Retractors and Principles of Exposure

Tim Gessmann, Markus Schäfer

Principles of Surgical Exposure

Introduction

Adequate exposure of the target organ represents a laudable prerequisite of every

successful operation. Therefore, it is worthwhile to be equipped with different retractors
and to invest enough time intraoperatively to optimize exposure. Basic principles of
exposure have recently been challenged 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.
 22 SECTION 1 General Principles

Retractor Systems
In general, a retractor system needs to fulfill the following requirements for an ideal
surgical exposure:
■ Broad, unrestricted view into the abdominal cavity

■ Wide access to the target organ

■ Illumination provided or enabled

■ Stable retraction of the abdominal wall and surrounding organs

■ Careful tissue retraction, preventing local ischemia

■ Freeing up the hands of the surgeon and assistants

■ Adaptability in usage (different patients, different incisions, etc.)

■ Various type of accessories to retract the abdominal wall and organs

Hand-held retractors have the main disadvantage of losing „free hands“ of the surgical
team. Self-retaining retractors are most commonly used 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 different
retracting devices and do not necessarily need to be fixed to the operating table (e.g.
Kirschner, A). The 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 fixed to the operating table. They allow for an asymmetric
exposure (e.g. Thompson, B).

B
Retractors and Principles of Exposure 23

Overview of Different Self-Retaining Retractors

Thompson (previous page, see figure B)

The basic compounds of this very stable retracting system are the rail arm, the two rods,
and the different retracting paddles that are attached to a retaining arm. The Thompson
retractor is favored for uni- and bilateral subcostal incisions, which are often used for
hepatobiliary procedures, in which most of the retraction required is oriented cephalic
and anteriorly. The exposure of the lower abdominal parts is limited. There is a wide
range of blades and paddles available as accessories.

Bookwalter (C)

This system has a frame (closed ring) fixed by a rail arm attached to the operating table.
Different retracting accessories, such as blades and paddles, are available that can be
clamped to the frame. The Bookwalter retracting system is used for both longitudinal
and transverse abdominal incisions. Although some training is necessary to achieve a
safe installation, fine adjustment is possible in three dimensions. Cleaning and steriliza-
tion need substantial effort due to the rather complex single components.

C
24 SECTION 1 General Principles

Omnitract

Although this retractor system needs precise installation, it offers excellent access for
most incisions. The open frame system can easily be completed to a closed ring.
This retractor can be used widely for intraperitoneal and retroperitoneal operations.
Maintenance and cleaning are not too elaborate. The figure shows longitudinal (A-1)
and transverse (A-2) laparotomy using the Omnitract system.

A-1

A-2
Retractors and Principles of Exposure 25

Rochard

The 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 fixed arm at the operating table. The main disadvantages are the unidirectional
tension and the lack of lifting the abdominal wall.

Kirschner, Balfour, O’Sullivan-O’Conner (A, B)

The Kirschner frame (A) and the Balfour retractor (B) are good examples of 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. They are rapidly usable, readily available, and are
preferred when only lateral exposure is desired.

Recommendation
Many factors and aspects influence the choice of a specific retractor. Some commonly
used retractors are compared in Table1. More than one type of retractor should be avail-
able to obtain the best possible exposure of the different parts of the abdominal cavity.

Table 1. Comparison of different retractor systems

System Construction Installation Adjustment Accessories Maintenance

Bookwalter Closing ring and fixation Complex Three dimensions +++ Elaborate
Thompson Arm Complex Three dimensions +++ Elaborate
Omnitract Arm Complex Three dimensions +++ Elaborate
Rochard Arm Complex Tension only in one direction + Elaborate
Kirschner Closing ring Quick Limited ++ Easy
Balfour Closing ring Quick Limited + Easy
26 SECTION 1 General Principles

Retractors in Laparoscopic Surgery

Whereas the abdominal wall is lifted by the pneumoperitoneum, intra-abdominal expo-
sure is achieved primarily by patient positioning and trocar placement. There are several
devices that may be used to retract the liver during upper GI operations, such as laparo-
scopic fundoplication, gastric bypass, or adrenalectomy.

Tricks of the Senior Surgeon

■ For optimal use, be familiar with several retractors and have a good knowledge of
their individual advantages.
■ Slow, incremental retraction prevents rib fractures and postoperative pain.
■ Intermittent release of the retraction during long duration operations prevents
local ischemic complications.