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Retractors and Principles of Exposure
Tim Gessmann, Markus Schäfer
Principles of Surgical Exposure
Adequate exposure of the target organ represents a laudable prerequisite of every successful operation. erefore, it is worthwhile to be equipped with dierent retractors and to invest enough
time intraoperatively to optimize exposure. Basic principles of exposure have been challenged recently by the advent of minimally invasive surgery. However, minimally invasive surgery has only
changed the means of surgical access; the procedures performed at the target organs remain largely
unchanged. In contrast to open surgery, exposure during laparoscopy is achieved predominantly
by patient position and trocar placement. Retractor systems are less important.
Retractor Systems
In general, a retractor system needs to full the following requirements for an ideal surgical
exposure:
Broad, unrestricted view into the abdominal cavity
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Wide access to the target organ
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Illumination provided or available if needed
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Stable retraction of the abdominal wall and surrounding organs
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Careful tissue retraction, preventing local ischemia
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Freeing up the hands of the surgeon and assistants
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Adaptability in usage (e. g., dierent patients, dierent incisions)
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Various type of accessories to retract the abdominal wall and organs
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Hand-held retractors have the main disadvantage of losing “free hands” of the surgical team. Selfretaining retractors are used most commonly to keep open the abdominal and thoracic cavity.
Two types of self-retaining retractors are available:
1. Closed ring retractors:
Ring system retractors are self-stabilizing by the retaining force of the dierent retracting devices
and do not necessarily need to be xed to the operating table (e. g., Kirschner,
several types can be xed to the table. e best exposure is achieved by placing one retracting
device strictly opposite to the other. In some systems, stabilization and exposure can further be
improved by attaching the ring to the operating table by a rail arm.
2. Arm retractors:
Arm retractors need to be xed to the operating table. ey allow for an asymmetric exposure
(e. g; ompson,
. Fig. 3.1b).
. Fig. 3.1a)
although
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_3, © Springer-Verlag Berlin Heidelberg 2016
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Section I • General Principles
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. Fig.3.1
Overview of Different Self-Retaining Retractors
Thompson (
e basic components of this very stable retracting system are the rail arm, the two rods, and the
dierent retracting paddles that are attached to a retaining arm. e ompson retractor is favored
for uni- and bilateral subcostal incisions, which are oen used for hepatobiliary procedures, in
which most of the retraction required is oriented cephalic and anteriorly. e exposure of the lower
abdominal parts is limited. ere is a wide range of blades and paddles available as accessories.
Bookwalter (. Fig. 3.2b)
is system has a frame (closed ring) xed by a rail arm attached to the operating table. Dierent retracting accessories, such as blades and paddles, are available that can be clamped to the
frame. e Bookwalter retracting system is used for both longitudinal and transverse abdominal
incisions. Although some training is necessary to achieve a safe installation, ne adjustment is
possible in three dimensions. Cleaning and sterilization need substantial eort due to the rather
complex single components.
. Fig. 3.2a)
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Chapter • Retractors and Principles of Exposure
. Fig.3.2
Omnitract
Although this retractor system needs careful installation, it oers excellent access for most incisions. e open frame system can be utilized as easily as a closed ring. is retractor can be used
widely for intraperitoneal and retroperitoneal operations. Maintenance and cleaning are not too
elaborate. e gure shows longitudinal (
ing the Omnitract system.
. Fig. 3.3a) and transverse (. Fig. 3.3b) laparotomy us-
. Fig.3.3
Rochard
e Rochard retractor (not shown) is a single blade retractor that is mainly used for upper GI
surgery. A large semicircular blade retracts the abdominal wall, and is attached to a xed arm at
Section I • General Principles
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the operating table. e main disadvantages are the unidirectional tension and the lack of anterior
liing the abdominal wall.
Kirschner, Balfour, O’Sullivan-O’Conner (. Fig. 3.4)
e Kirschner frame (.
systems that do not need any form of rail arm. However, retraction is not as stable and tension in
the vertical dimension is not possible. ey are rapidly usable, readily available, and are preferred
when only lateral exposure is desired.
Fig. 3.4a
) and the Balfour retractor (.
Fig. 3.4b
) are good examples of
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. Fig.3.4
Recommendation
Many factors and aspects inuence the choice of a specic retractor. Some commonly used retractors are compared in . Table 3.1. More than one type of retractor should be available to obtain the
best possible exposure of the dierent parts of the abdominal cavity.
. Table3.1 Comparison of Dierent Retractor Systems
System Construction Installation Adjustment Accessories Maintenance
Bookwalter Closing
ring + xation
Thompson Arm Complex Three dimen-
Omnitract Arm Complex Three dimen-
Rochard Arm Complex Tension only in
Kirschner Closing ring Quick Limited ++ Easy
Balfour Closing ring Quick Limited + Easy
Complex Three dimen-
sions
sions
sions
1 direction
+++ Elaborate
+++ Elaborate
+++ Elaborate
+ Elaborate
Chapter • Retractors and Principles of Exposure
Retractors in Laparoscopic Surgery
Whereas the abdominal wall is expanded anteriorly by the pneumoperitoneum, intra-abdominal
exposure to facilitate dierent aspects of the operation is achieved primarily by patient positioning
and trocar placement. ere are several devices that may be used to retract the liver during upper
GI operations, such as laparoscopic fundoplication, gastric bypass, or adrenalectomy (
. Fig. 3.5).
. Fig.3.5
Tricks of the Senior Surgeon
For optimal use, be familiar with several retractors and have a good knowledge of their indi-
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vidual advantages.
Slow, incremental retraction prevents rib fractures and postoperative pain.
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Intermittent release of the retraction during long-duration operations prevents local isch-
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emic complications.
Attention to the need for cranial retraction (exposure of esophagogastric junction) versus
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anterior retraction (for hepatectomy) will facilitate exposure.
Surgical Staplers
Christian E. Oberkofler, Antonio Nocito
Since the turn of the century, surgeons have been stimulated to develop devices to close o a hollow organ or to join two hollow organs. Early devices by the Hungarian surgeons Hültl and Petz
and later by the Germans Friedrich and Neuer were pioneering eorts. But the current prototypes
of mechanical staplers originated from Russia in the 1950s.
Linear and circular staplers were engineered to perform standardized surgical procedures safely
(e. g., gastrectomies and bowel resection). e American surgeons Ravitch and Steichen subsequently
brought these devices to the United States in the 1960s and focused on their improvement in terms of
applicability and reliability. In collaboration with industry, preloaded plastic cartridges with doublestaggered staple lines of dierent lengths were developed. In the mid-1970s, the rst single-use stapling
devices were developed and subsequently spread worldwide. Recently, mechanical staplers are used
increasingly for closure of large vessels (vascular staplers), especially during laparoscopic surgery.
Types of Mechanical Staplers
Modern surgical staplers are disposable, made of plastic, and loaded using disposable cartridges.
ere are currently two major types of mechanical stapling devices in clinical use for open and
laparoscopic surgery: linear and circular staplers.
e principles and prerequisites of mechanical stapling remain largely unchanged:
Principles of mechanical stapling
Tissue compression
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Tissue stapling using metallic wire as staples
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Conguration of the closed staples in the shape of a “B”
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Staggered positioning of the staple lines
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Aims of surgical stapling
Creating an adequate lumen
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Preserving adequate tissue vascularization
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Preventing tension of adapting tissues
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Avoiding leakage and stula formation
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Providing good hemostasis
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Ensuring mechanical reliability/uniformity of stapling devices
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Linear stapler
Two basic types of linear stapling devices exist: devices with and without an integrated scalpel.
Devices with an integrated scalpel re two (open surgery staples) or three (laparoscopic staples)
staggered lines of staples on both the patient and the resected tissue side, with the scalpel cutting
through the tissue in between. e stapling device without an integrated scalpel res two stapler
with no transection of the tissue between the staple lines.
Linear stapling devices are applied in open and in laparoscopic surgery and are available as
mono- and multiple-use instruments (.
hollow organs. Depending on the purpose, dierent stapler cartridges ranging from 30–90 mm of
length are available, as well as staples ranging in height from 3.5–4.8 mm before being red and
assuming the B shape.
Figs. 4.1 and 4.2
). ey are used to close partially or totally
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_4, © Springer-Verlag Berlin Heidelberg 2016
Section I • General Principles
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For closure of arteries and veins, three stapler lines are staggered. e staples used are 2.5 mm
in size.
. Fig.4.1
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. Fig.4.2
Circular stapler
Circular stapling devices re two staggered circular lines of staples (. Fig. 4.3). Aer “ring” the
stapler, an integrated circular scalpel resects overlaying tissue as “rings” or “donuts” of tissue and
creates a circular anastomosis. Circular stapling devices are applied in general surgery as well as
in thoracic and colorectal surgery. ey are used for end-to-end anastomosis aer bowel resection
or in esophagogastric surgery.
Using circular staplers, a “tobacco pouches seam” or “purse string suture” is mandatory to
approximate the intestinal lumen close to the anvil or device.
Diameters between 21–34 mm are available, whereas staple length is usually 5.5 mm in size,
but can also vary with the thickness of the tissues.
Chapter • Surgical Staplers
Circular staplers for vascular anastomosis were developed in the 1960s and 1970s but never
had a signicant impact on the standard hand-suture technique and are not used today.
. Table4.1 Approved Indications for Use of Staplers in Gastrointestinal Surgery
Organ area Application
Oesophagus Resection of or incorporation of a Zenker diverticulum
Small bowel Resection of Meckel diverticulum or the appendix
Stomach Closure of the stomach
Colon/rectum Deep colorectal, coloanal, and ileoanal anastomosis partly in “double-stapling
Gastric tube formation
Intrathoracic esophagogastrostomy
Closure of the duodenal stump
Esophagojejunostomy intraabdominal and intramediastinal
Formation of a jejunum or ileal pouch
technique”
Formation of an ileal pouch
Formation of a colonic pouch
. Fig.4.3
Types of Staples
Current staples assume the shape of the letter “B” (. Fig. 4.4). is special shape guarantees hemostasis and permits the tissue edges to be supplied suciently by blood. is shape supports wound
healing and prevents necrosis. Absorbable and nonabsorbable staples are available. Note that the
dierent stapler companies have multiple dierent size of staplers according to tissue thickness
and whether a hollow viscous or a vascular vessel is being stapled; consult each manufacturer for
their recommendations.
. Fig.4.4
Section I • General Principles
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Currently, nonabsorbable staples are made of titanium, which have the following key benets:
Minimal artifacts in computed tomography (CT)
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Not magnetic and thus cause only minimal distortions in magnetic resonance imaging
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(MRI)
High resistance and lighter, than stainless steel
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Corrosion resistant
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Biocompatible; can be safely used in patients who suer from chromate-nickel allergy
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Absorbable staples are made of a copolymer (lactomer) and are broken down to glycol and lactic
acid and absorbed through hydrolysis. e copolymer still shows adequate tear resistance in tissue
14days aer deployment. eir absorption starts aer 4weeks and is completed aer 180days.
. Table4.2 Pros and Cons of Mechanical Stapling Devices
Pros
Less operating time
Less tissue manipulation
Less tissue trauma
Less tissue edema
Less risk of contamination and infection
Minimizes the time of open bowel
Treated organ gets closed rst then resected
Less blood loss compared with hand-made suturing
Less anesthesia time
Stapling devices often decrease the need of a protective stoma
Cons
Bleeding from the anastomosis into the lumen
More expensive than suture material
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Tricks of the Senior Surgeon
After ring the stapler, wait 20–30seconds to allow the tissue to be squeezed together which
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helps to prevent bleeding from the stapler lines
The anastomosis should never be under tension
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Before resecting tissue using a mechanical stapler, make sure to have an adequate blood sup-
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ply of the remaining tissue
Check every anastomosis for leak-tightness
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z Acknowledgments
We would like to acknowledge Nicolas Attigah and Markus Schäfer who were the authors of this
chapter in the rst edition of the Atlas.
Principles of Drainage
Henrik Petrowsky, Stefan Wildi
Drains are designated to evacuate intraperitoneal uid collections. ey can be used for diagnostic,
prophylactic, or therapeutic purposes. In upper gastrointestinal surgery, diagnostic drains are
placed to assess intraperitoneal uid collections in order to establish a diagnosis. ese drains are
seldom le in place for an extended duration and are, therefore, of minor importance. In contrast,
prophylactic drains placed at the end of an operation are used frequently with two intentions:
rst, to prevent uid accumulations which could be harmful (i. e., pancreatic juice or bile) or to
prevent or evacuate expected uid collections that can become infected and lead to the formation
of intra-abdominal abscesses; second, prophylactic drains may be used to detect early postoperative complications, such as intra-abdominal bleeding or anastomotic leakage. Sometimes, uid
collections become infected and develop into abscesses; the management of these collections
requires therapeutic drainage either by the percutaneous route or by reoperative surgical irrigation or postoperative lavage.
Types of Drains
Drains can be divided into passive and active drains.
Passive Drains
Passive drains (.
sively by providing a route of access secondary to the natural pressure gradients, such as gravity
ow, muscle contraction, and overow. e opening in the abdominal wall for these drains should
be made large enough, because passive drains are potentially collapsible. Easy Flow drains have
intraluminal corrugations to prevent complete collapse (inlay). Passive drains cannot be sealed
and are open systems with the potential risk of retrograde infections. e advantages and disadvantages of open and closed-suction drains are outlined in
Fig. 5.1
), such as the Penrose and Easy Flow devices, serve to evacuate uid pas-
. Table 5.1.
. Fig.5.1
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_5, © Springer-Verlag Berlin Heidelberg 2016