The young Marine was brought into the operating room missing both legs and an arm, and fragments from an explosive device had penetrated his intestines, kidney, liver, and stomach. He had already lost a lot of blood. 

The surgeon, Dr. Ramon Cestero, worked fast to stabilize him, but it had taken too long. The Marine died soon after being transferred to the next level of care. 

The conditions under which trauma surgeons work in a modern San Antonio hospital are a far cry from the poorly lit, hot and dusty tents on a battlefield such as the one in Fallujah, Iraq, where Cestero raced against time to stop bleeding and save a service member’s life. 

But for Cestero, a 20-year Navy veteran, those experiences during three deployments to combat zones inspired him to develop a potentially life-saving device that improves the odds for surgeons and patients both in battle and back home. 

Cestero joined the military after medical school, while still in residency. He saw it as a way to use his skills where they were needed most. 

“Through each of my deployments, I was just impressed by the severity of these injuries and the ability for us to save many of these soldiers and Marines that are really going out there and putting their life on the line for us and our values,” he said. “I always found it to be very rewarding to be out there, even though there’s personal risk involved.”

There were also greater challenges to cope with than there are in civilian hospitals. “What we do on the battlefield is not too dissimilar from what we do here — it’s just a different set of injuries,” Cestero said. But when it comes to equipment, “we are just more limited on the battlefield. That experience just really magnified all the challenges that we have as trauma surgeons.” 

LCDR Ramon Cestero, of San Diego, CA treats an infected head wound on this Indonesian man while on missions with the United Nations World Health Organization in Indonesia on January 16, 2005.
LCDR Ramon Cestero treats an infected head wound on an Indonesian man while on missions with the United Nations World Health Organization in Indonesia on January 16, 2005. Credit: Photographer's Mate 3rd Class Tyler J. Clements / U.S. Navy

Cestero is now a trauma surgeon and professor of trauma surgery at UT Health San Antonio. The device he invented is a new kind of retractor, a tool doctors use during surgery to prop open a patient’s abdomen in order to repair internal injuries and stop bleeding that threatens the patient’s life. 

There are two basic types of retractors used for abdominal surgery. One is a large, complicated device that works well to expose the workspace in a body but requires attachment to a table and takes time to set up — not ideal in emergency situations. The other is a portable device, designed a century ago, that ratchets open quickly but provides limited visibility. 

“In a patient who might be bleeding and dying, you just don’t have the luxury of this time,” Cestero said. “Surgeons have to sacrifice either speed or exposure in selecting what retractors you are going to use.” 

Every time he returned from a deployment, Cestero told himself someone needs to make a better retractor to improve the military trauma surgeon’s ability to do the job. “But every civilian trauma surgeon would also benefit from that,” he said. 

In fact, most major advances in civilian trauma care came out of the military and various wars, he said. “Through each of those conflicts, we in trauma surgery have learned from those and adapted those lessons to the civilian setting.”

Wanting a tool that would combine the best qualities of existing retractors, Cestero developed a retractor that’s already been credited with saving at least one life. 

In partnership with an engineer and the Office of Technology Commercialization at UT Health San Antonio, Cestero built the retractor and founded a company, ASR Systems, to further develop and commercialize the TITAN Cestero Surgical Retractor (CSR). 

Since forming the company, led by Mike Girouard as president and CEO, they have raised $2 million in funding from private investors, including surgeons and venture capitalists, to develop more prototypes and prepare to take the CSR to market. 

Girouard said it’s common for military surgeons to find solutions to problems they encounter. “When you’re deployed like that, you’re always innovating,” he said. “It’s like, OK, I’m in a tent, I’ve got this equipment — how do I make it work?”

An inventor himself and longtime leader in medical device development, Girouard said he’s worked with other doctors for decades, but no one like Cestero. “He is focused. He makes things happen. He is always thinking. He’s got great ideas,” he said.

Dr. Ramon Cestero holds up his invention, the TITAN Cestero Surgical Retractor (CSR). The surgeon built it the device in partnership with an engineer and the Office of Technology Commercialization at UT Health San Antonio.
Dr. Ramon Cestero holds up his invention, the TITAN Cestero Surgical Retractor (CSR). The surgeon built the device in partnership with an engineer and the Office of Technology Commercialization at UT Health San Antonio. Credit: Courtesy / Dr. Ramon Cestero

Surgeons working to help a car crash victim with multiple broken bones and severe internal bleeding were the first to use the CSR. 

“The retractor helped us get in there quickly to assess the bleeding sources and control them, so we could stop the bleeding and get him to the ICU for further resuscitation,” Cestero said. 

Once the patient was stabilized and his blood pressure returned to normal, he was moved to the intensive care unit. En route, he flatlined. 

Working fast, the surgical team again used the CSR to open the man’s abdomen and control the bleeding. The patient survived, Cestero said. “He’s doing great. He’s back home.” 

Cestero’s invention is still being tested in hospitals, and recently began trials at Brooke Army Medical Center (BAMC) and the Shock Trauma Center in Baltimore. The Naval Medical Research Unit-San Antonio at BAMC and the 59th Medical Wing of the Air Force have signed cooperative research and development agreements to develop the retractor for other kinds of surgeries, Girouard said.

The first prototype of the CSR is focused on trauma and emergency general surgery, but future iterations could be used for surgeries on the spine or head and neck.

“The biggest satisfaction for me is that other surgeons say that it has helped them — because that’s why I designed it — to ultimately save patients,” Cestero said. “But to do that, it’s by a surgeon being more effective … being able to do their job better and faster.”

Shari Biediger

Shari Biediger is the development beat reporter for the San Antonio Report.