Photo © ECPAD,2016 / https://www.defense.gouv.fr/sante/rejoindre-service-sante-armees
The emphasis placed on Damage Control Surgery (DCS) techniques, – which consist of emergency surgical interventions aimed at stabilizing the wounded when definitive surgery would exceed physiological limits -, has highlighted the need for specialized instruments capable of acting quickly in extreme conditions.
This is particularly the case for self-retaining retractors, which reproduce the movement of hand-held retractors and offer better visibility, such as the new American system recently developed by the Texas company Advanced Surgical Retractor Systems. A comprehensive study funded by the U.S. Department of Defense has just identified the TITAN CSR® retractor as the most effective surgical retraction tool for military medical teams deployed on the front lines (1)
Introduced at the Military Health System Research Symposium 2025, this research represents a major advancement in field surgical capabilities and illustrates the constant evolution of military medical technologies on a global scale.
Entitled “Comparison of Self-Retaining Retractor Systems for Use in Forward-Deployed Surgical Teams,” the study evaluated several commercially available systems — notably the TITAN CSR®, Bookwalter®, Alexis™, and Balfour — according to criteria such as exposure quality, ease of use, portability, and adaptation to damage control surgery in austere environments.
The TITAN CSR® distinguished itself due to the following advantages:
• Optimized surgical exposure: it provided the best exposure among all tested retractors, measured by the visible surface area of the abdominal cavity.
• Rapid deployment: it can be assembled and positioned more quickly than certain existing systems that require table fixation and numerous components. This speed constitutes a crucial advantage in combat contexts, where every minute gained in controlling hemorrhages can save lives.
• Modular design: made of high-strength titanium and weighing barely 1 kilogram (exactly 998 grams), the TITAN CSR® is characterized by a modular design that assembles in less than one minute.
Such an evolution corresponds to the needs of the 21st-century battlefield, characterized by the necessity of providing maximum care on-site, often under unpredictable security conditions, and without the ability to rely on airborne evacuations as was the case during the previous decades’ overseas operations. These medical evacuations allowed action within the “first hour” — the famous “Golden Hour” — and saved many lives (2).
This return to maximum forward medicalization also corresponds to the needs in major crisis situations, with lessons learned directly applicable to disaster medicine and civil security professionals.
Generally speaking, evolutions in this field and the emergence of new surgical retraction concepts pave the way for next-generation integrated systems. These innovations include rapid-deployment modular retractors, devices compatible with telesurgery techniques, adaptive instruments according to pathology, as well as growing integration with imaging systems.
The future of surgical retractors is indeed part of a technological convergence dynamic, driven by artificial intelligence (AI) and adaptive systems. We are thus moving toward robotic devices capable of positioning themselves automatically, AI algorithms optimizing retraction according to patient morphology, as well as close integration with surgical navigation systems. Augmented reality should eventually complement this arsenal by offering precise assistance for intraoperative positioning.
In parallel, advanced materials and nanotechnologies open new perspectives, notably with the development of active surfaces with antimicrobial properties and self-repairing materials, reinforcing both safety and durability of tomorrow’s surgical devices. Research particularly focuses on lightweight and biocompatible composites, non-stick coatings facilitating sterilization, and single-use systems designed to reduce cross-contamination risks and improve patient safety.
One should however keep in mind that no system will ever replace human expertise and cannot compensate for structural inadequacies of rescue sites in war zones or during major events.
The limitations drawn from ICRC (International Committee of the Red Cross (3)) war surgery manuals and publications on surgery in degraded environments emphasize the prevalence of technical and logistical risks in any use of advanced devices in the field, including the necessity to prioritize training and be aware of potential logistical failures, not to mention septic risks and complications specific to this type of intervention under extreme conditions, regardless of the quality of technological innovations.
By Murielle Delaporte
Notes
(1) https://www.prnewswire.com/news-releases/us-military-study-identifies-titan-csr-retractor-as-top-surgical-retractor-for-deployed-trauma-care-302527038.html
(2) See for instance on this issue articles published in Opérationnels SLDS, such as: https://operationnels.com/wp-content/uploads/2020/05/SLD-4-dossier-soutien-sante-en-Afghanistan-de-lheure-Gold-a-la-minute-Platine.pdf ; https://operationnels.com/2014/05/11/au-coeur-du-metier-de-militaire-au-coeur-du-metier-de-medecin-la-chaine-soutien-sante-pamir-du-sc1-au-role-3-de-kaia/
(3) See for instance : https://www.icrc.org/sites/default/files/external/doc/fr/assets/files/other/icrc_001_0973.pdf