Abstract:
A self-retaining retractor which can be assembled and used without assistance, retracting a surgical incision, retaining the incision open, and providing for retraction of internal organs and tissues inside the patient&#39;s body through the open incision. Flexible, resilient incision retractor paddles are placed into the incision, a rigid frame consisting of two interlocking halves is laid longitudinally over the incision. The incision retractor paddles in the incision are manually clipped to each frame half then the frame halves are opened to the desired extent. Incision retractor paddles and frame provide the apparatus stability for retraction of internal organs and tissues through the open incision by the addition of mounting jigs containing attachment posts onto mounting means which radiate outward from the frame. Internal organ and tissue retraction means are affixed to the attachment posts.

Description:
This is a continuation-in-part of U.S. patent application Ser. No. 07/890,962, filed May 29, 1992 U.S. Pat. No. 5,231,974, which is a continuation-in-part of U.S. patent application Ser. No. 07/708,300, filed May 31, 1991, now abandoned, both incorporated herein by reference. 
    
    
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The present invention relates to surgical retractor apparatus and in particular to self-retaining surgical retractor apparatus which retract a surgical incision, retain the incision open and retract organs and tissues inside the body through the open incision. 
     2. General Background 
     Surgical &#34;retraction&#34; is the drawing back of body tissue. When the operation involves making an incision, the incision itself often must be retracted, and during surgery, internal organs and tissues are intermittently retracted through the opening created by the retracted incision. 
     An assistant&#39;s fingers are capable retractor paddles; however, greater technical ease should be available through the use of mechanical retractor systems. Mechanical retractor systems can be divided into two major groups: externally mounted &#34;fixed&#34; to the operating table, and self-retaining retractors. 
     Since the tactile sensitivity present in the assistant&#39;s fingers during hand retraction is lacking in mechanical retractor systems, the use of mechanical retraction increases the risk of tissue trauma; however, the mechanical system can be more stable and possesses infinite endurance. 
     The mechanical retractor systems attached to the operating table present the same type of physical obstruction to the surgeon&#39;s movement as presented by the assistant&#39;s body, arms and hands since the externally fixed retractor systems mimic the assistant&#39;s body, arms and hands through the use of a vertical column, supporting arm(s) or ring and retractor paddles attached thereto. Examples of this art include the systems illustrated in U.S. Pat. Nos. 4,949,707; 4,971,038 and 4,971,037. The retractor paddles, support arms or ring and vertical column in these apparatus are adjustable in multiple planes and axes of motion; however, these retractor paddles are not all independently adjustable in the vertical plane. Movement of a support arm or ring of these apparatus necessitates movement of all retractor paddles attached thereto. 
     Despite the advantage of adjustability in all planes and axes of motion, the externally mounted retractors all share these disadvantages: 
     A. Size and location of numerous pieces create an impediment to movement of surgeon and his assistant(s); 
     B. Length of time required for assembly; 
     C. Require assistance in assembly, and can break sterile field; 
     D. Retractor paddles are not independently adjustable in the vertical plane; 
     E. Planned patient movement requires time consuming disassembly and reassembly; 
     F. Involuntary patient movement can injure retracted tissue and organs; 
     G. Packing material (sponges) often required to cushion retractor paddles can cause injury; 
     H. Size and number of pieces increases cost; 
     I. Technical surgical ease restricted by height, location, size and multiplicity of pieces; 
     J. Disassembly in an emergency is time consuming; 
     K. Size of pieces makes sterilization difficult; and 
     L. Paddles are not interchangeable between different manufacturers. 
     Ideally, mechanical retractors both externally mounted and self-retaining need to provide for internal organ and tissue retraction, be quickly and easily assembled, positioned and repositioned in all planes and axes of motion, present as little obstruction to the surgeon&#39;s movement as possible, protect the sterile field, diminish the risk of tissue trauma, and yet be stable enough to function adequately while reducing the need for assistance. 
     Self-retaining retractors present less obstruction to the surgeon&#39;s movement and do not risk breaking the sterile field; however, the state of the art in self-retaining retractors falls far short of satisfying the surgeon&#39;s need for internal organ and tissue retractor paddles that can be quickly, independently, easily and safely adjusted without assistance in all planes and axes of motion. 
     The following patents illustrate self-retaining retractors that are capable of retraction of the surgical incision only or retraction of a body orifice only: U.S. Pat. Nos. 4,924,857; 2,893,378; 2,701,562; and 1,919,120. 
     The following patents illustrate self-retaining retractors that provide for retraction of an incision plus the retraction of organs and tissue through the opening created by the incision; however, the retraction paddles in these apparatus are not adjustable in more than one plane and perhaps one axis of motion: U.S. Pat. Nos. 4,421,107; 3,394,700; 3,129,706; 2,812,758; 2,623,517; and, 2,053,868. 
     Certain of the advantages and disadvantages of self-retraining retractors available on the market such as the &#34;Weitlaner&#34; (scissor action); &#34;Brunschwig&#34;; &#34;Wilkinson&#34; and &#34;Wexler&#34; (ring type); and &#34;Balfour&#34; (slide action) are discussed in the medical literature. Fackler, M. L., &#34;Extending the Usefulness of Self-Retaining Retraction,&#34; The American Journal of Surgery, Vol. 129, pp. 712-715, June 1975. 
     Self-retaining retractors that have attempted to provide for internal organ and tissue retraction through the open incision have failed to permit quick, independent, easy and safe adjustment of internal organ and tissue retractor paddles in all planes and axes of motion, and in effect the prior art is either ineffectual or unsafe, or both since these paddles are not easily adjustable in the vertical plane and such internal organ and tissue retractor paddles must traverse over (or through) internal tissue before reaching the desired location along the retractor handle and/or frame. The retractor paddle depth is not highly variable and the retractor paddles&#39; location on the retractor frame is limited. 
     This invention merges the advantages inherent in the externally mounted retractor systems with the advantages inherent in the self-retaining retractors while eliminating the disadvantages of each. 
     This invention achieves the above stated advantages while eliminating numerous disadvantages by recognizing that prior self-retaining retractors could not safely and effectively retract an incision and retract organs and tissue through the open incision utilizing paddles which are not discrete and which can only be attached on or inside the retractor frame. Another reason prior self-retaining retractors cannot safely and effectively retract both the incision and internal organs lies in the fact that the incision retractor paddles also stabilize the apparatus, and effective stabilization requires the prior apparatus to use multiple incision retractor paddles occupying a large part of the retractor frame capacity. This limitation is absent in the externally mounted retractors where retractor arms or ring are stabilized some distance away from the incision so that fewer incision retractor paddles are required, and incision retractor paddles are discrete, therefore, the arms or ring have ample space to accommodate incision retractor paddles and internal organ retractor paddles. 
     Due to the above described inherent design deficiencies, the prior self-retaining retractors share many of the following disadvantages: 
     A. Internal organ and tissue retractor paddles can neither be moved independently nor in all planes and axes of motion creating risk of tissue injury and limiting technical surgical ease; 
     B. Incision retractor paddles concentrate stress or overlap or are difficult to set up and move risking tissue injury; 
     C. Incision retractor paddles and internal organ and tissue retractor paddles are not discrete; therefore, neither the incision retraction function nor internal organ and tissue retraction function are carried out with a high degree of surgical ease. 
     D. Uneven opening of the incision; 
     E. Assistance required; 
     F. Non-conformity to many surgical procedures; 
     G. Non-conformity to many patient sizes; and 
     H. Do not accommodate retractor paddles supplied by other manufacturers. 
     SUMMARY OF THE PRESENT INVENTION 
     Therefore it is an object of this invention to provide a self-retaining retractor which can retract a surgical incision without assistance, retain the incision open, stabilize the apparatus, and retract without assistance internal organs and tissue through the opening created by the incision. 
     Another object of this invention is to provide a self-retaining retractor that is less obstructive to the surgeon&#39;s movement than externally mounted retractors. 
     Another object of this invention is to provide a self-retaining surgical retractor which is capable of internal organ and tissue retraction through the opening created by the incision which is safe and effective. This is to be accomplished by locating attachment means for internal organ and tissue retractor paddles on posts which themselves are on mounting jigs which ratchet in and out on mounting means which radiate from the outside of the retractor frame, thereby allowing safe, easy and independent movement of internal organ and tissue retractor paddles in all planes and axes of motion, yielding the highest possible technical surgical ease. 
     It is also an object of this invention to provide internal organ and tissue retraction using retractor paddles from various manufacturers that are independently adjustable in all planes and axes of motion. 
     It is a further object of this invention to provide incision retractor paddles of different depth and (combined) lengths to accommodate various patient sizes and incision lengths, respectively, and varied surgical procedures. 
     Another object of this invention is to provide incision retractor paddles that retract the incision, retain the incision open and stabilize the apparatus, which incision retractor paddles are discrete from internal organ and tissue retractor paddles. 
     It is a further object of this invention to provide incision retractor paddles that attach to the retractor frame with easy to connect and disconnect flexible, resilient clips. 
     It is also an object of this invention to provide incision retractor paddles with outwardly curved bottom edge sections which are in contact with the internal surface of the integument thereby providing the apparatus with additional stability against lifting and torsional forces which can occur during internal organ and tissue retraction. 
     It is a further object of this invention to provide incision retractor paddles which do not unduly concentrate stress, but evenly distribute stress along the length of the incision and depth of the integument. 
     It is also an object of this invention to provide attachment means which accommodate the handles of internal organ and tissue retractors provided by other manufacturers. 
     It is also an object of this invention to provide a means of retracting and retaining open an incision without assistance and thus stabilizing the retractor apparatus by first inserting incision retractor paddles into an incision, placing the retractor frame over and outside the incision paddles and then manually clipping the incision paddles onto the retractor frame, and then pulling the frame halves open, and thus retracting and retaining the incision. 
     A further object of this invention is to provide a self-retaining retractor which can use internal organ and tissue and other types of retractor paddles provided by other manufacturers. 
     Other objects, advantages and novel features of the present invention will become apparent to those skilled in the relevant art and to others from the following detailed description of the invention when considered in conjunction with the accompanying drawings. 
     Accordingly, a self-retaining retractor is disclosed comprising a retractor frame consisting of interlockable frame halves, the frame halves are provided at each end with posts and borings of matching dimension and cross section, the posts and borings are aligned so as to mate together, said posts are provided with ratchet grooves and ratchet stops, the ratchet grooves are acted upon by a tensioned ratchet clip which allow outward movement and retard inward movement; the frame halves are assembled by inserting the posts into the bores and by drawing back the ratchet clips and mating the halves by pushing them together. Two or more flexible, resilient incision retractor paddles are placed inside the patient&#39;s incision with the bottoms of paddles&#39; attachment means lying outside the body. The incision retractor paddles&#39; attachment means face away from each other toward the inside face of the retractor frame, which is laid longitudinally over the incision outside the incision retractor paddles. Incision retractor paddles vary in length (or number) and depth to accommodate varying length incisions and depth of integument being retained open. The surgeon manually clips the incision retractor paddles onto the frame halves and then further pulls the retractor frame open to the desired width. The retractor frame cannot be accidentally pulled apart due to the ratchet stops provided. The incision retractor paddles have outwardly curving bottom edge sections which project internally, inside the body wall integument providing additional stability against lifting and torsional forces. 
     The frame halves have one or more mounting means radiating away from the outside of the frame; onto these mounting means the surgeon can affix mounting jigs with attachment posts. Onto an attachment post the surgeon can affix attachment means for attaching internal organ and tissue retractor paddles. The attachment means has two attachment bores, one bore fits over the attachment post, thereafter an internal organ and tissue retractor paddle handle fits through the second bore which then allows for quick, easy, safe and independent adjustment of the internal organ and tissue retractor paddle in all planes and axes of motion. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS 
     For a further understanding of the nature and objects of the present invention, reference should be had to the following detailed description taken in conjunction with the accompanying drawings, in which like parts are given like reference numerals, and wherein: 
     FIG. 1 is a perspective view of the first embodiment of the self retaining retractor of the apparatus of the present invention shown in an opened position in a surgical incision; 
     FIG. 2 is a top view of the first embodiment of the apparatus of retractor paddles in situ with partially opened retractor frame in place longitudinally over the incision, and prior to attachment to the retractor frame; 
     FIG. 3 is a partial perspective view of the first embodiment of the apparatus of the present invention illustrating one half of the retractor frame, the retractor posts of the retractor frame, and one incision retractor paddle attached thereto; 
     FIG. 4 is a partial perspective view of the first embodiment of the apparatus of the present invention illustrating one half of the retractor frame, the retractor bores of the retractor frame, the ratchet clips and one incision retractor paddle attached thereto; 
     FIG. 5 is a partial perspective view of the first embodiment of the apparatus of the present invention illustrating one incision retractor paddle; 
     FIG. 6 is a top view of the first embodiment of the apparatus of the present invention; 
     FIG. 7 is a fragmentary perspective view of the mounting jig portion of the first embodiment of the apparatus of the present invention showing the attachment post and ratchet clip; 
     FIG. 8 is a fragmentary perspective view of the first embodiment of the apparatus of the present invention illustrating the mounting jig with attachment post, ratchet clip, and with internal organ and tissue retractor handle and paddle in place; 
     FIG. 9 is a fragmentary view of a second embodiment of the apparatus of the present invention illustrating an adjustable incision retractor paddle; 
     FIG. 10 is a fragmentary perspective view of a third embodiment of the apparatus of the present invention illustrating an adjustable jig for supporting a retractor from a position outside of and above the retractor frame; 
     FIG. 11 is a perspective view of a fourth embodiment of the apparatus of the present invention; 
     FIG. 12 is a perspective view of the preferred embodiment of the apparatus of the present invention illustrating one half of the retractor frame, and the other half of the retractor frame in phantom, the retractor bores of the retractor frame, and the ratchet clips; 
     FIG. 13 is a partially cut-away view of a mounting post of the preferred embodiment of the apparatus of the present invention; 
     FIG. 14 is an exploded view of an adjustable incision retractor paddle of the preferred embodiment of the apparatus of the present invention; 
     FIGS. 15 and 16 are details thereof; 
     FIG. 17 is a perspective view of the bracket assembly of the preferred embodiment of the apparatus of the present invention; and 
     FIG. 18 is a detail thereof. 
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     FIG. 1 shows an overall view of the self retaining retractor used in a first embodiment of incision retraction, retaining and apparatus stabilization along with internal organ and tissue retraction. The assembly includes a rigid frame member 1 with two posts 7 at either end, and a similar rigid frame member 2 with bores 20 corresponding to the posts 7 and ratchet clips 10 thereon. The post frame 1 is mated with the bore frame 2 by pushing the posts 7 into the bores 20. The ratchet clips 10 can be tensioned with spring 12 and provided with a catch 11 for engaging ratchet teeth 8. The frame halves 1, 2 are prevented from being accidentally pulled apart due to the ratchet stop 9. 
     Two appropriately sized resilient, flexible incision retractor paddles 13 are placed into the incision 39. Each paddle 13 can be removably attached to a frame member 1, 2 using spaced apart, horizontal flanges 15, 16. The bottom flange 16 rests on the outside upper surface of the patient&#39;s body during use. The depth of the incision retractor paddle 13 is determined, for example, by the thickness of body integument (as from the outside layer of skin to just inside the parietal peritoneum). At this lower depth, the incision retractor paddles curve to provide outwardly extending portions 19, providing additional retaining surface 19 to oppose lifting and torsional forces exerted during assembly and use (particularly internal organ and tissue retraction, see FIG. 1). 
     Prior to placement, the inside of the incision retractor paddles 13 face each other in situ and the incision 39 flanges 15, 16 are oriented toward the inside of the frame halves 3, 4. During installation, the surgeon manually squeezes the inside face of the pair of the incision retractor paddles 13 respectively onto the retractor frames, 1, 2 making a tight physical connection (and slightly retracting the incision). Flange 15 is placed over the frame section 1 or 2 and flange 16 under the selected frame 1 or 2. The top and bottom flanges 15, 16 each have a catch 17 which engages a frame member 3, 4 as selected and thus attaches the incision retractor paddle 13 onto the selected frame section 1 or 2. 
     FIGS. 1, 3 and 4 show incision retractor paddles, attached to the frame halves 1, 2. 
     FIG. 5 shows an incision retractor paddle 13, the attachment flanges 15, 16 which hold the incision retractor paddles 13 to the frame halves 1, 2 as well as the outwardly curved portions 19, the catch 17, and flange portions 18 that project beyond the catch 18 for allowing manual disengaging of the attachment flanges 15, 16 from the frame 1 or 2. 
     The surgeon can use outward manual pressure on the inside of the incision retractor paddles 13 in situ, spreading the frame halves 1, 2 further apart to the desired incision opening width (see FIG. 1). The clips 10 in contact with the ratchet teeth 8 maintain the desired incision opening width when manual pressure on the inside of the apparatus is released. 
     The underside of the frames 1, 2 rest against the outside upper surface of a patient&#39;s body. The outer surface 14 of each incision retractor paddle is in contact with the wall of the incision 39. The outwardly extending lower end portion 19 is in contact with the internal surface of the body wall integument, and these areas of contact between the paddles 13 and various body tissues stabilize against lifting and torsional forces, which primarily occur during use of internal organ and tissue retractor paddles 38. 
     With the incision 39 open to the required width, the incision retraction and retention functions have been accomplished, and the apparatus is stabilized and available for internal organ and tissue retraction, FIG. 1. 
     FIG. 7 shows a view of the mounting jig 21 with attachment post 22, and ratchet clip 23 which is mounted at pivot 25 to jig 21, and tensioned using coil spring 40. A catch 24 secures jig 21 to mounting beam 5. 
     The mounting jig 21 slides onto the mounting beam 5 that extends outwardly from the frame outer surface 3, 4. Ratchet clips 23 are provided with a tensioning spring 40 and catch 24 to prevent inward movement and without raising the ratchet clip 23. The ratchet clip 23 is tensioned to engage against ratchet teeth 6. 
     FIG. 8 shows an internal organ and tissue retractor paddle 38 attached to a retraction handle 37 which is held in place by mating it through the bore 29 of an attachment bracket 27, which is connected with shaft 36 to a second bracket 26. The second bracket 26 is held in place by mating its bore 28 with the attachment post 22 of the mounting jig 21. 
     The internal organ retractor paddle 38 is adjusted as desired then fixed in place by tightening the shaft 36 by grasping handle 30 and tightening it into a threaded base of the bracket 27. Shaft 36 has a stop 33 so that tightening can be effected. Handle 30 has end stops 31, 32 allowing the handle 30 to slide inside a transverse bore of the shaft 36, thus altering the length and position of the turning means handle 30. The spaces 34, 35 respectively between opposing legs of each bracket 26, 27 decrease when the shaft 36 is tightened, thus creating a frictional attachment at bores 28, 29 of the brackets 26, 27 and the respective attachment post 22, paddle handle 37 and between the two brackets 26, 27. 
     FIGS. 9-10 illustrate alternative embodiments of the apparatus of the present invention. In FIG. 9, a retractor paddle 40 is generally rectangular in shape, providing an upper 41 and a lower 42 end portion, and spaced apart generally vertically extending side portions 43-44. The paddle 40 provides an inner surface 45 which faces a similar opposing paddle during use. The rear or outer surface 46 engages body tissue during use. The bottom 42 portion provides one or more laterally extending flange members which can have gaps or slots 48 therebetween as shown in FIG. 9. 
     A plurality of longitudinal or vertically extending slots 49 are placed generally parallel to one another and to sides 43, 44 as shown in FIG. 9. Each slot 49 is comprised of a plurality of circular portions 50 interconnected with rectangular sections 51. Each circular portion 50 of slot 49 represents an adjustment position for clip 52. Clip 52 is comprised of an upper flange 53 and a lower flange 54 which are generally horizontally extending and are connected with vertical flange 55. Projecting portions 56 on each of the flanges 53, 54 are designed to engage a frame member 1, 2 during use. Because the clip 52 can be fixed in a number of different positions along slot 49, the vertical position of paddle 45 can be varied with respect to a frame section 1, 2 as desired. Further, because each clip 52 can be movable independently of another clip, it is possible that clips 52 can be placed in circular portions 50 of differing elevations such as for example diagonally so that the upper edge 41 of paddle 45 is angularly oriented with respect to a plane defined by the two frames 1, 2 which is typically horizontal. 
     In summary, the paddle 45 can be adjusted upward or downward and tilted into angular orientations. Each clip 52 provides a circular head portion 57 which is larger in diameter than the circular portions 50 but smaller in diameter than the uppermost circular portion 58 of slot 49. A rectangular member 59 extends between circular head portion 57 and vertical flange 55 on clip 52. The rectangular portion 59 is smaller in size than the rectangular portions 51 of slot 49. Thus, when the clip is rotated ninety degrees (90°) from the orientation shown in FIG. 9, this allows the rectangular portion 59 to pass through any one of the similarly configured rectangular portions 51 of slot 49 and affords vertical adjustability of clip 52 with respect to paddle 45 until head portion 57 aligns with a desired circular portion 50 of slot 49 as desired. 
     Rectangular member 59 can form an integral connection between vertical flange 55 and circular head member 57 such as for example by adhesive, welding, or integral construction such as by manufacturing vertical flange 55, rectangular portion 59 and circular head portion 57 from a single block of material such as stainless steel or the like. 
     In FIG. 10, an alternative embodiment of a jig is disclosed, designated generally by the numeral 61. Frame 1, 2 is shown in FIG. 10 as including a plurality of circular post members 62 that extend away from outer surface 3,4 of a particular frame section 1, 2. The posts 62 allow attachment of jig 61 using brackets 63, 66. The bracket 63 attaches to a post 62 and can be tightened using a thumb screw 64 and threaded shaft. Similarly, a vertical post 65 extends between bracket 63 and bracket 66. 
     A thumb screw 67 can be used to tighten bracket 66 against vertical post 65. Bracket 66 also supports retractor paddle shaft 68 which carries a deep retractor that can be curved as shown in FIG. 10, designated by the numeral 69. The curved retractor paddle 69 attaches to shaft 68 at weld 70 for example. 
     The embodiment of FIG. 10 allows a retractor to be supported above the plane defined by retractor frame 1, 2 and from a position outside of the area between frames 1, 2 during use i.e. outside of the incision. This is a particular utility in retracting portions of the anatomy such as organs which are disposed within the operative field but which are not supported by retractor paddles 13, 40. 
     Using the apparatus of FIG. 10, a particular organ can be retracted from a position above and removed from the operative field and in adjustable fashion with regard to multiple angular orientations of the shaft 68. For example, the bracket 63 rotates about the post 62. Similarly, the bracket 66 rotates about the vertical post 65. Also, the shaft 68 rotates in its supporting bracket 66. Thus, by loosening the thumb screws 64, 67, a desired rotational movement of each bracket 64, 66 can be made with respect to shafts 62, 65, and 68. Additionally, the bracket 63 can be moved inwardly and outwardly with respect to frames 1, 2 into a desired adjustable position. Further, the bracket 63, 66 can be moved upwardly and downwardly upon the post 65. Further, the shaft 68 can be moved inwardly and outwardly with respect to the frames 1, 2 and bracket 66. 
     In the embodiment of FIG. 11, a plurality of internally threaded openings 71 provide attachment openings for threadably receiving an externally threaded attachment stud that is connected to mounting beam 5 or to post 62. This feature allows selective location of a beam 5 or a post 62 along frame sections 1,2 as shown in FIG. 11. A surgeon can thus selectively locate the beams 5 and posts 62 and the retractors 38, 69 to suit a particular patient or a particular operation. 
     FIGS. 12-18 show the preferred embodiment of the present invention. 
     Frame member 101 is shown in FIG. 12. Frame member 101 mates with a like frame member 101, with posts 7 being received in bores 20, as described in conjunction with frame members 1 and 2, and ratchets 10 hold the two frame members 101 together. 
     A post 162 (see also FIG. 13) for receiving a bracket assembly 160 (see FIGS. 17 and 18) includes a base 172 having disposed therein two grooves 240 for leaf springs 259, which can be secured therein in any suitable manner. Leaf springs 259 have disposed thereon projecting pins 257. 
     Holes 171 in frame members 101 receive base 172 of post 162, and projecting pins 257 are received in holes 250 at the top and bottom of frame member 101. Post 162 is inserted into hole 171 by pressing leaf springs 259 inward into grooves 240, pushing base 172 into hole 171, then releasing leaf springs 259, which causes projecting pins 257 to lock into holes 250. When it is desired to remove post 162, one simply presses leaf springs 259 into grooves 240 and pulls post 162 out. 
     Bracket assembly 160 includes a pair of brackets 163 and 166. Bracket assemblies 160 can advantageously be used in the manner of bracket assemblies 63, 64 and 66, 67. Two bracket assemblies 160 are preferably used with each post 162, and the first bracket 163 receives post 162 when the first bracket 166 receives post 65, and the second bracket 163 receives post 65 when the second bracket 166 receives post 68. Brackets 163 and 166 are movable with respect to one another such that, for example, post 65 can be vertically aligned and post 68 horizontally aligned when post 65 is received in opening 191 of bracket 163 and post 68 is received in opening 192 of bracket 166. 
     A threaded tightening screw 185 includes left-hand threads 186 and right-hand threads 187, separated by a smooth portion 189. A square portion 188 of threaded tightening screw 185 receives a thumb wheel 167 for turning threaded tightening screw 185. Bracket assembly 160 is assembled by threading threaded bore 176 in bracket 163 onto the left-hand threads 186 of screw 185 and by threading threaded bore 177 in bracket 166 onto right-hand threads 187 of screw 185, then attaching thumb wheel 167 onto square portion 188, with smooth bore 178 in bracket 163 and smooth bore 179 in bracket 166 receiving smooth portion 189 of screw 185; locking retainer clips 193 are pressed onto grooves in screw 185, and washers 194 separate clips 193 from bores 178 and 179. Once bracket assembly 160 is assembled, then in a first bracket assembly 160, a post 162 is received in opening 191 in bracket 163, and a post 65 is received in opening 192 in bracket 166. Thumb wheel 167 is then turned clockwise, causing openings 191 and 192 to close slightly and clamp onto posts 162 and 65 (of course, post 162 is generally horizontal and post 65 is generally vertical). In a similar manner, a second bracket assembly 160 receives and is tightened on the upper portion of post 65 and post 68. Turning thumb wheel 167 counterclockwise causes openings 191 and 192 to open further. 
     Tightening screw 185 provides for positive opening and closing control of brackets 163 and 166. Thus, posts 162 and 65, and 65 and 68, can be fixed relative to one another, or posts 162 and 65, and 65 and 68, can be loosely engaged by brackets 163 and 166, to allow posts 162 and 65, and 65 and 68, to slide relative to one another. 
     The plurality of holes 171 and 250 in frame members 101 allows placement of posts 162, and thus retractor paddles 69, at a plurality of locations, thus providing greater flexibility of choice when retracting with retractor paddles 69. 
     FIGS. 14-16 show a paddle assembly 110 including paddle 113, paddle mounting bracket 115, and clip 152. A paddle assembly 110 is attached to each frame member 101 using two clips 152, one for each groove 278 in paddle mounting bracket 115. 
     Paddle 113 includes a vertical portion 118 and a lower, outwardly extending portion 119. Vertical portion 118 includes a plurality of holes 150 therein. Mounting bracket 115 includes a substantially vertical portion 114 having flanges 279 for receiving paddle 113, and a substantially horizontal portion 116 having grooves 278 for receiving foot portion 289 of threaded tightening screw 285. The vertical portion of paddle mounting bracket 115 has mounted thereon a leaf spring 159 having a projecting pin 157. Projecting pin 157 engages holes 150 in paddle 113, as will be described further. The underside of substantially horizontal portion 116 of mounting bracket 115 rests on the outside of a patient&#39;s abdomen, helping to support the apparatus of the present invention. 
     Clip 152 includes an upper flange 153, a lower flange 154, and a vertical flange 155. Projecting portions 56 are present on upper flange 153 and lower flange 154, and are designed to engage a frame member 101 during use. 
     Threaded tightening screw 285 includes threads 287, a square portion 288, and a foot portion 289. A thumb wheel 164 for turning threaded tightening screw 285 is attached to the square portion 288. A washer 294 is received over foot portion 289, threaded tightening screw 285 is received in threaded bore 277 in vertical flange 155, then thumb wheel 164 is attached to square portion 288. Two clips 152 are used for each paddle mounting bracket 115, and foot portions 289 are received in grooves 278 in paddle mounting bracket 115. Paddle mounting bracket 115 is fixed relative to clips 152 (and thus frame member 101) by turning thumb wheel 164 in a first direction which causes foot portion 289 to move upward, pressing washer 294 against the top of groove 278. 
     Lateral adjustment of paddle 113 is accomplished by loosening tightening screw 285, moving paddle mounting bracket 115 relative to frame member 101, and then again tightening screw 285. Vertical adjustment of paddle 113 is accomplished by pushing paddle 113 upward. Projecting pin 157 is shaped so that paddle 113 can easily be pushed upward, but cannot move downward without pulling leaf spring 159 outward in the direction of the single-headed arrow in FIG. 16. In this manner paddle 113 can freely move up relative to paddle mounting bracket 115 while apparatus 110 is mounted on a patient. Leaf spring 159 causes projecting pin 157 to engage a hole 150 and locks paddle 113 relative to paddle mounting bracket 115 against downward movement. 
     Many other variations, modifications, and alternative embodiments may be made in the apparatus and techniques hereinbefore described, by those having experience in this technology, without departing from the concept of the present invention. Accordingly, it should be clearly understood that the apparatus and methods depicted in the accompanying drawings and referred to in the foregoing description are illustrative only and are not intended as limitations on the scope of this invention, as defined in the following claims. 
     The following table 1 lists the part numbers and part descriptions as used herein and in the drawings attached hereto. 
     
                       TABLE 1______________________________________PARTS LISTPART NO.   DESCRIPTION______________________________________ 1      frame member 2      frame member 3      outer surface 4      outer surface 5      mounting beam 6      teeth 7      post 8      teeth 9      stop10      clip11      catch12      spring13      paddles14      outer surface15      attachment flange16      attachment flange17      catch18      projecting portion19      lower end20      bore21      jig22      post23      clip24      catch25      pivot26      bracket27      bracket28      bore29      bore30      handle31      end32      end33      stop34      space35      space36      shaft37      handle38      paddle39      incision40      paddle41      top42      bottom43      side44      side45      inside surface46      outer surface47      flanges48      gap49      slot50      circular portion51      rectangular portion52      clip53      upper flange54      lower flange55      vertical flange56      projecting portion57      head58      larger circular opening59      rectangular portion60      arrow61      jig62      post63      bracket64      thumb screw65      post66      bracket67      thumb screw68      shaft69      retractor paddle70      weld71      internally threaded opening72      externally threaded stud101     frame member110     paddle assembly113     paddle114     substantially vertical portion of paddle mounting   bracket 115115     paddle mounting bracket116     substantially horizontal portion of paddle mounting   bracket 115118     vertical portion of paddle 113119     lower, outwardly extending portion of paddle 113150     holes in paddle 113152     clip153     upper flange of clip 152154     lower flange of clip 152155     vertical flange of clip 152157     projecting pin on leaf spring 159159     leaf spring160     bracket assembly162     post163     bracket for posts 162 and 65164     thumb wheel f or turning threaded tightening screw   285166     bracket for posts 65 and 68167     thumb wheel for turning threaded tightening screw   185171     holes for post base 172172     base of post 162176     threaded bore in bracket 163177     threaded bore in bracket 166178     smooth bore in bracket 163179     smooth bore in bracket 166185     threaded tightening screw186     left-hand threads of threaded tightening screw 185187     right-hand threads of threaded tightening screw 185188     square portion of threaded tightening screw 185189     smooth portion of threaded tightening screw 185191     opening in bracket 163 for posts 162 and 65192     opening in bracket 166 for posts 65 and 68193     locking retainer clip194     washer240     groove in base 172 of post 162 for leaf spring 259250     holes for projecting pin 257257     projecting pin on leaf spring 259259     leaf spring of post 162277     threaded bore in vertical flange 155278     groove in paddle mounting bracket 115 for foot   portion 289 of threaded tightening screw 285279     flanges in paddle mounting bracket 115 for   receiving paddle 113285     threaded tightening screw287     threads of threaded tightening screw 285288     square portion of threaded tightening screw 285289     foot portion of threaded tightening screw 285294     washer______________________________________ 
    
     Because many varying and different embodiments may be made within the scope of the inventive concept herein taught, and because many modifications may be made in the embodiments herein detailed in accordance with the descriptive requirement of the law, it is to be understood that the details herein are to be interpreted as illustrative and not in a limiting sense.