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From Fallujah battlefield to University Hospital, Navy veteran forges lifesaving idea

New surgical retractor design combines advantages of speed and exposure

As a veteran Navy trauma surgeon, Dr. Ramon Cestero has put a lot of people back together. He's done multiple tours, working in combat zones in tough conditions, stopping bleeding in horribly injured soldiers and Marines, propping their abdomens open with a portable retractor, rapidly controlling life-threatening injuries, stabilizing them enough to get them to the next level of care.

While he would work on the battlefield, often in a tent at night with shelling nearby, Cestero imagined a better retractor, one that could change shape according to the patient, giving him better visibility into their wounds.

"There are essentially two types of retractors for abdominal surgery used worldwide. One consists of two metal bars on a ratcheted system that you insert into the wound and quickly ratchet it open, but unfortunately it provides limited visibility," Cestero said. The other type is a larger, more complicated device that gives a greater range of options in exposing a visible workspace in the body, but it requires an attachment to a table and takes time to set up and maneuver into place.

Either way, the surgical team loses something important.

"Why should a surgeon have to sacrifice either speed or exposure when a patient's life is at risk?" he said.

So he came back to San Antonio, invented the TITAN CSR, and put it to the test.

In a combat zone, there were many challenges that simply had to be accepted-ORs were tents or "buildings of opportunity", beds were litters or tables they could find, lighting sources were headlamps, blood products were very limited (they almost never had platelets that are vitally helpful in stopping bleeding), assistants were typically Marines or soldiers with no medical training. Under these circumstances medical personnel would have to work on patients who were as severely injured as a person could be and still be alive-blown up or shot with high-velocity weapons, often bleeding badly internally. To hold open the abdomen so that he could find the bleeding and stop it, Cestero would have to use the very simple, century-old portable retractor.

Every patient matters, Cestero said, but when asked to recall one in particular, it didn't take long.

"One of the cases that really brought this home for me was a young Marine who was involved in an IED explosion. He came in missing both of his legs and his left arm, and fragments had penetrated his abdomen," Cestero said.

"We were in a tent. It was hot-it was about 120 degrees outside in Fallujah, Iraq. I don't remember rockets during this particular case. We do operate in body armor, though, because you just never know"

"We took him to the operating room, and there were a lot of patients coming in at once. He had injuries to his intestines, kidney, liver, stomach, and had lost a significant amount of blood."

The team had to stop his bleeding- fast- so they could do damage-control surgery and transfer him to the next level of care.

It took longer than it should have. Even as he and the team worked frantically, Cestero remembered watching the odds ebb on the young man's life. They managed to stabilize and transfer him, but it wasn't enough.

"He died after transfer to the next level of care," Cestero said. "He had lost too much blood."

There was no guarantee the Marine could have been saved, but Cestero knew a better retractor could have shifted the odds more in his favor.

"If I had a better retractor," he said, "I could have controlled the bleeding faster."

Fast forward several years and head 7,500 miles west to San Antonio, Texas. Now a trauma surgeon with University Health and Professor of Surgery with UT Health San Antonio, Cestero worked with UT Health San Antonio's Office of Technology Commercialization, and after partnering with an engineer, he built the better retractor he'd been visualizing. He subsequently founded Advanced Surgical Retractor Systems, Inc., to further develop and commercialize the TITAN Cestero Surgical Retractor (CSR).

The TITAN CSR was introduced last summer in University Hospital's level 1 trauma center.

Dr. Brian Eastridge has plenty of experience with battlefield surgeries, and many more at University Hospital as a trauma surgeon and division chief of trauma and emergency general surgery. He is also the Jocelyn and Joe Straus Endowed Chair in Trauma Research with UT Health San Antonio.

"The most important part of any operation is exposure. And to get good exposure you need a good retractor," Eastridge said. "This retractor gives us such an advantage because of its modularity- the other retractors are basically fixed-range."

"It easily snaps open in the middle," he said. "A second benefit is that it can be reconfigured around an operating surgeon's hands."

In other words, it sacrifices neither speed nor exposure.

The TITAN CSR had not yet been in use for one full day when once again Dr. Cestero found himself working madly to save a badly injured young man.

Josh Johnson had been in a motor vehicle crash and had multiple broken bones and severe internal bleeding.

"He was bleeding in the pelvis, which is a difficult area to expose," Cestero said.

This time, he had a better tool in hand.

"The retractor helped us get in there quickly to assess the bleeding sources and control them, so we could stop the bleeding and get him to the ICU for further resuscitation."

Johnson was still in a bad way. Stopping the main pelvic bleeding had stabilized him enough that his blood pressure began to return. They began the move to the ICU.

As Johnson's blood started pumping at a more normal pressure, it began to push its way out of several other, smaller wounds that had previously not been apparent, creating a new internal bleeding crisis. He died on the way to the ICU.

The team pivoted fast. As they worked to resuscitate him they used the TITAN again to go back into his abdominal cavity, find the new bleeding sources, and stop those. They were able to do so quickly- they had to or he wouldn't make it.

He made it.

"The retractor helped the surgeons identify the sources of bleeding faster than they could with other available sources of technology," Cestero said. "He lost less blood, and it likely led to an improved outcome."

Several surgeries and a long period of rehabilitation later, Josh Johnson is home with his family and on the way to recovery. It's a long way from Fallujah, the birthplace of the idea that helped save him, to the crossroads of innovation in San Antonio, Texas, where Cestero was able to transform his idea into reality. From here, the TITAN carries the promise of improved outcomes for surgery patients everywhere.

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