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6 Fundamentals ofRetractors andExposure
https://t.me/med1917
Fig. 6.2 Determining distance between working port and
operative eld
6.3 Retraction
It can be useful to consider three spaciotemporal
levels of retraction during a surgical case in order
to maintain ideal exposure at all times:
1. Large-scale eld exposure
On the largest scale is retraction that sets the
stage for the entire operative eld. This
includes factors that are set and may remain
unchanged for the duration of a case: patient
positioning, gravity retraction, and selfretaining retractors. While these elements of
exposure can be easy to “set and forget,” it is
important to consider adjusting them when
visualization or ergonomics are compromised.
It may be the case that various steps of a long
operation benet from subtle adjustments to
gravity and self-retaining retractors. These
adjustments can be worth the time when economy of motion subsequently improves.
2. Effective recruitment of the operative assistant
The second level of retraction is that offered
by the assistant; the assistant’s hand is providing retraction at a smaller and more mobile
scale than gravity or self-retaining retractors.
It is the job of the surgeon to offer the correct
instrument for the particular circumstance and
97
to demonstrate appropriate positioning and
tension. Over time, a good assistant will
achieve synergy with the surgeon, anticipating
the order of maneuvers and providing the correct exposure for each when needed.
3. Moment-by-moment use of the surgeon’s
nondominant hand
The third level of retraction is the moment-bymoment adjustments made by the operating
surgeon’s nondominant hand. The only thing
moving more than the surgeon’s nondominant
hand in the operative eld is the surgeon’s
dominant hand. Motion-tracking studies of
surgeons’ instruments have demonstrated
working-space volume, and path length of
instrument tips can differentiate novice from
expert surgeons [4]. The nondominant hand of
novices tends to move more than the dominant
hand, while the opposite is true of expert surgeons. Expert surgeons also operate in a volumetrically smaller space than novices. The
shift in the use of the nondominant hand
reects improved economy of motion—making the appropriate exposure adjustments only
when they are needed to improve performance
of the dominant hand.
6.3.1 Retractors
Many types of surgical retractors have been developed over time. Many of the traditional retractors
still in use today were developed alongside the
procedures they are intended to assist, with specic shapes designed to provide exposure for a
particular surgical maneuver. Both new materials
and new procedures have continued the pursuit of
designing the ideal tools to assist surgical exposure. This section will place various retractors
into general categories and describe their distinguishing characteristics. See Tables 6.1, 6.2, and
6.4 for lists and brief descriptions of handheld,
self-retaining, and laparoscopic retractors, respectively. Associated photographs are provided for
specic examples. Tables 6.3 and 6.5 provide
some retraction pearls for common open and laparoscopic procedures (Tables 6.4 and 6.5).
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M. B. Ujiki and H. MasonHedberg
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Table 6.1 Handheld retractors
Handheld
Name Description Figure
Richardson retractor Broad slightly saddled blade for body wall retraction
Green retractor An open-ended Richardson for visualization of retracted tissue
Kocher retractor Broad at blade with inward bent tip
RichardsonGoelet retractor Similar to but smaller than Richardson-Eastman
US Army retractor “Army-Navy” medium double ended with at, narrow blades
Mayo-Collins retractor Like US Army with forked blades
Mathieu retractor One end like US Army, one end like Mayo-Collins
Farabeuf retractor Similar to but smaller than US Army with at, solid handle
Roux retractor Farabeuf with saddle blades
Parker retractor Farabeuf with curved blades
Parker-Mott retractor Parker with one curved and one straight at blade
Little retractor Small, curved blade for ne, supercial retraction
Cushing vein retractor Small, saddle blade for gentle retraction of vein or nerve
Love nerve retractor Thin, long handle with small curved blade
Blair (Rollet) retractor Small, ne rake for supercial retraction of wound edge
Volkman retractor Larger Blair—rake with blunt or sharp teeth
Freeman facelift retractor A rake with sharp, widely spaced prongs in a curvilinear pattern
Ragnell retractor Small, double ended with narrow, perpendicular spatulas
Linde-Ragnell retractor Ragnell with rough surface for increased friction
Senn retractor Small, one end like Ragnell, one end like Blair
Davis retractor Larger Ragnell
Crile retractor Similar to Davis or Ragnell with proportionally wider blades
Jackson tracheal hook Provides vertical elevation of the trachea for emergent airway
Meyerding nger retractor One end like a Ragnell or Blair, other end with a nger-loop
Lahey retractor Single-ended US Army or Ragnell with solid handle
Langenbeck retractor Similar to a Lahey with a thinner, deeper blade
Skin hook Small, pair of hooks for supercial retraction, raising skin aps 6.4c
Deaver retractor Broad, at, and deep retractor with at handle 6.5
Kelly retractor Deaver-like blade with a formed handle
Harrington retractor “Sweetheart” heart-shaped end for deep, gentle retraction
Davidson retractor Broad, bent shape for scapula retraction 6.6a
Doyen retractor Large, saddle blade for pelvic exposure
Ribbon retractor “Malleable” bendable strip for customizable use
Eastman retractor Double-ended Richardson 6.3b
6.3a
6.3c
6.4a
6.4b
6.6b
6.7
Table 6.2 Self-retaining retractors
Self-retaining
Name Description Figure
Weitlaner retractor Opposing rakes with nger rings and ratchet-locking mechanism 6.8a
Gelpi retractor Opposing spikes with nger rings and ratchet-locking mechanism 6.8b
Beckman retractor A long Weitlaner with hinged ends 6.8c
Beckman- Weitlaner retractor A Weitlaner with hinged ends
Adson retractor A long Weitlaner with ends at a xed angle
Beckman- Eaton retractor A Beckman with broader rakes
Bookwalter retractor system Ring mounted to bed suspended over incision. Various retractors can be
Omni retractor system Adjustable arms mounted to bed positioned around incision. Various
positioned to provide sustained, opposing tension
retractors mount to arms to provide sustained tension
6 Fundamentals ofRetractors andExposure
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Table 6.2 (continued)
Self-retaining
Name Description Figure
Rultract Skyhook retractor
system
Lone star retractor Hooks with elastic tethers that can be stretched from a rm, circular
Balfour retractor A pair of deep, opposing retractors on rails to open a laparotomy, with a
Finochietto retractor “Rib spreader” opposing blades with rack-and-pinion mechanism
Wound protector Set of plastic rings separated by a thin, exible plastic cylinder
Positions an adjustable arm vertically over the operative eld to provide
tension with retractors of various types and sizes
scaffold to produce circumferential retraction
6.9
third retractor in between to apply perpendicular tension
6.10
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Table 6.3
Open procedures Wrong Right
Inguinal hernia Using a metal retractor to
Cholecystectomy Inadequate initial exposure
Laparotomy “Set and forget” self-retaining
Table 6.4
Laparoscopic
Name Description Figure
Hasson “S” retractor Thin curved blades to aid open entry initial trocar placement
Keith needle and suture Can be passed across the abdominal wall to elevate structures
Laparoscopic peanut Simple shaft with cotton fabric tip
Laparoscopic Deaver Retractable curved blade for blunt dissection and retraction
Fan retractor End of shaft has spreadable blades to form broad surface 6.11
Nathanson retractor Curved, rigid rod passed through abdominal wall, mounted to bed
Articulating retractors Rod with one to four joints that ex and lock. Can be inserted
Table 6.5 Retraction pearls for common laparoscopic procedures
Laparoscopic
procedures Wrong Right
Inguinal hernia Neglecting a full urinary
Cholecystectomy Inadequate manipulation of
Exploration Leaving the patient supine Take advantage of gravity retraction to minimize unnecessary
Retraction pearls for common open procedures
retract cord structures
leads to difculty as the
dissection proceeds deeper
into the abdomen
retractor technique
Laparoscopic retractors
through port and mounted to bed for self- retained retraction
bladder
gallbladder infundibulum
Using a soft retractor like a Penrose to prevent injuries
A self-retaining retractor system can be helpful to achieve
ideal exposure: right ribs elevated, Deaver or sweetheart to
retract the liver, colon inferior, and stomach medial. Packs can
be used to elevate segment IV and expose the porta hepatis
Self-retaining retractor systems should be adjusted as the
operation proceeds to provide ideal exposure in the operative
area and relieve pressure on tissues when possible
Bladder should be emptied prior to surgery to avoid trocar
injury and improve exposure
Infundibulum should be retracted toward the camera and
laterally for best exposure of biliary anatomy
tissue manipulation
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Fig. 6.3 Common
handheld retractors. (a)
Richardson, (b)
Richardson-Eastman, (c)
US Army
Fig. 6.4 Fine handheld
retractors. (a) Cushing
vein retractor, (b) Senn
retractor, (c) skin hook
a
b
c
a
b
Fig. 6.5 Various Deaver
retractors
c
ab
ab
6 Fundamentals ofRetractors andExposure
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Fig. 6.6 (a) Davidson scapula retractor, (b) Harrington
“sweetheart” retractor
Fig. 6.7 Various
malleable ribbon
retractors
101
c
Fig. 6.8 (a) Weitlaner
retractor, (b) Gelpi
retractor, (c) Beckman
retractor
102
ab
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Fig. 6.9 Self-retaining Balfour retractor
M. B. Ujiki and H. MasonHedberg
Fig. 6.10 Wound protector: This self-retaining retractor
is a set of plastic rings separated by a thin, exible plastic
cylinder (a). One ring is placed through the incision, and
Fig. 6.11 Laparoscopic
fan-style retractor
6.3.2 Handheld Retractors
the other is used to wrap and shorten the cylinder, which
opens the incision and isolates wound edges (b)
Retractor blades are rectangular, positioned at
a right angle to the handle. The intended use of
Handheld retractors are meant to be mobile and
easily repositionable. They are generally in the
hands of the surgical assistant, who should
change position in between maneuvers as appropriate to the procedure. All handheld retractors
have two basic commonalities: the working end
to manipulate tissue and the handle. They may be
double ended, with two working ends and a handle in the middle, to allow rapid exchange
between two types of working ends. Working
ends come in two major varieties: blades or rakes.
bladed retractors determines the shape and
height/width proportion of the blade. Blades
come in three shapes: at, curved, or saddled.
Retractors with at blades often come in two
varieties, with or without a slightly inwardly bent
distal tip that forms a lip to prevent retractor slip-
page. The US Army retractor (Fig.6.3c) is a very
common instrument that is manufactured both
with and without a distal lip. Curved retractors
conform to cylindrical structures for secure
retraction. Saddle-shaped blades are similar to
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curved but have a second curve opposite and perpendicular to the rst, like a hyperbolic paraboloid. This shape helps reduce tissue damage at the
edges of the retractor. The Richardson (Fig.6.3a)
is a familiar retractor utilizing this shape. The at
portion of the Richardson’s blade reects its
intended use against the abdominal wall, whereas
the Cushing vein retractor (Fig.6.4a) has no at
surface and is intended for gentle retraction of a
cylindrical structure.
The second type of retractor working end is
the rake. The individual prongs of rakes vary both
in number and sharpness. For example, Fig.6.4c
is of a skin hook, which is a small retractor with
two sharp prongs, intended to raise a thin, supercial layer to develop skin aps. The hooks allow
penetration and stable retraction of thin tissue
without distorting or concealing the wound edge.
The Senn retractor (Fig. 6.4b) features one end
with multiple, thicker prongs, which results in
less tissue penetration than the two hooks on the
skin hook. The number, distribution, and sharpness of the rake determine the application it is
best suited to.
6.3.3 Self-Retaining Retractors
Self-retaining retractors are appropriate for exposure that is expected to remain unchanged for
long periods of time or when the hands available
at the operating table are needed for more active
tasks than retraction. They fall into two major
categories: relatively small, self-contained instruments and large, table-mounted retraction
systems.
In order to provide retraction without xation
to the operating table, self-contained instruments
utilize opposing forces. One of the most familiar
examples is the Weitlaner (Fig.6.8a), which uses
nger loops and a ratchet mechanism to direct
two rakes away from each other. Two of these
instruments placed perpendicularly to each other
can provide excellent exposure through a small
wound, such as with open inguinal hernia repair.
Another example is the Lone Star, often used to
retract the anus for transanal rectal surgery. The
Lone Star is a circular plastic scaffold with slots
to secure elastic bands that tether small hooks for
tissue retraction. Opposing hooks are placed circumferentially, resulting in widening of the orice and access to the rectum. Another notable
self-contained retractor is commonly known as a
wound protector (Fig.6.10). This is a set of plastic rings connected by a cylindrical plastic sheet.
One ring is passed through the wound, and the
extracorporeal ring is turned around its circumference order to wrap and shorten the cylindrical
sheet. As the sheet shortens, it applies pressure
against the wound edges and forces them apart.
This retractor isolates wound edges from the
operative eld, and has been shown to reduce risk
of wound infection [5, 6].
Retraction systems are mounted to the operating table and can support multiple different retractors at once. Common examples are the
Bookwalter and Omni systems. The Bookwalter
involves mounting to the table a steel ring that
surrounds the incision. Individual retractors are
then secured to the ring. Similar to self- constrained
retractors, the Bookwalter relies on opposing
forces to keep the ring in centered; too much tension on one side or the other can skew the original
xation to the table. There are several different
sizes of supporting rings to accommodate different sized surgical incisions. In contrast, the Omni
system utilizes steel arms that can be positioned
around the incision to support various retractors.
This eliminates the need for different size components as with the Bookwalter rings. While both of
these systems can be considered critical to long,
open surgical cases, they also are bulky and can
restrict access around the operating table.
Sustained pressure against tissues can result in
ischemia and injury. Risk of injury is proportional
to the quantity and duration of force applied and
as such is more often associated with self-retaining retractors used during long cases. Clinically
relevant retractor injury is rare when proper precaution is taken. Steel retractor blades of mounted
retractor systems should be separated from tissue
with moist laparotomy pads to provide padding
and prevent tissue desiccation. Self- retaining
retractors utilized in laparoscopic surgery carry
the same risks, and ischemic injury due to laparoscopic liver retraction has been reported [7].
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M. B. Ujiki and H. MasonHedberg
6.3.4 Laparoscopic Retraction
As with open surgery, various techniques and
instrumentation for retraction have accompanied
the development of laparoscopic procedures.
Laparoscopic retractors can also be considered
self-retaining or handheld. The simplest of the
handheld laparoscopic retractors is the peanut,
simply a shaft with a cotton tip. Some designs,
such as one with spreading fanlike projections
(Fig.6.11), can increase surface area after passing
through the trocar for more broad retraction. In the
case of robotic surgery, a robotic assist arm can act
as both a handheld and self-retaining retractor. The
assist arm can be toggled and adjusted easily to
change exposure and then left in place for as long
as needed, providing an extremely versatile and
easily adjustable retraction.
Anterior retraction of the left lobe of the liver
is necessary for most laparoscopic procedures in
the upper abdomen, and several approaches have
been developed to serve this purpose. The
Nathanson retractor is a curved steel rod that can
be percutaneously introduced subxiphoid and
rotated to retract the liver. A support mounted to
the table holds the retractor in place. An alternate
approach utilizes a trocar just inferior to the right
lateral edge of the liver to introduce an articulating retractor, a rod that can be tightened into a
polygonal shape. Articulating retractors may be
exchanged through trocars as needed like any
laparoscopic instrument or secured to the table
for self-retaining retraction. A recent approach
for liver retraction involves grasping the liver
edge with a locking grasper, the end of which can
be dropped from the device, leaving behind a
magnet attached to the liver edge. This magnet
can be directed to a larger magnet placed on the
patient’s skin to achieve incisionless, percutaneous liver retraction. Another simple but useful
retraction technique in the upper abdomen is
passing a Keith needle through the abdominal
wall around the falciform. A gentle knot will
keep the falciform suspended out of the way of
the operative eld.
Take-Home Points
Take-home points, to include a summary of the
most important points (5–10 bullets):
• Perfecting exposure improves efciency and
safety.
• Spaciotemporal levels of retraction during a
case:
– Field exposure (positioning, gravity
retraction)
– Assistant retraction (appropriate instru-
mentation and guidance)
– Surgeon’s nondominant hand
• Know the correct retractor for the job at hand.
• Be mindful to avoid retractor injury during
long cases.
Editors’ Comments
• Learning to arrange the retractors for a specic procedure is a critical skill that any surgical trainee needs to concentrate on.
• While the surgeon should consider whether or
not adequate exposure has been achieved, one
should beware of how inefcient it is to
frequently interrupt the procedure to adjust
the retractors.
• “An accomplished surgeon practices economy
of movements and economy of words,”
F.E.Rosato Sr., MD FACS.
Suggested Readings
Chassin’s chapter on Incision, Exposure, Closure in
open abdominal surgery: Scott-Conner CEH, editors. Chassin’s operative strategy in general surgery.
NewYork: Springer. p.19–25.
Review and rationale for ergonomic laparoscopic
port placement: Supe AN, Kulkarni GV, Supe
PA. Ergonomics in laparoscopic surgery. J
Minim Access Surg. 2010;6(2):31–6. https://doi.
org/10.4103/0972-9941.65161.
6 Fundamentals ofRetractors andExposure
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105
References
1. Scott-Conner CEH, Chassin JL. Incision, exposure,
closure. In: Scott-Conner CEH, editor. Chassin’s
operative strategy in general surgery. New York:
Springer; 2014. p.19–25.
2. Tinelli A, Malvasi A, Mynbaev OA, et al.
Bladeless direct optical trocar insertion in laparoscopic procedures on the obese patient. JSLS.
2013;17(4):521–8.
13X13693422519398
3. Supe AN, Kulkarni GV, Supe PA.Ergonomics in laparoscopic surgery. J Minim Access Surg. 2010;6(2):31–
6. https://doi.org/10.4103/0972-9941.65161.
https://doi.org/10.4293/1086808
.
4. D’Angelo A-LD, Rutherford DN, Ray RD, Laufer
S, Mason A, Pugh CM. Working volume: validity
evidence for a motion based metric of surgical efciency. Am J Surg. 2016;211(2):445–50.
org/10.1016/j.amjsurg.2015.10.005
5. Lee P, Waxman K, Taylor B, et al. Use of woundprotection system and postoperative woundinfection rates in open appendectomy. Arch Surg.
2009;144:872–5.
6. Sookhai S, Redmond HP, Deasy JM. Impervious
wound-edge protector to reduce postoperative wound
infection: a randomised, controlled trial. Lancet.
1999;353:1585.
7. Nozaki T, Kato T, Komiya A, Fuse H. Retractionrelated acute liver failure after urological laparoscopic
surgery. Curr Urol. 2013;7:199–203.
https://doi.
.
Fundamentals ofDissection
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NealS.McCall andHarishLavu
7
7.1 Introduction
Surgery distinguishes itself from other elds of
medicine by its emphasis on operator dependence. Studies suggest that surgical outcomes
relate to not only what procedure is being performed but also by the technical competency of
the operating surgeon [1–4]. Over a 5-year clini-
cal time period, surgical trainees are expected to
attain the skills to perform approximately 121
independent operations, despite the fact that on
average, they will perform less than 15% of these
procedures more than ten times during their residency [5–7]. And yet, research reveals that more
than 60% of operative errors stem from improper
surgical technique [8]. Human error—due to
inadequate judgment, understanding, education,
experience, or skill—thus remains among the
most relevant factors in surgical morbidity and
mortality outcomes [8–11]. This speaks to the
N. S. McCall
Department of Surgery, Sidney Kimmel Medical
College, Thomas Jefferson University,
Philadelphia, PA, USA
e-mail: neal.mccall@jefferson.edu
H. Lavu (*)
Jefferson Pancreas, Biliary and Related Cancer
Center and the Department of Surgery, Thomas
Jefferson University, Philadelphia, PA, USA
Sidney Kimmel Medical College, Thomas Jefferson
University, Philadelphia, PA, USA
e-mail: Harish.lavu@jefferson.edu
importance of the fundamentals of surgical technique. There exists a great deal of literature about
surgical dissection within the context of specic
types of surgery and their respective considerations, yet few texts provide readers with an
appreciation of the general and broad concepts as
they relate to surgical dissection. This chapter
explores fundamental surgical dissection techniques as well as more advanced instrumental
techniques and their applications across many
surgical elds.
7.2 General Concepts
7.2.1 Positioning
Conditions in the operative room should be
designed to optimize the surgeon’s visualization
of the surgical eld and allow for maximal exposure. Gravity should be used to a surgeon’s
advantage whenever possible. For example, many
gynecologic procedures are facilitated by placing
the patient in the Trendelenburg position, in
which the patient’s head is angled 15–30° toward
the ground. This maneuver allows for easy mobilization of the small intestine away from the pelvis [12]. In contrast, the reverse Trendelenburg
position (Fowler), placing the patient’s feet
15–30° below the horizontal, can decrease
engorgement of the jugular veins, facilitating
safer dissection during head and neck surgery.
© Springer International Publishing AG, part of Springer Nature 2018
F. Palazzo (ed.), Fundamentals of General Surgery, https://doi.org/10.1007/978-3-319-75656-1_7
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