Patent Publication Number: US-2022211362-A1

Title: Surgical access device comprising internal retractor

Description:
CROSS REFERENCE TO RELATED APPLICATION 
     This application claims is a continuation of U.S. application Ser. No. 16/580,469, filed Sep. 24, 2019, currently pending, which is a continuation of U.S. application Ser. No. 15/844,336, filed Dec. 15, 2017, which is now U.S. Pat. No. 10,456,125, which is a continuation of U.S. application Ser. No. 13/909,669, filed Jun. 4, 2013, which is now U.S. Pat. No. 9,867,604, which is a continuation of U.S. application Ser. No. 12/840,989, filed Jul. 21, 2010, which is now U.S. Pat. No. 8,469,883, which claims the benefit of U.S. Application No. 61/227,206, filed Jul. 21, 2009, the disclosures of which are incorporated by reference in their entirety. 
    
    
     BACKGROUND 
     Technical Field 
     The present disclosure is generally directed to surgical devices, and more specifically, to a surgical access device comprising a wound retractor and an internal retractor. 
     Description of the Related Art 
     Abdominal surgical procedures often entail entry into a patient&#39;s abdominal cavity and subsequent manipulation of internal structures therein, such as the small intestine, colon, mesentery, and other fatty structures. For example, large portions of a patient&#39;s small intestine are often displaced to provide clear access to the patient&#39;s spleen in some surgical procedures thereon. Gauze pads and/or sponges are often used to dam-up the displaced structures. Pads and/or sponges often slip and/or are difficult to place, however, especially through smaller incision sites. The pads and/or sponges are also typically carefully accounted for during surgery, thereby preventing one from being left behind within the patient. 
     Recent abdominal surgical procedures prefer smaller incisions, for example, laparoscopic surgeries. Laparoscopic surgical procedures often involve multiple small incisions of from between about five millimeters to about twelve millimeters. Some more complex procedures include a larger single incision. For instance, a five centimeter incision at the umbilicus that is circumferentially retracted by a circular wound retractor accommodates several laparoscopic instruments at the same time, or even a surgeon&#39;s hand extending into the abdominal cavity. Maintaining a clear operative area within the abdominal cavity while limiting the access area is desirable. 
     Additionally, surgical procedures of the lower abdomen and pelvis are also performed using single-incision techniques, in which a clear, unrestricted working space is also desirable. 
     SUMMARY OF THE INVENTION 
     Devices, methods, and systems provide a surgical access device comprising an internal retractor device integrated with or coupled to a body wall or wound retractor. The wound retractor retracts an opening in a body wall into a body cavity, while the internal retractor permits a user to control the positions of internal structures within the body cavity, thereby permitting a user to define a surgical field. Embodiments of the internal retractor are adjustable. 
     Some embodiments provide surgical access device comprising: a wound retractor comprising an outer ring, an inner ring, and a tubular sheath extending between the outer ring and the inner ring; and an internal retractor coupled to the wound retractor in an operative state of the surgical access device, the internal retractor comprising a deformable frame, wherein in the operative state, at least a portion of the internal retractor extends distally of the inner ring. 
     In some embodiments, the outer ring of the wound retractor is rotatable around an annular axis thereof, thereby permitting adjustment of an effective length of the tubular sheath between the inner ring and the outer ring. 
     In some embodiments, the internal retractor and the wound retractor are integrated. In some embodiments, the internal retractor is user coupled to the wound retractor in the operative state. 
     In some embodiments, the internal retractor further comprises a connection member, wherein the connection member couples the internal retractor to the wound retractor. In some embodiments, the internal retractor comprises at least one of a flexible cover and a dam portion. In some embodiments, the internal retractor comprises at least one window therethrough. 
     In some embodiments, the internal retractor defines a generally rectangular or nonrectangular shape. In some embodiments, defines a generally serpentine shape. In some embodiments, the frame comprises at least one of a lattice, a mesh, a solid sheet, and a perforated sheet. 
     Some embodiments further comprise a cover disposed over the frame. 
     In some embodiments, the internal retractor comprises a deformable, planar frame, a cover disposed over the frame, and a connection feature couplable to the wound retractor. 
     In some embodiments, the frame comprises a plastically deformable material. In some embodiments, the frame comprises an elastically deformable material. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1A  is a front view of a patient for surgery of the abdomen.  FIG. 1B  is a partial front cross section illustrating abdominal content.  FIG. 1C  is a partial front cross section of a patient schematically illustrating the placement of a wound retractor in the abdomen.  FIG. 1D  is a partial side cross section of a patient illustrating the placement of a wound retractor in the abdomen. 
         FIG. 2  is a perspective view of an embodiment of an access device comprising an internal retractor comprising a plurality of shapeable members. 
         FIG. 3  is a perspective view of another embodiment of an access device comprising an internal retractor comprising an inflatable member. 
         FIG. 4  is a perspective view of another embodiment of an access device comprising an internal retractor comprising a fan-like device. 
         FIG. 5  is a perspective view of another embodiment of an access device comprising an internal retractor comprising a shapeable or deformable support member. 
         FIG. 6A  is a perspective view of another embodiment of an access device comprising a shapeable internal structure in an undeployed configuration.  FIGS. 6B and 6C  are perspective views of the access device illustrated in  FIG. 6A  in partially deployed configurations.  FIG. 6D  is a perspective view of the access device illustrated in  FIG. 6A  in a deployed configuration. 
         FIG. 7  is a perspective view of another embodiment of an access device comprising an internal retractor comprising an inflatable, toroidal internal retractor. 
         FIG. 8  is a perspective view of another embodiment of an access device comprising an internal retractor comprising a radially compressible tube. 
         FIG. 9  is a perspective view of another embodiment of an access device comprising an internal retractor comprising a circumferentially serpentine frame defining a tube. 
         FIG. 10A  is a perspective view of another embodiment of an internal retractor comprising a longitudinally serpentine frame defining a tube. 
         FIG. 10B  is a perspective view of the embodiment of  FIG. 10A  in the undeployed state. 
         FIG. 10C  shows a distal support member engaging the distal end of the internal retractor of  FIG. 10A  when deployed. 
         FIG. 11  is a perspective view of another embodiment of an internal retractor comprising a lattice frame defining a tube. 
         FIG. 12  is a perspective view of another embodiment an internal retractor comprising a planar, deformable frame. 
         FIG. 13A  is a side view of another embodiment of an access device comprising an internal retractor comprising a body couplable to a wound retractor.  FIG. 13B  is a detail of the internal retractor.  FIG. 13C  is a perspective view of the body illustrated in  FIG. 13A  and an extender couplable to the body. 
         FIG. 14  is a perspective view of another embodiment an internal retractor comprising a plurality of elongate, shapeable members. 
         FIG. 15  is a perspective view of another embodiment an internal retractor comprising a plurality of elongate, shapeable members. 
         FIG. 16A  is a partial side cross section of a patient prior to deploying an internal retractor in the abdomen.  FIG. 16B  is a partial front cross section and  FIG. 16C  is a partial side cross section of a patient in which an internal retractor has been deployed in the abdomen. 
     
    
    
     Similar reference characters refer to similar features throughout. 
     DETAILED DESCRIPTION OF CERTAIN EMBODIMENTS 
       FIG. 1A  is a front view of a patient  10  for surgery of the abdomen  20  with an incision site  22  at the umbilicus.  FIG. 1B  is a partial cross section illustrating abdominal content  30  confined by a body wall  40 , various adhesions, and connections. The content  30  is generally moist, slippery, and difficult to manage, and is especially true for the small intestine  32 . As shown schematically in  FIG. 1C  and in a partial side cross section in  FIG. 1D , a circular retractor  50  is placed through an incision in the body wall  40  and into an abdominal cavity  42 , thereby providing a surgeon with clear access to the abdominal content  30 . 
       FIG. 2  is a perspective view of an embodiment of a surgical access device  200  comprising a wound retractor  250  and an adjustable internal retractor  270 . The wound retractor  250  is disposed at a proximal end  202  of the device  200 , and the internal retractor  270  is disposed at a distal end  204 . A longitudinal axis  206  extends from the proximal end  202  to the distal end  204 . An access channel  208  extends through the device  200 . 
     In the illustrated embodiment, the wound retractor  250  comprises a proximal or outer ring  252 ; a deformable distal or inner ring  254 ; and a flexible, tubular sheath  256  disposed between the outer ring  252  and the inner ring  254 . 
     The inner ring  254  is deformable or flexible, which permits a user to insert the inner ring  254  through an incision or opening in a body wall with a smaller diameter than a relaxed diameter of the inner ring  254 , and into a body cavity. The inner ring  254  is also sufficiently rigid to resist deformation when disposed against an inner surface of the body wall and under tension by the tubular sheath  256  extending through the incision or opening. 
     The wound retractor  250  is adjustable or non-adjustable. In the illustrated embodiment, the wound retractor  250  is an adjustable wound retractor. In the illustrated embodiment, the outer ring  252  is rotatable around an annular axis thereof, which winds and/or unwinds the tubular sheath  256  therearound, thereby adjusting an effective length of the tubular sheath  256  and a distance between the outer ring  252  and the inner ring  254 . This adjustability permits a user to retract an opening or wound in a body cavity. The illustrated outer ring  252  comprises a first tube  252   a  and a second tube  252   b.  In other embodiments, the outer ring  252  has another shape, for example, comprising an oval, elliptical, and/or elongated cross section, with a major or longer axis either parallel with or perpendicular to the longitudinal  206 . In some embodiments, the outer ring  252  further comprises one or more circumferential lumens. In some embodiments, a wire or hoop is disposed in one or more of the lumens. In some embodiments, the wire(s) or hoop(s) is non-compliant. In some embodiments, the wire(s) or hoop(s) is a split hoop. 
     The outer ring  252 , inner ring  254 , and tubular sheath  256  independently comprise any suitable biocompatible material, for example, one or more polymer resins. In embodiments in which the outer ring  252  comprises a wire or hoop, the wire or hoop comprise at least one of metal, stainless steel, spring steel, nitinol, polymer, ceramic, fibers, composites thereof, and the like. 
     In some embodiments, the retractor  250  is manufactured in a plurality of sizes, for example, diameters of at least one of the outer ring  252 , the inner ring  256 , and sheath  256 , and/or length of the sheath  256 . Some embodiments of the access device  200  further comprise a cap or lid (not illustrated) couplable to the outer ring  252 , which closes and/or seals the access channel  208 . Some embodiments of the cap or lid permit instrument and/or hand access through the cap or lid and into the access channel  208 . Suitable wound retractors, caps, and lids are also disclosed in U.S. Pat. Nos. 7,727,146; 7,650,887; and 7,704,207, and U.S. Patent Application Publication No. 2010/0094227 A1, all the disclosures of which are incorporated by reference. 
     The internal retractor  270  in the illustrated embodiment is coupled to the inner ring  254  of the retractor  250  and extends distally of the inner ring  254 . In the illustrated embodiment, the internal retractor  270  comprises a plurality of a plurality of elongate, shapeable members  272 , each extending distally from the inner ring  254  of the wound retractor  250 . In the illustrated embodiment, each shapeable member  272  angles away from the longitudinal axis  206 , although in other embodiments, one or more of the shapeable members  272  extends in a different direction, for example, substantially parallel with the longitudinal axis  206  and/or towards the longitudinal axis  206 . 
     Each shapeable member  272  in the illustrated embodiment comprises an elongate segment and/or wing that comprises any suitable material, for example, at least one of a polymer resin or metal. Some embodiments of the shapeable members  272  comprise an elastically deformable material, for example, metal, stainless steel, spring steel, polymer, fibers, and combinations thereof. Some embodiments of the shapeable members  272  comprise a malleable and/or plastically deformable material, for example, metal, stainless steel, a super elastic material, a shape memory material, clay, clay-like material, and combinations thereof. In some embodiments, one or more of the shapeable members  272  is partially or completely coated and/or covered with at least one of fabric, gauze, and foam thereby improving traction and/or fluid absorption. In some embodiments, one or more of the shapeable members  272  is partially or completely coated and/or covered with a fluid repellant and/or fluid impermeable material. In some embodiments, one or more of the shapeable members  272  comprises a textured and/or non-slip surface. Some embodiments of the shapeable members  272  comprise, for example, wire, strips, sheets, and perforated sheets. 
     In some embodiments one or more of the shapeable members  272  is curved along a transverse axis, thereby stiffening the shapeable members  272  using the principle that stiffens a Venetian blind slats. In the illustrated embodiment, at least one of an angle with the longitudinal axis  206 , and a shape of each individual shapeable member  272  is adjustable, thereby retracting structures or organs from, and/or preventing structures or organs from entering a selected surgical field or area, thereby improving access to surgical targets therein. For example, in some embodiments, at least a portion of a shapeable member  272  is bendable transverse to a local longitudinal axis  274  thereof. In some embodiments, at least a portion of a shapeable member  272  is bendable or twistable around the local longitudinal axis  274 . 
     In some embodiments, at least one of the shapeable members  272  is integrated with the inner ring  254 . In some embodiments, at least one of the shapeable members  272  is separately manufactured, then coupled to the inner ring  254 . For example, some embodiments of the inner ring  254  comprise at least one connecting feature to which the shapeable members  272  are coupled. In some embodiments, a proximal end of at least one shapeable member  272  comprises a connecting feature that secures the shapeable member  272  to the inner ring  254  at a desired angle with respect to the longitudinal axis  206 . Suitable connecting features include, for example, mechanical fasteners, clips, clamps, friction fittings, hook-and-loop fasteners, snaps, ties, screws, latches, joints, hinges, ball joints, living hinges, and the like. In some embodiments, the shapeable members  272  are coupled to the inner ring  254  as a unit, for example, joined by a web and/or ring at a proximal end of the internal retractor  270 . In some embodiments, shapeable members  272  are individually coupled to the inner ring  254 . In some embodiments, one or more of the shapeable members  272  are removable as desired, for example, by cutting, breaking off, and the like. In some embodiments, the internal retainer  270  is removable, for example, after completing a portion of a surgical procedure. Some embodiments of the internal retractor  270  are not coupled to a wound retractor and are used independently of the wound retractor. 
     In the illustrated embodiment, the local axis  274  of each shapeable member  272  is substantially normal to the inner ring  254 . In other embodiments, the local axis  274  of at least one shapeable member  272  subtends another angle with the inner ring  254  in a generally helical configuration. For example, in some embodiments, all of the shapeable members  272  together define a helical internal retractor  270 . 
     Some embodiments of the internal retractor  270  further comprise a dam or cover (not illustrated) that is securable to one or more of the shapeable members  272 , thereby defining an umbrella-like structure, which improves retraction of internal organs. The cover is similar to the dam portions described and illustrated below, and like the dam portions, comprises a single piece or a plurality of pieces, and similar materials. The cover is permanently or temporarily secured, for example, using adhesive, pressure sensitive adhesive, mechanical fasteners, clips, clamps, friction fittings, hook-and-loop fasteners, snaps, ties, screws, latches, and the like. In some embodiments, the cover comprises one or more pockets dimensioned to receive one or more of the shapeable members  272  therein. In some embodiments, one or more portions of the cover are removable by a user, for example, by cutting or tearing. 
       FIG. 3  is a perspective view of an embodiment of a surgical access device  300  generally similar to the embodiment discussed above. The access device  300  comprises a proximal end  302 , a distal end  304 , a longitudinal axis  306 , an access channel  308 , a wound retractor  350  disposed at the proximal end  302 , and an adjustable internal retractor  370  disposed at the distal end  304 . The wound retractor  350  is generally similar to the embodiment of the wound retractor  250  described above, and comprises an outer ring  352 , an inner ring  354 , and a flexible sheath  356 . The internal retractor  370  is integrated with the wound retractor  350  or manufactured as a separate component, which is preattached to the wound retractor  350  or user attached, or used without coupling to a wound retractor, as discussed above. 
     The illustrated embodiment of the internal retractor  370  comprises a plurality of longitudinally extending inflatable supporting members  372  and a plurality of dam portions  374  extending between adjacent supporting members  372 . In other embodiments, a single dam portion  374  extends across a plurality of inflatable supporting members  372 . The illustrated embodiment also comprises a peripheral ring  376 . In some embodiments, the peripheral ring  376  is fluidly connected to at least one supporting member  372 , and consequently, is inflatable with the at least one supporting member  372 . In other embodiments, the peripheral ring  376  is not inflatable. In some embodiments, the peripheral ring  376  comprises a plurality of linked members, for example, ball-and-socket segments. In the illustrated embodiment, the internal retractor  370  is generally frustoconical in an inflated state, diverging distally from the longitudinal axis  304 . 
     In the illustrated embodiment, the internal retractor  370  comprises an open area or window  378 , which permits access to tissue and/or organs outside the perimeter of the internal retractor  370 . The open area or window  378  allows a surgeon to place instruments and/or a hand into areas above, to the side of, and/or below the internal retractor  370 , which is useful, for example, when working in the lower abdomen or pelvis. Some embodiments comprise a plurality of open areas or windows  378 . Some embodiments of the internal retractor  370  do not comprise an open area or window. In some embodiments, the internal retractor  370  is supplied without an open area or window  378 , and the user creates one or more as desired, for example, by removing selected dam portions  374 . In some embodiments, the spacing of the supporting members  370  is not uniform, thereby permitting a user to select a desired size of the open area or window  378 . 
     Embodiments of the internal retractor  370  comprise at least one of rubber, polymer resin, fabric, foam, and elastomer. In some embodiments, the supporting members  372 , the dam portions  374 , and the peripheral ring  376  comprise different materials. Some embodiments of the dam portions  374  comprise at least one of polymer, membrane, film, rubber, webbing, gauze, film, fabric, woven fabric, non-woven fabric, and knit fabric. In some embodiments, the dam portions  374  comprise an elastomeric or stretchable material, for example spandex. Some embodiments of the internal retractor  370  further comprise at least one flexible reinforcing member, for example, one or more ribs disposed on, through, or within at least one supporting member  372 , dam portion  374 , and/or the peripheral ring  376 . In some embodiments, at least one supporting reinforcing member  372  is elastically deformable. In some embodiments, at least one supporting member  372  is plastically deformable. Suitable materials for the supporting member are described above. Suitable materials for the reinforcing members  372  include at least one of metal, a super elastic material, a shape memory material, polymer, fibers, and composites thereof. In some embodiments, the reinforcing members comprise at least one of wires, strips, bands, and the like. 
     In some embodiments, a retraction and/or retention force that the internal retractor  370  exerts on internal organs depends on the degree of inflation thereof. Consequently, the retraction and/or retention force is adjustable by the end user. Embodiments of the internal retractor are inflatable with gas, carbon dioxide, nitrogen, air, liquid, water, saline, Ringer&#39;s solution, isotonic solutions, and the like. In some embodiments, the inflation fluid is cooled and or heated as desired. 
       FIG. 4  is a perspective view of another embodiment of a surgical access device  400  that is generally similar to the embodiments discussed above. The access device  400  comprises a longitudinal axis  406  extending from a proximal end  402  to a distal end  404 , an access channel  408  extending through the device  400 , a wound retractor  450  at the proximal end  402 , and an adjustable internal retractor  470  at the distal end  404 . The wound retractor  450  is generally similar to the embodiments of the wound retractor described above, and comprises an outer ring  452 , an inner ring  454 , and a flexible sheath  456 . Embodiments of the internal retractor  470  are integrated, preattached, or user attached to the wound retractor  450 , or used without coupling to a wound retractor, as discussed above. 
     In the illustrated embodiment, the internal retractor  470  comprises a plurality of individual segments  472  arrayed in a fan-like configuration. In the illustrated embodiment, each segment  472  angles away from the longitudinal axis  406 . At least some of the segments  472  are slidably coupled to a hub  480 , thereby defining an iris-like or folding-fan structure, there by allowing a user to adjust an opening or window  478  in the internal retractor as desired, thereby adjusting the degree of retention and/or retraction of internal organs. In the illustrated embodiment, the hub  480  comprises one or more tracks in which a proximal end of at least some segments  472  is slidably coupled. In some embodiments, the internal retainer  470  comprises a one-way mechanism that permits opening in one direction, only. In some embodiments, at least a portion of some of the segments  472  is malleable or plastically deformable. In the illustrated embodiment, a flexible cover or dam  474  similar to the cover or dam described above, is disposed over one or more of the segments  472 . 
       FIG. 5  illustrates in a perspective view another embodiment of a surgical access device  500  that is generally similar to the embodiments described above. The surgical access device  500  comprises a longitudinal axis  506  extending from a proximal end  502  to a distal end  504 , an access channel  508  extending through the device  500 , a wound retractor  550  disposed at the proximal end  502  and an internal retractor  570  disposed at the distal end  504 . The wound retractor  550  is generally similar to the embodiments of the wound retractor described above, and comprises an outer ring  552 , an inner ring  554 , and a flexible sheath  556 . Embodiments of the internal retractor  570  are integrated, preattached, or user attached to the wound retractor  550 , or used without coupling to a wound retractor, as discussed above. 
     The internal retractor  570  comprises a distally extending skirt member  574  and a support member  576  coupled to a distal portion of the skirt member  574 . Embodiments of the skirt member  574  comprise any material as discussed above for the cover or dam portion. Embodiments of the support member  576  comprise one or more of elastic, malleable, and/or plastically deformable portions, for example comprising one or more of the materials described above. In the illustrated embodiment, the support member  574  comprises an inwardly extending projection  582  defining and extending over an undercut or hollow portion  584 , which provides the support member  574  with shape-memory characteristics. In other embodiments, the support member  574  comprises a plurality of linked members, for example, ball-and-socket segments. 
     The illustrated embodiment also comprises a window  578 . In some embodiments, the window  578  is preformed. In others, the window  578  is user created. In the illustrated embodiment, the window  578  includes a gap in the support member  576 . In other embodiments, the window  578  extends only through the skirt member  574  and does not comprise a gap in the support member  576 . 
       FIG. 6A  is a perspective view of another embodiment of an access device  600  that is generally similar to the embodiments described above. The surgical access device  600  comprises a longitudinal axis  606  extending from a proximal end  602  to a distal end  604 , an access channel  608  extending through the device  600 , a wound retractor  650  disposed at the proximal end  602  and an internal retractor  670 . The wound retractor  650  is generally similar to the embodiments of the wound retractor described above, and comprises an outer ring  652 , an inner ring  654 , and a flexible sheath  656 . Embodiments of the internal retractor  670  are integrated, preattached, or user attached to the wound retractor  650 , or used without coupling to a wound retractor, as discussed above. 
     The internal retractor comprises a tubular skirt  674  coupled to the wound retractor  650  and a retention ring  676  coupled to the free end of the skirt  674 . In the illustrated embodiment, a diameter of the retention ring  676  is larger than a diameter of the outer ring  652  or the inner ring  654 . In the illustrated embodiment, the tubular skirt  674  is coupled to the distal end of the wound retractor  650 , for example, the inner ring  654 . In other embodiments, the tubular skirt  674  is coupled to the proximal end of the of the wound retractor  650 , for example, the outer ring  652 . The skirt  674  comprises any suitable flexible material, for example, the materials described above for the cover or dam portion. The retention ring  676  comprises a malleable, deformable, shapeable, plastically deformable, and/or elastically deformable material, for example any of the materials described above. Some embodiments of the retention ring  676  comprise an internal malleable or plastically deformable spine. Some embodiments comprise a plurality of linked members, for example, ball-and-socket segments. Consequently, some embodiments of the retention ring are shapeable in a plane or in all directions. 
     The illustrated embodiment of the internal retractor  670  does not comprise a window. In some embodiments, one or more windows are preformed in the skirt  674 . In some embodiments, a user creates windows in the skirt  674  as desired. 
     The internal retractor  670  is illustrated in an undeployed state in  FIG. 6A  with the retention ring  676  is disposed proximally of the outer ring  652  of the wound retractor  650 , with the skirt  674  extending through the access channel  608 .  FIGS. 6B-6C  illustrate a intermediate states in converting the internal retractor  670  from the undeployed state or configuration illustrated in  FIG. 6A , to a deployed state or configuration illustrated in  FIG. 6D  in which the retention ring  676  is distal of the inner ring  654 . In the illustrated method, the retention ring  676  is passed through the access channel  606  through the wound retractor  650 . In the conversion process, the large-diameter retention ring  676  is squeezed, twisted, and/or otherwise deformed to a size that fits through the access channel  608 . In the deployed state or configuration illustrated in  FIG. 6D , the large-diameter retention ring  676  is shaped and/or adjusted to retract the internal organs from a desired area in the body cavity. For example, in some embodiments, the retention ring  676  is nested beneath internal structures  30  ( FIGS. 1B-1D ), where the weight of the structures  30  secures the retention ring  676  in place. 
       FIG. 7  illustrates in perspective view another embodiment of a surgical access device  700  that is generally similar to the embodiments described above. The surgical access device  700  comprises a longitudinal axis  706  extending from a proximal end  702  to a distal end  704 , an access channel  708  extending through the device  700 , a wound retractor  750  disposed at the proximal end  702  and an internal retractor  770 . The wound retractor  750  is generally similar to the embodiments of the wound retractor described above, and comprises an outer ring  752 , an inner ring  754 , and a flexible sheath  756 . Embodiments of the internal retractor  770  are integrated, preattached, or user attached to the wound retractor  750 , or used without coupling to a wound retractor, as discussed above. 
     In the illustrated embodiment, the internal retractor  770  comprises a proximal, short tubular skirt  774  coupled to a distal, inflatable torus  776 . Some embodiments of the internal retractor  770  do not comprise a skirt. In the undeployed state, the torus  776  is uninflated, while in the deployed state, the torus  776  is selectively inflated. Some embodiments of the skirt  774  and/or torus  776  comprise stiffening or reinforcing members. 
       FIG. 8  is a perspective view of another embodiment of an access device  800  that is generally similar to the embodiments described above. The surgical access device  800  comprises a longitudinal axis  806  extending from a proximal end  802  to a distal end  804 , an access channel  808  extending through the device  800 , a wound retractor  850  disposed at the proximal end  802  and an internal retractor  870 . The wound retractor  850  is generally similar to the embodiments of the wound retractor described above, and comprises an outer ring  852 , an inner ring  854 , and a flexible sheath  856 . Embodiments of the internal retractor  870  are integrated, preattached, or user attached to the wound retractor  850 , or used without coupling to a wound retractor, as discussed above. 
     In the illustrated embodiment, the internal retractor  870  comprises a generally hollow cylinder or tube with open ends through which the access channel extends. In other embodiments, the internal retractor  870  has another shape, for example, an elliptical cylinder, or frustoconical with the larger end distal or with the smaller end distal. Embodiments of the internal retractor  870  are manufactured in a range of diameters and/or lengths. The internal retractor  870  is elastically deformable or plastically deformable. In some embodiments, one or more portions of the internal retractor  870  are elastically deformable and one or more portions are plastically deformable. Plastically deformable portions permit a user to shape the internal retractor  870  as desired. The internal retractor  870  is sufficiently deformable radially to permit insertion through an incision and/or the wound retractor  850 . 
     In the illustrated embodiment, the internal retractor  870  comprises a plurality of stacked, annular segments  872 . In the illustrated embodiment, the annular segments  872  are toroidal; however, in other embodiments, the annular segments have other shapes and/or a mixture of shapes. In some embodiments, the annular segments are detachable or separable from each other, for example, by cutting or tearing, which permits a user to adjust a length of the internal retractor. Some embodiments of the internal retractor  870  are separable longitudinally, for example, using one or more partial or complete longitudinal cuts, which permits a user to generate openings or windows as desired. Some embodiments of the internal retractor  870  further comprise a complete or partial cover, as discussed above. 
     In some embodiments, the internal retractor  870  is coupled to the wound retractor  850  such that the internal retractor  870  is translatable, thereby permitting the user to isolate a surgical field that is not directly below the wound retractor  850 . In use, the wound retractor  850  is well anchored to a patient, thereby anchoring the internal retractor  870 . Suitable coupling devices are known in the art, for example, rods, bars, clamps, clips, swivels, hinges, and the like. In some embodiments, the internal retractor  870  is not coupled to the wound retractor  850 . 
       FIG. 9  is a perspective view of another embodiment of an internal retractor  970 , which is similar to the embodiments described above. The internal retractor  970  is integrated with, couplable with, used with, or used independently of a wound retractor, as discussed above. The illustrated embodiment of the internal retractor  970  comprises a longitudinal axis  906 , an access channel  908 , and a serpentine frame  972  defining a hollow cylinder or tube. In other embodiments, the frame  972  defines a different shape, for example, frustoconical or an elliptical cylinder. The serpentine frame  972  defines a plurality of circumferential voids or openings  982  in the cylindrical surface into which circumferential fingers  984  defined by the frame  972  interleave when the frame  972  is compressed radially, for example, when inserting the internal retractor  970 . Those skilled in the art will understand that in other embodiments, the serpentine frame  972  has a different shape that defines voids  982  and fingers  984  with different shapes. The frame  972  comprises a plastically deformable material, an elastically deformable material, or a combination thereof. In embodiments comprising a plastically deformable material, the internal retractor  970  is reshapeable or adjustable on deployment. 
     In the illustrated embodiment, the internal retractor  970  further comprises a cover or dam portion  974 , as discussed above. In some embodiments, the cover is cuttable through a void area  986 , which permits further adjustment in the deployed state. Other embodiments do not comprise a cover or dam portion. 
       FIG. 10A  is a perspective view of another embodiment of an internal retractor  1070 , which is similar to the embodiments described above. The internal retractor  1070  is integrated with, couplable with, used with, or used independently of a wound retractor, as discussed above. The illustrated embodiment of the internal retractor  1070  comprises a longitudinal axis  1006 , an access channel  1008 , and a serpentine frame  1072  defining a hollow cylinder or tube. In other embodiments, the frame  1072  defines a different shape, for example, frustoconical or an elliptical cylinder. The serpentine frame  1072  defines a plurality of longitudinal voids or openings  1082  in the cylindrical surface, which permit a user to compress the frame  1072  radially, for example, when inserting the internal retractor  1070 . Those skilled in the art will understand that in other embodiments, the frame  1072  comprises a plurality of longitudinal members instead of a single serpentine or sinuous member. The frame  1072  comprises a plastically deformable material, an elastically deformable material, or a combination thereof. In embodiments comprising a plastically deformable material, the internal retractor  1070  is reshapeable or adjustable on deployment. 
     The illustrated embodiment further comprises a distal support member  1076  disposed at a distal end of the internal retractor  1070 . As illustrated in  FIG. 10B  in an undeployed state, the internal retractor  1070  is conical. In deploying the internal retractor  1070 , the distal support member  1076  is advanced along the access channel  1008  until it engages a distal end of the frame  1072 , for example in a set of hooks  1086 , as shown in  FIG. 10C . 
     Some embodiments of the internal retractor  1070  comprise a cover or dam portion (not illustrated). Some embodiments are openable, for example, by cutting the distal support member  1076 , if present, or portions of the frame  1072 , which permits additional adjustability. 
       FIG. 11  is a perspective view of another embodiment of an internal retractor  1170 , which is similar to the embodiments described above. The internal retractor  1170  is integrated with, couplable with, used with, or used independently of a wound retractor, as discussed above. The illustrated embodiment of the internal retractor  1170  comprises a longitudinal axis  1106 , an access channel  1108 , and a lattice frame  1172  defining a hollow cylinder or tube. In other embodiments, the frame  1172  defines a different shape, for example, frustoconical or an elliptical cylinder. The lattice frame  1172  defines a plurality of voids or openings  1182  in the cylindrical surface, which permit a user to compress the frame  1172  radially, for example, when inserting the internal retractor  1170 . In the illustrated embodiment, the frame  1172  comprises a diamond lattice. In other embodiments, the frame  1172  comprises a different lattice, for example, a hexagonal lattice. The frame  1172  comprises a plastically deformable material, an elastically deformable material, or a combination thereof. In embodiments comprising a plastically deformable material, the internal retractor  1170  is reshapeable or adjustable on deployment. 
     In the illustrated embodiment, the internal retractor  1170  further comprises a cover or dam portion  1174 , as discussed above. Other embodiments do not comprise a cover or dam portion. Some embodiments are openable, for example, by cutting portions of the frame  1172 , which permits additional adjustability. 
       FIG. 12  is a perspective view of another embodiment of an internal retractor  1270 , which is similar to the embodiments described above. The internal retractor  1270  is integrated with, couplable with, used with, or used independently of a wound retractor, as discussed above. The illustrated embodiment of the internal retractor  1270  comprises a longitudinal axis  1206  extending between a proximal end  1202  and a distal end  1204 , a deformable frame  1272 , and a cover or dam portion  1274 . The illustrated embodiment also comprises a connection feature  1280 , which permits coupling the internal retractor  1270  to a wound retractor, as discussed above. In the illustrated embodiment, the frame  1272  defines a generally rectangular internal retractor  1270 . In other embodiments, the frame  1272  defines a different shape, for example, trapezoidal or rhomboidal. The frame  1272  is serpentine in the illustrated embodiment. In other embodiments, the frame  1272  has a different structure, for example, a lattice, a mesh, a solid sheet, a perforated sheet, or a combination of structures. The frame  1272  comprises a plastically deformable material, an elastically deformable material, or a combination thereof. In embodiments comprising a plastically deformable material, the internal retractor  1270  is reshapeable or adjustable on deployment. 
     In the illustrated embodiment, the internal retractor  1270  further comprises a cover or dam portion  1274 , as discussed above. Other embodiments do not comprise a cover or dam portion. Some embodiments are reshapeable, for example, by cutting portions of the frame  1272  and/or cover  1274 , which permits additional adjustability. 
       FIG. 13A  illustrates a side view another embodiment of a surgical access device  1300  that is generally similar to the embodiments described above. The surgical access device  1300  comprises a longitudinal axis  1306  extending from a proximal end  1302  to a distal end  1304 , an access channel  1308  extending through the device  1300 , a wound retractor  1350  disposed at the proximal end  1302  and an internal retractor  1370 . The wound retractor  1350  is generally similar to the embodiments of the wound retractor described above, and comprises an outer ring  1352 , an inner ring  1354 , and a flexible sheath  1356 . Embodiments of the internal retractor  1370  are integrated, preattached, or user attached to the wound retractor  1350 , or used without coupling to a wound retractor, as discussed above. 
     As best seen in the detailed view in  FIG. 12B , the internal retractor comprises a body  1372  comprising a groove  1380  extending at least partially along a proximal edge thereof, which is dimensioned to receive the inner ring  1354  of the wound retractor  1350  therein. The body  1372  comprises a plastically deformable material, an elastically deformable material, or a combination thereof. In embodiments comprising a plastically deformable material, the body  1372  is reshapeable or adjustable on deployment. In some embodiments, the body  1372  is tubular and dimensioned to the diameter of the inner ring  1354 . In other embodiments, the body  1372  is supplied as an elongate strip. In either case, some embodiments of the body  1372  may be trimmed as desired. 
     In the illustrated embodiment, a connection feature  1388  extends at least partially along the distal edge of the body  1372 . As best seen in the perspective view in  FIG. 13C , the connection feature  1388  of the body  1372  couples to an extender  1390 , which comprises a complementary connector  1392   a  extending at least partially along a proximal edge of the extender  1390 . In the illustrated embodiment, the connection feature  1388  and the complementary connector  1392   a  are self-complementary, that is, have the same shape. As with the body  1372 , the extender  1390  comprises an elastically deformable material, plastically deformable material, or a combination thereof. In the illustrated embodiment, the extender  1390  further comprises a second complementary connector  1392   b  disposed along at least a portion of a distal edge of the extender  1390 , which permits a user to add as many extenders  1390  as desired. Consequently, in the illustrated embodiment, the internal retractor  1370  comprises the body  1372  and any number of extenders  1390  desired. 
     In other embodiments, the connection feature  1388  has the same cross-sectional shape as the inner ring  1354  of the wound retractor  1350 . Consequently, the body  1372  is also an extender in these embodiments. 
       FIG. 14  is a perspective view of another embodiment of an internal retractor  1470 , which is similar to the embodiments described above. The illustrated embodiment of the internal retractor  1470  comprises a longitudinal axis  1406  extending between a proximal end  1402  and a distal end  1404 , an access channel  1408 , and a plurality of shapeable members  1472 . The shapeable members are similar to the shapeable members  272  described above, except that the shapeable members  1472  of the illustrated embodiment are coupled to an outer ring  1452  of a wound retractor rather than an inner ring. 
     In the illustrated embodiment, the proximal end of each shapeable member  1472  comprises a connection feature  1480  that couples the shapeable member  1472  to the outer ring  1452 . The illustrated configuration permits a user to determine the number and spacing of shapeable members  1472  used in any particular situation. In one embodiment, the user inserts a distal end of the shapeable member  1472  through the access channel  1408 , then couples the shapeable member  1472  to the outer ring  1452 . 
     In other embodiments, one or more shapeable members  1472  are deployed as a unit, for example, comprising a common connection feature  1480 . In some embodiments comprising a common connection feature  1480 , the shapeable members  1472  are substantially longitudinal or convergent when inserted through the access channel  1408 , then reshaped after coupling to the outer ring  1452 . 
       FIG. 15  is a perspective view of another embodiment of an internal retractor  1570 , which is similar to the embodiments described above. The illustrated embodiment of the internal retractor  1570  comprises a longitudinal axis  1506  extending between a proximal end  1502  and a distal end  1504 , an access channel  1508 , and a plurality of shapeable members  1572 . The shapeable members are similar to the shapeable members  272  and described above, except that the shapeable members  1572  of the illustrated embodiment are coupled to an outer ring  1552  of a wound retractor rather than an inner ring. 
     In the illustrated embodiment, an arcuate base  1580  releasably mates with the outer ring  1552 . In other embodiments, the connection feature has a different arc length, for example, a full circle. The base  1580  comprises a connector  1582  that couples to the shapeable members  1572 . In the illustrated embodiment, the connector  1582  comprises a T-track into which is received a complementary portion disposed at a proximal end of each shapeable member  1472 . Those skilled in the art will understand that other embodiments use connectors with other configurations, for example, rails, tracks, holes, posts, and the like. In the illustrated embodiment, the connector  1582  is disposed along an inner surface of the base. In other embodiments, the connector is disposed on another surface, for example, a proximal face, an outer face, or a face at another angle to the longitudinal axis  1506 . The shapeable members  1572  are slidable along the T-track. The T-track comprises a gap  1584  dimensioned to permit a user to insert or remove shapeable member therethrough. The illustrated configuration permits a user to determine the number and spacing of shapeable members  1572  used in any particular situation. In one embodiment, the user couples the base  1580  to the outer ring  1552 , inserts a distal end of the shapeable member  1572  through the access channel  1508 , aligns the shapeable member with the gap  1584 , then couples the shapeable member  1572  to the connector  1582 . 
     An embodiment of a method for using a surgical access device in abdominal surgery is schematically illustrated in  FIGS. 16A-16C  and described with reference to the embodiment of the access device  300  illustrated in  FIG. 3 , although one skilled in the art will understand that the method is also applicable to all of the embodiments of the access device described herein.  FIG. 16A  is a side, partial cross section of a patient in which a wound retractor  350  has been placed through a body wall  40  and into a body cavity  42 , which is an abdominal cavity in this case. The inner ring  354  and internal retractor  370  are first inserted through an incision in the body wall  40  into the body cavity  42 . The outer ring  352  is then inverted through or rotated around itself, thereby winding the tubular sheath  356  around the outer ring  352 , thereby retracting the incision. In some embodiments, the outer ring  352  of the proximal portion is easily invertible in a snap-over motion, which provides a neutral position that resists rotation under tension generated in the retraction process. The tension secures the retractor  350  to the body wall  40 . 
     In the illustrated embodiment, the abdominal cavity  42  is inflated with gas, thereby facilitating access to internal structures  30 . In some embodiments, a cap or cover (not illustrated) is secured to the proximal portion of the retractor  350 , thereby creating a substantially gas-tight closure to the body cavity  42 , after which, the body cavity  42  is inflated or insufflated, for example, with CO 2  gas. 
     The internal retractor  370  is then deployed as desired within the body cavity  42 , thereby retracting or retaining internal structures during the surgical procedure.  FIG. 16A  illustrates the surgical site  70  before deploying the internal retractor  370 . For example, in the illustrated procedure, the position of abdominal content  30  is adjusted for an operation below the small intestine  32 .  FIG. 16B  illustrates a front partial cross section and  FIG. 16C  illustrates a side partial cross section of a retention pattern in which the internal retractor  370  holds the small intestine  32  away from the operative site  70 . 
     In the illustrated embodiment, deploying the internal retractor  370  comprises positioning the peripheral ring  376  of the internal retractor  370 , and inflating the inflatable supporting member  372  to a desire state of retention or retraction of the internal structures  30 . The inflated internal retractor  370  dams or walls-off loose structures from the operative site  70 . In inserting the access device  300 , as well as in deploying the internal retractor  370 , the internal retractor  370  is manipulated manually and/or with an instrument. For example, in some embodiments, the access device  300  is dimensioned and configured for access to the body cavity  22  by a surgeon&#39;s hand  100  through the orifice access channel  608  of the access device  300 . Other embodiments use a smaller access device  300  that is sized and configured to accept surgical instruments, such as laparoscopic tools, therethrough, but not a hand. In some cases, using a single, smaller device  300  limits the number of incisions needed in a laparoscopic procedure. Those skilled in the art will understand that the particular deployment procedure for the extendable member differs for each embodiment described above. 
     While certain embodiments have been particularly shown and described with reference to exemplary embodiments thereof, it will be understood by those of ordinary skill in the art that various changes in form and details may be made therein without departing from the spirit and scope thereof as defined by the following claims.