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77
Surgical First Assistant: The Essentials of Practice, First Edition. Editedby JulieQuick andMarkOwen.
© 2025John Wiley & Sons Ltd. Published 2025 by John Wiley & Sons Ltd.
CHAPTER 7
Tissue Handling and Retraction
Lee Rollason and Julie Quick
Birmingham City University, Birmingham, UK
INTRODUCTION
Among William Stewart Halsted’s seven principles of surgery are the tenets of gentle
tissue handling, preservation of blood supply and minimum tension on tissues
(Osborne 2007). When assisting during surgery, it is therefore essential that the
surgical first assistant (SFA) is competent in tissue handling and retraction to reduce
the risk of injury to the patient. Subsequently, the practitioner requires a sound
understanding of the appropriate knowledge and understanding of their
responsibilities as an SFA, including an appreciation for the types of tissue one will
encounter, and an awareness of the instrumentation and techniques that are used in
tissue handling and retraction. It is paramount that a tissue viability assessment is
carried out prior to surgery and that the SFA has an awareness of factors that could
disrupt tissue viability including patient factors such as comorbidity and wound
healing. In this chapter, the responsibilities of the SFA in relation to tissue handling
and manipulation will be explored, while the next chapter identifies some of the
technical aspects of retraction. While these chapters focus on some of the
responsibilities and technical aspects of the SFA, human factors and non- technical
skills, such as communication and teamwork, also need to be considered. These are
covered within Chapters 11 and 12, respectively.
78 Chapter 7 Tissue Handling and Retraction
TISSUE VIABILITY ASSESSMENT
In order to perform tissue handling and retraction competently, the SFA should
understand the principles of tissue viability. Tissue viability as a speciality relates to
the integrity of skin and soft tissue, as well as injuries that result from common risk
factors such as pressure or moisture (Dealey2012). Tissue viability assessment prior
to surgery is covered in Chapter3.
During surgery, the basic requirement for tissue viability is adequate oxygen
supply to the tissues to avoid hypoxic injury (Dima et al. 2013; Myint 2019;
Rothrock2022). The condition of a patient’s skin and underlying soft tissue may affect
the choice of instrumentation that an SFA might employ during surgery, and they also
need to consider the amount of force that they exert during tissue handling or retrac-
tion to reduce the risk of damage to tissue and neurovasculature. It is within the
responsibilities of the SFA to ensure that a tissue viability assessment has been carried
out prior to surgery commencing to identify any risks to the patient in relation to their
tissue integrity and to mitigate against these risks during surgery. The tissue viability
assessment may need to be reassessed or evaluated by the SFA during and/or after
surgery, depending on the surgery and the patient.
TISSUE TYPES
The human body is a complex organism and has evolved to accommodate many vital
organs such as the stomach, bowel and liver within confined spaces. The SFA might
work exclusively in one speciality or may be required to work across several specialities.
Whether a specialist or working generally, it is important to have a basic understanding
of the types of tissue that the SFA might handle.
Skin
In almost all surgical procedures, the SFA will be required to retract skin. Skin is
durable and has a degree of plasticity; however, it is also very sensitive (Waugh and
Grant2018). A patient’s skin may be intact and healthy, while others may have broken,
tissue paper- like skin. The SFA should always consider the condition of the patient’s
skin and plan care appropriately, using tissue viability tools to identify risks where
necessary, for example, the Waterlow Score (Waterlow2005).
Adipose Tissue
Adipose, or fat tissue, is a connective tissue that is located beneath the skin with a
range of colours and has an oily texture; adipose tissue acts as an energy store, internal
cushioning and insulation for the body (Allison etal.2020). This type of tissue is light
and can be manipulated easily; however, it can be slippery to hold manually and may
need to be held with tissue forceps or a swab to ensure it is secure.
Tissue Types 79
Muscle
There are three types of muscle tissue: cardiac, skeletal and smooth, each of which
has a specific function within the body (Marieb and Hoehn2014). Unless the SFA is
working in cardiovascular surgery, the most common types of muscle they will
encounter will be the latter two. Retracting muscle can be strenuous work due to the
strength of the tissue. Manual retraction of muscle tissue for short periods of time is
achievable; however, where larger muscles or groups of muscles require retention, a
self- retaining retractor might be a more appropriate choice.
Organs
Organs are essential to the function of the human body and contribute towards the
maintenance of homeostasis (Hickin et al. 2015; Blanchard and Abell 2022;
Cross2022). Organ tissues such as the lungs, stomach or liver are not necessarily of
the consistency expected and may be denser, softer, more pliable or rigid than initially
thought; this might be especially true when they are damaged or diseased. It is para-
mount, when handling organs, that the SFA does so gently and only as directed by
the surgeon.
Vasculature andNerves
Vascular tissues vary in size from small capillaries and venules to the aorta and vena
cava and are responsible for the transport and supply of blood around the body to
ensure oxygenation of tissue cells. There are a variety of diseases and pathologies
that can affect the integrity of blood vessels which may cause them to rupture and
bleed during manipulation (Sidawy and Perler 2019). When assisting with the
retraction of blood vessels and nerves, it is recommended that the surgeon should
place and remove the retractor as these are easily damaged by surgical instruments
and even minor nerve damage can result in temporary or permanent changes in
sensation and/or movement (Phillips2016). It is further noted that intra- operative
compression of nerves can lead to painful neuropathy post- surgery (Çetiz 2017;
Vancaillie etal.2018).
Bone
An SFA may be called upon to manipulate a limb to assist with skin preparation and
draping but manipulation of bones in the reduction of fractures or dislocations is a
procedure exclusive to the operating surgeon. The SFA may also be called upon to
hold a limb steady during surgery, but this should be under the direction of a surgeon,
following their instructions carefully if required to adduct or abduct the limb to pre-
vent avulsion of tendons or fractures (Whalan2006).
80 Chapter 7 Tissue Handling and Retraction
THE RESPONSIBILITIES OFTHE SFA
The SFA’s scope of practice is considered in Chapter2; however, due to the high risk of
direct tissue damage due to the nature of surgery, it is worth highlighting here that it is
important that the SFA is aware of and keeps up to date with the guidance and standards
on assisting published by professional bodies such as the Royal College of Surgeons and
standard operating procedures issued by their employer. Both the HCPC (2023) and the
NMC (2018) stipulate that registrants in any role need to make reasoned decisions based
on evidence to implement care. It is therefore imperative that the SFA has an in-
depth
understanding of a range of information that can be collected from and about each
individual patient focusing on person- centred care to reduce the risk of injury when
handling or manipulating tissue. This information includes but is not limited to:
• Anatomy and physiology
• Surgical technique
• Patient age
• Patient’s past medical history including co- morbidities (see Chapter3 for more
details on this)
Furthermore, the SFA should seek to review the patient with the operating sur-
geon and attend the team brief, part of the eight steps of the National Safety Standards
for Invasive Procedures 2 (NatSSIPs2). This is where information about the patient
and procedure is discussed in detail prior to surgery from the perspective of the oper-
ator, the surgical assistant and other key team members (CPOC2023). When working
in a new area, or with a new surgeon, the SFA should communicate their level of
knowledge and experience to the lead surgeon so that the appropriate level of
expectation and supervision can be agreed upon. For more information on the SFAs’
professional scope of practice, see Chapter2.
It is essential that the SFA understands their responsibilities and limitations
before undertaking tissue handling and the SFA should be guided by the Position
Statement issued by the Perioperative Care Collaborative (PCC) (2018), which iden-
tifies the SFA may assist with handling of tissue and manipulation of organs for
exposure and access as well as providing superficial skin, and superficial and deep
nerve and tissue retraction. While the PCC recommends that the SFA should only
move or place a retractor under the direct supervision of the operator (PCC2018), the
Royal College of Surgeons (RCSn.d.) recommends that the retractor should be placed
by the operating surgeon. It is, therefore, best practice for the SFA to ask the operator
when they identify that placing, moving or removing a retractor is required.
HANDLING OFTISSUE
Tissue handling is a process where tissue is manipulated, either manually or by other
means, to provide exposure to the surgical field. Retraction may also be used to
provide exposure, but it is also commonly used to protect tissue during surgery
Types ofRetractor 81
(Whalan 2006). Retraction of tissue is a requirement in most surgeries (Steele
etal.2013). Therefore, the SFA can be asked to move, hold or retract different types
of tissue or organs to enable the operating surgeon access to tissues or structures that
are occluded by the presence of other tissues or structures. For example, the SFA may
be required to hold a limb for skin preparation and draping, retract the liver so that
the surgeon can gain access to the gallbladder, lift a sloop that is around an artery so
that a repair can take place on the blood vessel or moving the uterus while holding a
Spackman cannula to assist with tubal ligation. There are a number of different
methods used for tissue handling by the SFA, for example, the hand or by mechanical
means such as tissue forceps or manual retractors. Some organs and body tissues are
often heavier and sturdier than expected, however, they should always be treated
delicately; mishandling weak or diseased tissue may lead to complications during
surgery or long- term effects for the patient (Tamhankar et al.2011; Amanatullah
etal.2020).
Therefore, the surgeon must always place or move the retractor and determine
the level of force applied. Once the SFA has taken over retraction from the operating
surgeon, the same position and force must be maintained until directed to stop. It is
essential that the SFA does not change the position of the retractors or increase
pressure as this must only be done by the surgeon. Holding tissue or providing retrac-
tion for long periods of time can cause fatigue, and if the SFA feels they can no longer
safely hold the retractor in place at the required level of force, then they should indi-
cate this to the surgeon in a timely manner to prevent injury to the patient and
themselves.
TYPES OFRETRACTOR
Retraction can be achieved through methods that range from the use of one’s own
hand to a variety of handheld or mechanical retractors. The type of retractor selected
depends on what needs to be accomplished, but regardless of the method or tool, the
aim of tissue handling and retraction is the same: to display or gain access to a deep
structure (Myint 2019). AORN has developed a tool to help in the selection of an
appropriate retractor and can be consulted where guidance is required (Spera
etal.2011).
Retraction by Hand
The hand is a natural retractor. It is dexterous and broad, meaning that it can access
and apply pressure over a larger area than some of the available instrumentation. The
main disadvantage to using the hand is that the SFA risks injury to self as they will be
in close proximity to where blades, sutures or other surgical instrumentation is being
used. Another disadvantage to using a hand to retract is that the SFA may become
tired with the discomfort of having to provide retraction for a long time or at a difficult
angle. If required, hand retraction should be only undertaken for short periods of
time, maintaining focus on the surgery at all times.
82 Chapter 7 Tissue Handling and Retraction
Hand- Held Retractors
Manual, hand- held retractors come in a variety of shapes and sizes; for example, fine
skin hooks often used during plastic surgery, medium- sized Langenbecks, used in
general or orthopaedic cases, or larger still, the Morris Retractor which is used when
working in and around the pelvic region. Examples of deeper tissue retractors are the
St. Mark’s and the Deaver used in abdominal surgery. For information on the use of
hand-
held retractors, see Chapter8.
Though manual retraction has its benefits, for instance, being able to change the
level of force being applied through the instrument, it requires a consistent level of
strength and stamina to achieve optimal tissue retraction, and more still to maintain
it over what might be a number of hours. Providing manual retraction for long periods
of time can cause the SFA to develop musculoskeletal injuries that can affect the arms
and neck (Spera etal.2011). In addition, where they are busy holding a retractor, the
SFA is unable to assist the operating surgeon in other ways. The SFA might have to
consider retracting tissue with their non- dominant hand so that they might use their
dominant hand for other tasks, for example, the cutting of sutures. If they need to
change hands at all during surgery, then they should announce this to the surgeon
prior to swapping hands.
Self- Retaining Retractors
Where manual retraction is problematic, for example, when there is limited space or
during a lengthy procedure, then a self- retaining retractor may be of more use. Self-
retaining retractors can be placed and locked into a position using an in- built ratchet
or similar mechanism (Tighe2015). Self- retaining retractors are used where it would
not be practical for a single person to hold back strong and rigid tissues, like a solid
organ, over extended periods of time. They vary substantially in size ranging from the
small Weitlaner retractor to the imposing Balfour retractor, which is commonly used
in abdominal surgery (Goodman and Spry2016).
While the use of a self- retaining retractor allows the SFA to better aid the sur-
geon to achieve an optimal view, the SFA might not necessarily be aware of the
pressure or tension a self- retainer is creating and the damage that can ensue, and so
the operating surgeon themselves should place or reposition a self- retaining retractor,
not the SFA.
Other self- retaining retractors, such as the Omni- Tract™ system, can be clamped
to an operating table and fixed into place, although it is important that steps are taken
to protect tissue where the retractor blades press. This is usually accomplished by pad-
ding the space between the retractor blades and the tissue with a large wet swab. It is
key that the swab is wet to ensure that it does not adhere to tissue. Where swabs are
retained under retractors inside cavities, such as the abdomen, it is important that the
scrub practitioner is informed, and this is recorded as part of the accountable item
check to prevent a retained swab which could result in a never event.
References 83
IMPLICATIONS OFTISSUE HANDLING ANDRETRACTION
The aim of any surgery is to minimise the damage to tissue through good surgical
technique (Quick etal.2014). Injuries caused as a result of tissue handling or retraction
are well- recognised complications (Orr and Williams2014; Brown and Rapaport2020;
Roca and Ramorino 2022). The SFA should use the minimum amount of force
required to achieve retraction as pressure damage may occur when the tissue is
exposed to greater force than it can naturally withstand, as a result, cells become
damaged and begin to break down.
Damage to skin can be the easiest to assess, as injury, such as bruising or
inflammation, is often visible. If any skin damage is noted, then this should be reported
to the consultant surgeon and documented in the patient records. Damage to internal
tissues or structures may be harder to diagnose. While bleeding may be easy to see,
tissue necrosis may not be evident at the time of surgery and may require additional
investigation, for example, the use of ultrasound and/or computed tomography (CT)
scans, to identify tissue atrophy or other signs of injury (Engelke etal.2018; Drakonaki
etal. 2019). Diagnosis of internal damage is beyond the scope of the SFA but they
should notify the surgeon as soon as any actual or potential damage is noted.
Although pressure injury is just one of many factors influencing wound healing
after surgery, tissues that are subjected to pressure- related issues may be subject to a
delay in wound healing (Peate and Glencross2015). An expedient recovery is optimal
to the outcome of a successful surgery, including fewer surgical site infections and
post- operative complications (Li et al. 2023). An effective and efficient period of
recovery means less opportunity for an infection to form at the surgical site and less
pain for the patient, in turn, this leads to earlier mobilisation of the patient which
helps combat several post- surgical complications (Tazreean etal.2022)
When the SFA has appropriate knowledge and understanding of their responsi-
bilities in handling and retracting tissue, including an appreciation for the types of
tissue they will encounter during each procedure, and an awareness of the instrumen-
tation and techniques that they will be asked to perform, it equates to safer surgery, an
overall reduction in the length of time that a patient is required to stay in hospital and,
therefore, improves outcomes.
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