The St Mark's retractor.

Introduction

The St Mark's retractor is an instrument essential in open pelvic surgery. It is of great help in exposing structures deep in the narrow pelvis. This rigid retractor has specific properties including a shaped hollow handle with two prominences on the upper ridge, a 90° angle in the blade and a varying angle from blade to handle. The slightly curved blade is 6 cm wide and 12·5 cm or 18 cm deep. Lipped and non‐lipped blades are available (Fig. 1). Although the instrument is known internationally as ‘St Mark's retractor’, its origin and creator are unknown. In this article, the authors aim to describe the origin of this useful instrument in order to appreciate its historical value and acknowledge its developer.

Figure 1

St Mark's retractors

The name ‘St Mark’

Frederick Salmon founded St Mark's Hospital, Harrow in 1835. The outpatient dispensary was originally named the ‘Infirmary for the Relief of the Poor Afflicted with Fistula and other Diseases of the Rectum’. Soon it became known as the ‘Fistula Infirmary’. By the 1840s, the success of the services required new, bigger accommodation, which was founded in the parish of St Mark's Church1, 2. This church was named after St Mark, who was an evangelist and likely the founder of one of the most important episcopal sees of early Christianity3. In 1854, the new hospital was given a new name – St Mark's – which, beneficially, also sounded more appealing for funding. However, Frederick Salmon insisted on honouring the specialized character of the hospital, so the official name of the hospital became ‘St Mark's Hospital for Fistula and other Diseases of the Rectum’. There is no obvious relationship between St Mark the Evangelist and surgery in any other way. It thus seems likely that the retractor's name refers to the hospital and not the saint.

Evolution of handheld retractors

A retractor is a surgical instrument used to hold back underlying organs and tissues so that body parts under the incision may be accessed. Artificial retractors are used to mimic natural retractors like human hands and hooked fingers. Although archaeologists have found that basic tools were already in use in the Stone Age, surgical dissection depended predominantly on hands and fingers until the Renaissance. The evolution of surgical handheld retractors parallels the evolution of safe body‐cavity surgery after the introduction of thermal sterilization techniques around 1850. Strong, rigid retractors were especially crucial for surgical exploration before the introduction of muscle‐relaxing anaesthesia in 19424.

Many handheld retractors used in open abdominal surgery nowadays were developed at the end of the 19th and beginning of the 20th centuries, and named after their inventors. Well known examples are the Mathieu's double‐ended retractor, Kelly's deep retractor for kidney exposure and the Morris retractor for abdominal surgery. However, catalogues of instrument manufacturers based in London at the beginning of the 20th century did not include a St Mark's retractor. So why was the St Mark's retractor developed and why was it not named after its inventor? Use of the St Mark's retractor is best demonstrated during pelvic surgery. Fig. 2 shows the typical handling of a St Mark's retractor. The instrument is of crucial importance for adequate exposure during open rectal resections. The history of this specific procedure might therefore shed some light on the development of the instrument.

Figure 2

Typical handling of a St Mark's retractor

Development of abdominoperineal rectal resection

Although resection of the rectum via the perineum or sacrum was already being performed in the 18th and 19th centuries, it was Ernest Miles who performed the first abdominoperineal rectal resection (APR) at the beginning of the 20th century in London. He reported his results in the Lancet in 1908, where he described 12 procedures with a mortality rate of 42 per cent5. In the ‘methods of operation’ section he explained his two‐stage procedure. During the first (abdominal) phase, the patient was placed in an ‘exaggerated Trendelenburg posture’. After making a midline incision, Miles placed a ‘self‐retaining abdominal claw’, but did not mention any other retractors in this article. In his 1933 black‐and‐white film entitled Technique of the Radical Abdomino‐perineal (Miles's) Operation 6, the anterior side of the wound is simply being retracted with fingers and no handheld retractors are used (Fig. 3).

Figure 3

Screenshot of view into the pelvis from the Technique of the Radical Abdomino‐perineal (Miles's) operation, by Ernest Miles (1933)

The technique was also adopted at St Mark's Hospital, but some consultants remained hesitant about the abdominoperineal procedure. They advocated the posterior approach as having a lower operative mortality rate. In 1939, Oswald Vaughan Lloyd‐Davies published a remarkable improvement in the Lancet 7. As an assistant surgeon to St Mark's Hospital, he stated in his article: ‘Everyone is familiar with the lithotomy and Trendelenburg positions, but I wish to point out some of the merits of using a combination of these two positions when operating on the rectum and lower colon. I have used this method for the past eighteen months and have had time to assess its advantages and eliminate some of its faults’. Combining the two approaches avoided several turns of the patient (depending on whether an abdominoperineal or perineoabdominal approach was used) and shortened the operating time. For this new approach, he designed special leg supports that could be attached to the table and adjusted to the patient's needs. The leg supports were made by the surgical instrument maker Messrs A. L. Hawkins & Company Limited, who were acknowledged by Lloyd‐Davies at the end of the article. Lloyd‐Davies also stressed careful positioning of two sandbags to lift the sacrum, because good exposure of the coccyx was essential. Although the St Mark's retractor itself was not mentioned in his article, hypothetically this new approach might also have initiated the development of new instruments to meet the surgeon's needs. The medical reports of St Mark's Hospital from early 1940s show that Mr Lloyd‐Davies put his idea into practice, performing perineoabdominal resections in the lithotomy–Trendelenburg position, still known as the Lloyd‐Davies position (Fig. 4).

Figure 4

Page from a medical report of St Mark's Hospital (1944) P.A (LTP), perineoabdominal resection in lithotomy–Trendelenburg position. Available at St Bartholomew's Archives, London, UK (SBHK/MR/15/1).

The absence of the St Mark's retractor in the 1933 film by Miles, and the assumption that the development of new instruments paralleled new developments in rectal surgery, mean that the 1940s and beyond are of special interest in the quest for the origin of the St Mark's retractor. Unfortunately, evidence to demonstrate use of instruments in rectal surgery is scarce. Although many articles have been published on surgery for rectal cancer, references to retractors are difficult to find because instruments used during the procedure hardly ever make it to the articles' text. During the 1980s, the journal Diseases of the Colon and Rectum published a series on classic articles in colonic and rectal surgery from the 1950s. These articles show figures of pelvic procedures in which retractors were being used, but these do not resemble the St Mark's retractor (Fig. 5).

Figure 5

Illustrations of pelvic procedures in Diseases of the Colon and Rectum (1958–1959)

The St Bartholomew's Hospital Archives in London also hold the St Mark's Hospital archives. They have a few pictures of abdominal procedures on display, but none containing a St Mark's retractor. A lot of material is unfortunately still uncatalogued and not available for public viewing. The authors supplied the archivists working on the St Mark's Hospital Archive Project with images of the retractor to ease recognition of the instrument during the course of listing the uncatalogued material. The St Mark's Archive Project was due to be completed by the middle of December 2018. To date, listed images seem to contain predominantly people and very few clinical instruments. A 1959 film entitled Synchronous Combined Excision of the Rectum 8, by William Bashall Gabriel, a consultant surgeon at St Mark's Hospital at that time, shows a patient operated on in the Lloyd‐Davies position, but without the use of a St Mark's retractor. A 1971 film entitled Abdomino‐perineal (Miles) Operation for Cancer of the Rectum 9 by Arthur Lawrence Abel (1895–1978), who had been a surgical registrar under Ernest Miles, shows the use of several retractors. One shot shows two retractors with similarities to the St Mark's retractor, but the convexity of the blade also shows differences (Fig. 6).

Figure 6

Screenshot from Abdomino‐perineal (Miles) Operation for Cancer of the Rectum, by Arthur Lawrence Abel (1971)

Although the basic surgical instruments used are not often specified in articles and other surgical documentation, sometimes the manufacturers of the instruments are. For example, Messrs A. L. Hawkins & Company Ltd was acknowledged by Lloyd‐Davies as the manufacturer of the leg supports in his 1939 article on the lithotomy–Trendelenburg position. The next section explores the instrument makers for St Mark's Hospital in the 20th century in relation to the St Mark's retractor.

Instrument makers for St Mark's Hospital

The Medical Committee of St Mark's Hospital in the first decades of the 20th century consisted of all consultant surgeons working at the hospital. They gathered on a monthly basis, and discussed hospital management and policy. The detailed minutes of these meetings from 1940 until 1961 are available at the St Bartholomew's Hospital Archives (Fig. 7 a).

Figure 7

St Mark's Hospital Medical Committee minute book and entries Available at St Bartholomew's Archives, London, UK (SBHK/MC/1/1/1‐3, 1930‐1961).

Within these minutes, references to two instrument makers were made when the Medical Committee decided to have a new operating table ordered. Both Allen & Hanbury's Limited and A. L. Hawkins & Company Limited were considered carefully as possible candidates (Fig. 7 b,c). Allen & Hanbury's Limited was a company founded in 1715, mostly working in pharmacy10. In 1878, their instrument factory was documented to be located in Bethnal Green, London. Glaxo Laboratories absorbed the company in 1958. A small note in the Medical Committee minutes of October 1954, however, showed that the workmanship of the company was not always appreciated (Fig. 8). Messrs A. L. Hawkins & Company Limited was a manufacturer of surgical instruments based at 15 New Cavendish Street in London between 1920 and 197511. Not only was the company acknowledged as the manufacturer of the leg supports in the Lloyd‐Davies' 1939 article, the Medical Committee considered the company as the manufacturer of their new operating table in 1954 and for the repair of instruments in 1952. A. L. Hawkins & Company have ceased to trade and their patterns passed to Seward Thackray. Seward Thackray Ltd itself does not hold any historical records dating back to this period. There is, however, a Thackray museum in Leeds.

Figure 8

October 1955 Medical Committee minutes with respect to a consultants' requisition of a Canny Ryall's probe Available at St Bartholomew's Archives, London, UK (SBHK/MC/1/1/1‐3, 1930‐1961).

One of the treasures of the Thackray Medical Museum is a set of six drawing books from the Thackray works, showing new instruments devised or ordered by surgeons from around 1929 to 1973. Volume 4, page 138, contains a drawing of a ‘St Mark's retractor’, ordered by Mr Shucksmith, a prominent Leeds surgeon, on 5 September 1950 (Fig. 9). The reference for the pattern is ‘Hawkins’. The drawing shows a St Mark's retractor with similar properties to the retractor known today, including the slightly curved blade that narrows to the end. The handle was made from nickel steel. There is a note about a ‘double’ lug, which might refer to the two prominences on the handle that are also seen in modern versions (Fig. 1). It would seem that Mr Shucksmith bought a retractor, used it at the Leeds General Infirmary, liked it and asked Seward Thackray Ltd to make some more. The drawing of the retractor also has an annotation ‘Alter Shucksmith's to the same’. The Thackray catalogues otherwise do not contain any reference to St Mark's retractors until the 1955 edition, where two sizes of a St Mark's Hospital pattern retractor are catalogued (Fig. 10). These retractors look very much like the St Mark's retractors in current use (Fig. 1). On the same page, ‘Shucksmith's retractors’ are displayed below the St Mark's retractors. They share similarities with the St Mark's retractor, which could be the result of Mr Shucksmith's earlier order to alter his instrument to mimic features of the St Mark's retractor. The museum also has three St Mark's retractors in its collection, which are all Thackray pattern instruments.

Figure 9

Drawing of a ‘St Mark's retractor’ in drawing book from the Thackray works (volume 4, page 138, 1950)

Figure 10

Detail from a Seward Thackray Ltd catalogue showing two St Mark's retractors and Shucksmith's retractors (1955)

Down Brothers Ltd was another surgical instrument maker based at St Thomas's Street in London from 1874 until about 194812. Unfortunately, the firm was bombed out in the Second World War and, apart from a few temporary orthopaedic and ophthalmic catalogues, did not produce a full catalogue again until 1952–1955. In their 1955 catalogue, which is available at the Thackray Medical Museum, a ‘Lloyd‐Davies’ retractor is displayed (Fig. 11). This retractor has the exactly the same features and proportions as St Mark's retractors currently in use (Fig. 1).

Figure 11

Detail from a Down Bros. and Mayer & Phelps Ltd catalogue, showing a Lloyd‐Davies' retractor (1955)

It is likely that a few improvements have been made to the original design because there are slight differences between the 1950 drawing (Fig. 9), the instruments displayed in the 1955 Seward Thackray Ltd catalogues (Figs 10 and 11) and the current features of a St Mark's retractor (Fig. 1). First, the side of the ‘lugs’ or prominences on the handle changed. In the 1955 Seward Thackray catalogue, these lugs point in the same direction as the handle, like the Kelly retractor in Fig. 10. However, the Down catalogue shows that they have been replaced to the opposite side, as they are still today. The second alteration was the ‘lip’ that is available on the blade nowadays. This lip is not present on instruments in the Down or Thackray catalogues, although it seen on two ‘Thackray pattern’ instruments in the museum, which are thought to be from the 1960s–1970s. The concept of a lip at the end of a blade was already known, as demonstrated by the Shucksmith and Kelly retractors (Figs 10 and 11 respectively). The lip helps to lift tissues at the end of the instrument and could have been added to the original design for this reason. Finally, a decision was made to add a bend at the junction of the blade and the handle. As demonstrated in Fig. 1, the angle between the handle and the horizontal part of the blade increases with longer and lipped blades. The museum has two patterns demonstrating the changes in design. One of the patterns available (undated) has no bend or lip, has the lugs on the same side as the handle and is actually marked ‘Old pattern’. The second one has the bend, a lip, the changed position of the prominences and is marked as ‘Improved pattern with lipped blade and angled handle’ (Fig. 12). The latter must have been added after 1973 as it is marked with a new catalogue number style (51‐0327) that was introduced after computerization of the stock system in 1973. The mark on this instrument is ‘THACKRAY LEEDS SS’, which demonstrates a final alteration from using nickel steel to stainless steel. Hypothetically, all these alterations were implemented to increase visibility in the deep pelvis while improving ergonomics for the assistant holding the retractor for long periods of time (Fig. 2). Seward Thackray still has St Mark's retractors in their catalogue, and their retractors are a part of the standard instrument tray currently used at St Mark's Hospital13.

Figure 12

St Mark's retractors in Thackray Medical Museum Upper image: retractor marked with ‘Old pattern’ (undated); lower image: retractor marked with ‘Improved pattern with lipped blade and angled handle’ (dated after 1973).

Mr Oswald Vaughan Lloyd‐Davies

Oswald Vaughan Lloyd‐Davies (1905–1987) started working as an assistant surgeon to St Mark's Hospital in 1935 (Fig. 13). In 1946, the Medical Committee appointed him ‘full surgeon’. During his career he published nine articles that can be found on Pubmed, of which the abovementioned paper on positioning of the patient during APR is the best known. His main interest was rectal cancer but he also published articles on diverticulitis and liver resections. Unfortunately, none of his publications mention the use of retractors. However, Mr Lloyd‐Davies is often acknowledged to have developed and perfected many of the instruments used in colorectal surgery today14. His obituary in the Lancet 15 stated that: ‘…he was an original and inventive man who constantly thought about technical improvements. He designed and introduced a proximal‐light sigmoidoscope of small diameter…and the introduction of other instruments for abdominal and perineal surgery, which are now in routine use in this country and in much of the world’. From his 1939 article, it is clear that A. L. Hawkins & Company worked with Mr Lloyd‐Davies to develop surgical instruments, making it conceivable that they or Seward Thackray Ltd could have collaborated in creating a new retractor as well. Moreover, Down Brothers Ltd had a retractor displayed in their 1955 catalogue that was called ‘Lloyd‐Davies’ retractor', which is identical to the St Mark's retractor except for the lip (Fig. 11).

Figure 13

Oswald Vaughan Lloyd‐Davies (1905–1987) Available at

In 1939, Lloyd‐Davies married Menna Morgan. Their son Edward Lloyd‐Davies also became a surgeon and worked with his father on several occasions in the 1970s. Mr Edward Lloyd‐Davies has suggested that the St Mark's retractor was devised by his father alongside other specialist colorectal instruments, such as the Lloyd‐Davies' sigmoidoscope, a specific long artery forceps, the Lloyd‐Davies' scissors, an enterotome and, of course, the leg supports. He remembers his father as a very innovative surgeon and fastidious technician. He also remarked on Lloyd‐Davies always being keen for St Mark's to take credit for the instruments he devised rather than making a personal claim.

Conclusion

As in Sherlock Holmes' mysteries, several indirect clues and hints can lead to a plausible answer. In this case, the known collaboration with surgical instrument maker A. L. Hawkins & Company Limited, the information available at the Thackray Medical Museum on the development of the instrument, the resemblance between in the 1955 Lloyd‐Davies' retractor from the Down Brothers' catalogue, and his innovation and creation of several other surgical instruments, are quite convincing. Mr Oswald Vaughan Lloyd‐Davies should most likely be acknowledged for the development of the St Mark's retractor among many other surgical instruments and techniques essential in current rectal surgery. Mr Lloyd‐Davies probably devised the instrument in the 1940s. It was most likely adopted as standard by St Mark's Hospital in the early 1950s and took the hospital's name, as was in Lloyd‐Davies' modest nature. In spite of the development of many minimally invasive procedures, the St Mark's retractor is present in operating rooms all over the world. Surgeons often still find refuge in the St Mark's retractor, especially during difficult moments in pelvic surgery. Mr Lloyd‐Davies succeeded in his wish to credit his hospital; however, with this article the authors wish to acknowledge him for his valuable contributions to colorectal surgery.