A Quasi-experimental Study of Optimized Retractor Management on the Incidence of Femoral Nerve Injury Following Gynecological Surgery.

Background Femoral neuropathy is a significant postoperative complication in gynecological surgery that can severely impact patient mobility and quality of life. Among various mechanisms of nerve injury, retractor-induced compression against the pelvic sidewall has been identified as a particularly crucial causative factor. Despite this well-recognized mechanism and its clinical importance, few studies have investigated specific preventive strategies for this iatrogenic complication. Objective This study aimed to evaluate the effectiveness of standardized modifications in retractor management protocols for reducing the incidence of retractor-associated femoral nerve injury following gynecological surgery for benign tumors. Methods This single-center quasi-experimental study compared two consecutive cohorts of patients undergoing gynecological surgery for benign tumors between February 2018 and July 2019. Women aged ≥20 years who received combined general and epidural anesthesia were eligible. The study consisted of two phases: an eight-month pre-intervention phase evaluating femoral nerve injury incidence under conventional retractor management (n = 107), followed by a 10-month post-intervention phase (n = 108) assessing the impact of three standardized protocol modifications, i.e., optimization of a hand-held retractor insertion depth, mandatory 30-minute intervals for retractor release, and conversion to non-metallic self-retaining abdominal wall retraction systems. Results Implementation of modified retractor management protocols resulted in a significant reduction in the incidence of femoral nerve injury from 6.5% (7/107 patients) to 0.9% (1/108 patients) (P = 0.035), with an odds ratio of 0.134 (95% CI: 0.012-0.807). All cases presented with unilateral neurological deficits confined to femoral and lateral femoral cutaneous nerve distributions, manifesting as quadriceps and iliopsoas muscle weakness with associated sensory disturbances. Complete neurological recovery was achieved in all cases within one to 12 months (mean duration: 5.5 ± 3.9 months). Conclusions This study demonstrates that implementing standardized modifications in retractor management protocols significantly reduces the risk of femoral nerve injury following gynecological surgery for benign tumors. The combination of optimized retractor depth, standardized release intervals, and non-metallic retraction systems provides a practical and effective approach to preventing this significant surgical complication. Future studies incorporating quantitative measures of retractor positioning and pressure may help establish standardized guidelines for optimal retractor management.