheld separators; however, when these are used, direct traction on the skin is also avoided.4 The device is removed by simply pulling the inner ring.

The device has been demonstrated to reduce surgical site infection rates in gastrointestinal surgery by protecting the wound from contamination by intestinal bacteria.8,9 Surgical site infection in thyroid surgery is very rare, so it offers no advantages for these procedures. None of the cases in which the Alexis® retractor has been used have presented surgical wound infections, or any other type of postoperative complication related to the use of the device.

In conclusion, the authors have found that the Alexis® retractor ring allows the tissue to be exposed in thyroid and parathyroid surgery with a minimal incision in a quick, simple and static manner. The device improves visibility compared to other methods, while facilitating hemostasis and protecting the skin from traction injuries, so the authors recommend its use in this type of procedure.

Conflict of Interests

The authors have no conflict of interests to declare.

References
[1]
F.R. Miller.
Surgical anatomy of the thyroid and parathyroid glands.
Otolaryngol Clin North Am, 36 (2003), pp. 1-7
[2]
R.D. Bliss, P.G. Gauger, L.W. Delbridge.
Surgeon's approach to the thyroid gland: Surgical anatomy and the importance of technique.
World J Surg, 24 (2000), pp. 891-897
[3]
Alexis retractor [Internet].
Applied medical.
[4]
Y. Wong, P. Lee, T. Sullivan.
Utilising the Alexis retractor for lateral orbital access, a case series.
[Epub ahead of print]
[5]
A. Rutledge, G. Carroll, S. Smith, J. Gani.
How to do it: use of the Alexis wound protector as a laparostomy device.
ANZ J Surg, 87 (2017), pp. 732-733
[Epub 2017 Jul 5]
[6]
S. Mubeen, S. Mubeen, D. Falconer.
Use of the Alexis ring retractor in oral and maxillofacial surgery.
Br J Oral Maxillofac Surg, 52 (2014), pp. 470-472
[Epub 2014 Mar 27]
[7]
M. Perenyei, T.D. Dobbs, L.R. Fraser, S.C. Winter.
Use of the self-retaining Alexis ring retractor in transoral robotic surgery.
Head Neck, 39 (2017), pp. 2132-2134
[Epub 2017 Jul 24]
[8]
C. Gomes Ferreira, I. Lacreuse, D. Geslin, F. Schmitt, A. Schneider, G. Podevin, et al.
Staged gastroschisis closure using Alexis wound retractor: first experiences.
Pediatr Surg Int, 30 (2014), pp. 305-311
[Epub 2013 Dec 12]
[9]
K.P. Cheng, A.C. Roslani, N. Sehha, J.H. Kueh, C.W. Law, H.Y. Chong, et al.
ALEXIS O-Ring wound retractor vs conventional wound protection for the prevention of surgical site infections in colorectal resections.
Colorectal Dis, 14 (2012), pp. e346-e351

Please cite this article as: Lois-Ortega Y, García-Curdi F, Brotons-Durbán S, Vendrell-Marqués JB. Uso de retractor Alexis en cirugía de tiroides y paratiroides. Cir Esp. 2019;97:46–49.

Copyright © 2018. AEC
Article options
Tools
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos