126 How to do it
An easy-to-source, inexpensive, self-retaining
anorectal retractor
Ahmed H. Morsi
Objective The aim of this study was to build a Conclusion This self-retaining anorectal retractor
self-retaining anorectal retractor using easy-to-source proved to be a simple-to-build, inexpensive, and effective
components, to use in regular clinical practice. This surgical tool in transanal endorectal pull-through
retractor is used primarily in transanal endorectal procedure. Ann Pediatr Surg 12:126–127
c 2016 Annals of
pull-through. Pediatric Surgery.
Materials and methods The components used to build Annals of Pediatric Surgery 2016, 12:126–127
this retractor were as follows: a set of elastic rubber straps, Keywords: endorectal, hirschsprung, hook, pull through, retractor
a set of stainless steel fish hooks, and a frame made of
Pediatric Surgery Unit, Department of Surgery, Zagazig University Hospital,
acrylic (plexiglass). Every fish hook was fixed to one end of Zagazig, Egypt
each rubber strap and used to anchor the anal mucosa. The
Correspondence to Ahmed H. Morsi, MS, Pediatric Surgery Unit, Department of
other end of each rubber strap was stretched over the Surgery, Zagazig University Hospital, Zagazig 44519, Egypt
acrylic frame to achieve the desired degree of retraction. Tel: + 201001246586; fax: + 20552307830;
e-mail: [email protected]
Results The retractor is effective, providing adequate
Received 11 November 2013 accepted 8 February 2016
exposure of the surgical field throughout the pull-through
procedure. It is light, yet robust, and reusable.
Introduction Fig. 1
Retractors are some of the oldest surgical instruments. They
have uses in all branches of surgery and have various designs.
Broadly speaking, they can be blunt or sharp and handheld or
self-retaining [1]. The need to achieve adequate exposure
and a clear operative field is essential during surgery. In
transanal endorectal pull-through procedure, one preliminary
step is to retract anal mucosa, everting the anus, to expose
the rectum. Retraction at the level of anal mucosa can be
achieved using a variety of methods. Many authors apply six
to eight perianal traction sutures. Others use commercially Elastic rubber strap with hook.
available self-retaining anorectal retractors. The latter
inspired us to build a handmade retractor with similar
functionality, using inexpensive and easy-to-source compo-
nents even in the resource-scarce areas.
Fig. 2
Materials and methods
This retractor is made up of three components: (a) elastic
rubber straps; (b) stainless steel hooks; and (c) acrylic board.
The elastic rubber straps used here were about 10 cm long
and 2 mm thick each. Hooks were of fishing-hook type that
are essentially sharp-tipped when bought. The hooks were
machined to get a blunter tip if needed. Each hook was fixed
to one end of a rubber strap (Fig. 1). The acrylic (plexiglass)
board, measuring 3–4 mm in thickness, was cut and
machined to a rectangular frame with peripherally cut slits
along the outer border. The slits should be made to admit
rubber straps with some resistance, so as to possess a self-
retaining capability (Fig. 2).
After positioning the patient on the operating table, the
retractor can be applied after anal dilatation. An assistant
holds the acrylic frame vertically with the anus at its
center. The surgeon inserts the first two hooks at the 3
and 9 O’clock positions hooked to anal mucosa proximal
to the dentate line, exerting the desired tension for Acrylic frame.
retraction. The other free end of each rubber strap passes
1687-4137
c 2016 Annals of Pediatric Surgery DOI: 10.1097/01.XPS.0000481346.51841.D9
Copyright r 2016 Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited.
An easy-to-source, inexpensive self-retaining anorectal retractor Morsi 127
Fig. 3 Fig. 5
Retractor in action during transanal endorectal pull-through procedure.
Fig. 4
Retractor in action during transanal endorectal pull-through procedure,
delivering the megacolon.
Discussion
Hooks have been used throughout surgical history, to
secure specific tissues or organs with minimal trauma.
The hooks are either handheld or secured with clips or
sutures [2]. When a hook is secured with an elastic
material, it has the ability to maintain near-constant
tension. Similar self-retaining retractors are commercially
available, with their action and functionality similar to the
Retractor in action during transanal endorectal pull-through procedure, author’s handmade retractor. However, the author’s
closer look. retractor has unique features: it is inexpensive, light yet
robust, highly customizable, reusable, and made up of
easy-to-source components. All these features make this
through the corresponding slit in the frame. Here, the retractor a good alternative, especially in resource-scarce
assistant can take his hands off the retractor. The next areas.
hook is better inserted at the 6 O’clock position to set the
frame to the desired height. Continue inserting hooks Acknowledgements
until an adequate and symmetrical exposure is achieved Conflicts of interest
(Figs 3–5). At any point, hooks can be readjusted, There are no conflicts of interest.
advanced, recessed, or removed as needed. At the end
of the procedure, the rubber straps can be released from References
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Copyright r 2016 Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited.
