Retracting and Exposing Instruments

Retracting and Exposing Instruments

Retractors hold tissue away from the operative site so the surgeon can see and work safely. Without adequate exposure, every other step of the operation becomes harder and riskier. As a surgical technologist, you must know each retractor by name, understand how it is designed to work, and recognize the tissue and nerve injuries that improper use can cause.

Handheld Retractors

Handheld retractors are held by an assistant throughout use. They require active attention but allow the holder to adjust pressure instantly in response to what is happening in the field.

Army-Navy retractor — A double-ended, flat-bladed instrument with a small blade on one end and a larger blade on the other. It is lightweight and used for shallow to moderate-depth retraction in many general and orthopedic procedures. The name comes from its development for military use.

Richardson retractor — Available in small, medium, and large sizes. Its rounded, right-angle blade hooks under tissue and retracts it steadily. The Richardson is a workhorse of abdominal surgery, used to retract the wound edge and expose the peritoneal cavity or organ layers. Choosing the correct size matters: a blade that is too small will slip; one that is too large will crush adjacent structures.

Deaver retractor — A long, curved, thin blade shaped like a slightly bent spatula. The Deaver reaches deep into the abdominal or pelvic cavity to retract the liver, bladder, or bowel. Because it contacts a broad surface of tissue, it must be repositioned regularly to prevent ischemia (tissue death from sustained pressure). Never allow a Deaver to rest with full force on a ureter, blood vessel, or nerve.

Brain retractors (ribbon/malleable retractors) — Thin, flexible metal strips used in neurosurgery and other delicate procedures. They can be bent to custom angles. Pressure must be minimal and intermittent because neural tissue is extremely sensitive to sustained compression.

Self-Retaining Retractors

Self-retaining retractors maintain their position without a human holder, using a ratchet, frame, or spring mechanism. They free the assistant's hands but must be set with particular care because no one is continuously monitoring pressure.

Balfour retractor — A frame-style abdominal retractor with a central bladder blade and two lateral arms that accept interchangeable blades. It is used for open abdominal and pelvic surgery. After placement, confirm that the lateral blades are not pressing on the iliac vessels or femoral nerves, a common source of postoperative nerve injury.

Weitlaner retractor — A self-retaining retractor with sharp or blunt prongs that spread open and lock. It is used for smaller incisions in orthopedic, vascular, and general surgery. Sharp prongs grip tissue more securely but increase the risk of laceration; select the appropriate tip type per surgeon preference and procedure.

Gelpi retractor — A small, pointed self-retaining retractor commonly used in spinal and orthopedic surgery. Its fine tips retract muscle or fascia in narrow fields. Because the tips are sharp and the spring tension is high, confirm correct placement before locking.

Safe Handling and Passing Technique

When passing any retractor, orient the blade away from both your hand and the surgeon's hand so neither is struck. Announce the instrument by name if the surgeon has not already called for it. Place the handle firmly in the surgeon's palm—do not dangle it. For heavy retractors such as the Balfour, use two hands to support the weight during transfer.

Maintain sterile field integrity at all times. Never reach across the field. If you must pass a retractor to the opposite side, hand it to the circulator or use a neutral zone.

Pressure, Angle, and Depth of Field

Three physical factors determine whether retraction is safe:

1. Pressure — Use the minimum force needed. Excessive or sustained pressure compresses vessels and nerves. For self-retaining retractors, ask the surgeon to confirm that blade tension is appropriate after placement.

2. Angle of pull — Retract parallel to tissue planes whenever possible. Pulling at a sharp angle concentrates force on a small edge and increases the risk of tearing or crush injury.

3. Depth of field — Match blade length to wound depth. A blade that is too short does not protect underlying structures; one that is too long can injure the structure beneath.

Injury Prevention

The most common retraction-related injuries include:

• Femoral nerve palsy from Balfour lateral blades placed too far medially or inferiorly
• Brachial plexus injury from shoulder retraction during thoracic or cardiac procedures
• Crush injury to the ureter or bowel from unrelieved Deaver pressure
• Dural tear or neural contusion from excessive brain retractor force

If a handheld retractor must stay in one position for more than a few minutes, alert the surgeon. Periodic release of pressure allows tissue perfusion to recover. Document or communicate any change in retractor position or unexpected patient response to the circulator.

Your Role as Scrub

You are responsible for presenting the correct retractor, correctly oriented, at the right moment. Study the setup card before each case to anticipate which retractors will be needed and in what order. During the procedure, keep retractors organized on your back table so you can retrieve them without searching. After use, inspect each retractor for damage—cracked blades or faulty ratchets must be pulled from service.