Johnson & Johnson DePuy Synthes INSIGHT Lateral Access System User manual

Surgical Technique
Minimal Invasive Access System for the Thoracolumbar Spine
INSIGHT™ Lateral
Access System

Image intensifier control
This description alone does not provide sufficient background for direct use
of DePuy Synthes products. Instruction by a surgeon experienced in handling
these products is highly recommended.
Processing, Reprocessing, Care and Maintenance
For general guidelines, function control and dismantling of multi-part
instruments, as well as processing guidelines for implants, please contact your
local sales representative or refer to:
http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance
For general information about reprocessing, care and maintenance of Synthes
reusable devices, instrument trays and cases, as well as processing of Synthes
non-sterile implants, please consult the Important Information leaflet
(SE_023827) or refer to:
http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance

INSIGHT Lateral Access System Surgical Technique DePuy Synthes 1
Introduction INSIGHT™ Lateral Access System 2
Description of Retractor Parts 4
AO Spine Principles 5
Indications and Contraindications 6
Surgical Technique Preparation 7
Access and Exposure 9
Retraction 14
Accessories 25
Removal 32
Product Information Cleaning Positions/Assembly 36
Instruments 44
Instruments for Neuromonitoring 48
Trays and Vario Cases 49
Bibliography 50
Table of Contents

2 DePuy Synthes INSIGHT Lateral Access System Surgical Technique
INSIGHT™ Lateral Access System
The INSIGHT™ Lateral Access System is a comprehensive
modular system designed to support the minimal inva-
sive approach to the spine.
X-Ray Visibility:
• Key parts are semi radiolucent (alumi-
num) for  uoroscopic visualization
• Radiolucent carbon fi ber handles
to avoid interference during anterior/
posterior  uoroscopy
Low Profile Accessories:
• In blade embedded accessories designed
to enhance surgeon view
• Winglets to provide further 7 mm
anterior/posterior soft tissue retraction
• Blade extensions to provide additional
10 mm of blade length in situ
• Disc anchor blade designed to increase
retractor stability

INSIGHT Lateral Access System Surgical Technique DePuy Synthes 3
Retractor Blades:
• Click-on blades for
quick assembly
• Blade length 40 to
180 mm
Independent Angulation:
Individual left and right blade
angulation up to 20°
Seamless Retraction:
Speed nut designed
for quick and fi ne
adjustment of
retractor opening
up to 70 mm
Different Retraction Techniques:
Various fi xation points to strong arm
system are designed to enable surgeon
preferred technique:
• Backward retraction of third blade
(fi xation to retractor body)
• Forward retraction of left-right blades
(fi xation to third blade holder)
Light System:
• Light accessory to illumi-
nate the surgical fi eld
• Disposable light with ad-
justable depth

4 DePuy Synthes INSIGHT Lateral Access System Surgical Technique
Description of Retractor Parts
Attachment point for connector for
Strong Arm for forward retraction
Attachment point for connector for
Strong Arm for backward retraction
Speed nut
RETRACT nut
PUSH button
Third blade holder
Left blade holder
Left and right
blade
Right
blade
holder
Angulation nuts
Accessory
grooves
Light
slot

coronal
axial
sagittal
1Aebi et al (1998)
2Aebi et al (2007)
INSIGHT Lateral Access System Surgical Technique DePuy Synthes 5
The four principles to be considered as the foundation for
proper spine patient management underpin the design
and delivery of the Curriculum: Stability – Alignment–
Biology – Function.1,2
AO Spine Principles
Stability
Stabilization to achieve
a specifi c therapeutic out-
come
Biology
Etiology, pathogenesis,
neural protection,
and tissue healing
Copyright © 2012 by AOSpine
Alignment
Balancing the spine in
three dimensions
Function
Preservations and resto-
ration of function to pre-
vent disability

6 DePuy Synthes INSIGHT Lateral Access System Surgical Technique
Indications and Contraindications
Intended Purpose
The INSIGHT Lateral Access System is a surgical access
system intended to provide a minimally invasive ap-
proach to the thoracolumbar spine. It is designed for
needs of various indications and/or surgical techniques.
Indications and Contraindications
In case the INSIGHT Lateral Access System is used in
combination with implants or instruments, please refer
to the respective surgical techniques for indications and
contraindications and additional surgical steps.

1
INSIGHT Lateral Access System Surgical Technique DePuy Synthes 7
Preparation
1. Patient Positioning
Instruments
03.662.028S Electrode Kit for Neuromonitoring
03.809.942 Table Clamp for Universal Arm
03.816.800 Strong Arm
or
03.809.941 Universal Arm
For the lateral approach, the patient is placed and taped
in the lateral decubitus position as illustrated (1).
Note: Ensure that the position of the operative level
is perpendicular to the oor for easier orientation of
uoroscopy and approach by conrming:
• In lateral uoroscopy, the endplates are parallel
with superimposed pedicles.
• In A/P uoroscopy, the endplates are parallel, the
pedicles reside in the cranial portion of the verte-
bral body and the spinous process is equidistant
to both pedicles.
For further information, please refer to the dedicated
implant surgical techniques. If neuromonitoring is being
used, refer to the respective neuromonitoring surgical
technique.
Precaution: A thorough education and a compre-
hensive understanding of the respective anatomy
as well as practical experience in performing
the lateral approach to the thoracolumbar spine
is a prerequisite for use of this system.

2
8 DePuy Synthes INSIGHT Lateral Access System Surgical Technique
2. Set Up Strong Arm System
Install table clamp onto the preferred side of the operat-
ing table by loosening it and attaching it onto the table
rail. Insert the strong arm or universal arm with at side
facing away from the table (2). Secure table clamp by
tightening it.
Precaution: Ensure that the rotation of the strong
arm or universal arm is securely locked by the
table clamp.
Preparation

1
2
INSIGHT Lateral Access System Surgical Technique DePuy Synthes 9
1. Approach the Spine
Locate and mark the correct operative level and asso-
ciated incision site under lateral uoroscopy and make a
skin incision. Incision should be large enough to accom-
modate the retractor and subsequent retraction. Retract
the subcutaneous tissue and bluntly dissect through the
abdominal muscle layers and incise the transversalis
fascia to enter the retroperitoneal space (1). Move the
peritoneum anterior with forefinger and continue with
blunt dissection to gently palpate down to the psoas by
following the anterior border of the quadratus lumbo-
rum(2).
Before puncturing the psoas, uoroscopy is recom-
mended to ensure targeting the area of interest of
the affected disc space. The anterior third of the psoas
muscle is the most likely safe zone for avoiding the
neural elements of the lumbar plexus.3
Access and Exposure
3Moro et al (2003)

1
10 DePuy Synthes INSIGHT Lateral Access System Surgical Technique
2. Neuromonitoring
Instruments
03.662.027S Neuromonitoring Stimulation Probe
03.662.028S Electrode Kit for Neuromonitoring
03.662.029 Handle for Neuromonitoring
Stimulation Probe
or
02.809.002 Kirschner Wire 3.0 mm with blunt
tip, length 285 mm, Stainless Steel
In order to avoid neural structures it is recommended
to use triggered EMG neuromonitoring (detection of
motoric nerves). Additionally use direct visual control
(detection of sensoric nerves).
Note: With the eccentric dilation technique the
retractor will be positioned a maximum of 8 mm
off-center.
Map out a safe corridor through the psoas muscle to
the operating level by stimulating with the neuromoni-
toring probe (1). Once achieved, continue to perform a
blunt dissection of the psoas muscle under direct visual
control.
Access and Exposure

2
INSIGHT Lateral Access System Surgical Technique DePuy Synthes 11
Precaution: In addition, lateral and AP uoroscopy
should be utilized to place the neuromonitoring
probe/Kirschner Wire through the psoas and into
the annulus of the desired intervertebral disc
space (2).
In case no neuromonitoring is used, the 3.0 mm
Kirschner Wire can be utilized.
Precaution: Ensure the neuromonitoring probe or
Kirschner Wire remains securely in position until
the retractor is in place by having it sufciently
anchored in the disc space.
For further information, please refer to the dedicated
implant surgical techniques and to the respective neuro-
monitoring surgical technique.

1
12 DePuy Synthes INSIGHT Lateral Access System Surgical Technique
3. Insert Dilators
Instruments
03.816.806 Dilator, 6 mm, eccentric, small,
for INSIGHT Lateral Access System
03.816.810 Dilator, 10 mm, eccentric, medium,
for INSIGHT Lateral Access System
03.816.816 Dilator, 16 mm, eccentric, large,
for INSIGHT Lateral Access System
03.662.027S Neuromonitoring Stimulation Probe
or
02.809.002 Kirschner Wire 3.0 mm with blunt tip,
length 285 mm, Stainless Steel
The eccentric dilators allow for dilation away from any
sensitive structures (e.g. posterior nerves). Slide the small
dilator (rounded tip first) over the neuromonitoring
probe or Kirschner Wire in the orientation of preferred
direction of dilation. Continue with the remaining two
dilators with the groove for the stimulation probe facing
the preferred direction of dilation (midline or eccen-
tric(1)).
Precaution: Use uoroscopy (lateral and AP) to de-
termine location of dilators. Also ensure that dila-
tors rest rmly against the vertebral body wall in
order to determine an accurate skin depth measure-
ment. Keep downward pressure on the dilators until
the strong arm or universal arm has been xed to
the retractor.
Access and Exposure

2 3
INSIGHT Lateral Access System Surgical Technique DePuy Synthes 13
A second stimulation probe can be placed in the dilator
groove in order to check on surrounding nerve struc-
tures (2). By turning the outermost dilator with a second
probe in place, surrounding tissue can be monitored for
presence of motoric nervous structures (3).
Precaution: Do not stimulate against any instru-
ments in the surgical eld.
Determine the appropriate retractor blade length from
the markings on the dilators and round up to the next
available blade length.
Note: When determining the blade length, consider
the surrounding anatomy (iliac crest, ribs etc).

2
11
14 DePuy Synthes INSIGHT Lateral Access System Surgical Technique
1. Preparation
Instruments
03.816.001 Retractor Body
03.816.010 Screwdriver, for INSIGHT Lateral Access
System
03.816.002 Blade Holder, left, for No. 03.816.001
03.816.003 Blade Holder, right,
for No. 03.816.001
03.816.004 Third Blade Holder,
for No. 03.816.001
03.816.040– Blade, length 40–180 mm
03.816.180 (in 10 mm increments)
Assemble the retractor by attaching the blade holders
to the retractor body (see chapter “Cleaning Positions /
Assembly” p. 37).
Open the retractor by compressing the handles and turn-
ing the speed nut (1) and attach the appropriate blades
((2) top loading click-on connection).
If a disc anchor will be used, a disc anchor blade of cor-
responding length should be attached to the third blade
holder (see chapter “Accessories, Additional Stability”
instruction p. 28).
Note: The disc anchor blade can only be attached to
the third blade holder.
Retraction

1
2
2
2
3
INSIGHT Lateral Access System Surgical Technique DePuy Synthes 15
Place Retractor In Zero Position:
Close the retractor by releasing speed nut (1). Return
angulation of left and right blades to the zero position
by turning the angulation nuts with the Screwdriver for
INSIGHT Lateral Access System accordingly (2). Set the
third blade to zero position by pushing the PUSH button
and/or turning the RETRACT nut in the appropriate di-
rection at the same time (3) until the “0” on the third
blade aligns with the “0” on the retractor body.

1
16 DePuy Synthes INSIGHT Lateral Access System Surgical Technique
Retraction
Attach Connector
Instruments
03.816.801 Connector, for Strong Arm
No.03.816.800
03.816.010 Screwdriver, for INSIGHT Lateral Access
System
Optional
03.816.019 Wrench, for INSIGHT Lateral Access
System
Attach connector to the respective point on the retractor
(A or B, see next page) and tighten with the Screwdriver
or wrench depending on tightening preference (1). The
connector can only be attached in the illustrated posi-
tions and orientations (from the left and right side) to
avoid subsequent conict with angulation mechanism.
For the role of the different attachment options, see
next page.

A
B
INSIGHT Lateral Access System Surgical Technique DePuy Synthes 17
Forward/Backward Retraction Options
Retract Forward
If forward retraction is desired (A), attach the connector
to the third blade holder connection point.
Subsequent clockwise rotation of the RETRACT nut
results in forward retraction of the retractor body (with
left and right blade holders) relative to the fixed third
blade holder.
or
Retract Backward
If backward retraction is desired (B), attach the connec-
tor to either one of the attachment points on the
retractor body.
Subsequent clockwise rotation of the RETRACT nut
results in backward retraction of the third blade holder
relative to a fixed retractor body (with left and right
blade holder).
Precaution: Do not place any accessories before
retraction.

90°
1
2
18 DePuy Synthes INSIGHT Lateral Access System Surgical Technique
2. Slide Retractor over the Dilators
Use uoroscopic imaging to determine the position of
the dilators (1). Slide the retractor with the blades and
connector attached over the dilators.
Note: The handles of the retractor can be placed
either anterior or posterior depending on surgeons
preference.
Retraction
Use uoroscopic imaging to determine the position of
the retractor. Retractor blades should rest against the
disc space and/or vertebral endplates in a perpendicular
orientation to the disc space (2). Maintain the dilators
and retractor in place until the strong arm or universal
arm has been fixed to the retractor.