Maximising surgical access

Example of a Bookwalter retractor in use from Laohapensang K et al. (2004). Thai Journal of Surgery; 25:57-62

SAC Technique

For improved surgical access and to avoid the use of hand-held retractors in prolonged surgery, a self-retaining retractor is used – usually the Bookwalter but occasionally use the Alexis O.

Bookwalter retractor

The vertical post of the Bookwalter is secured to the side rail of the operating table, being cautious to avoid trapping any lines or the patient. The crossbar is then mounted and either a round or oval ring placed into the jaws. Abdominal wall retractors of various shapes and sizes, the blades of each protected by a small wet swab, are then fitted around the frame and adjusted via a ratchet system.

Next, the bowel is packed systematically. To do so, the rectosigmoid is preserved in its natural position and the root of the small bowel identified. A large wet abdominal pack is first used to retract the small bowel, secured in place by two further rolled packs positioned in each para-colic gutter. A larger retractor blade is affixed to the Bookwalter frame to hold the packing in place.

It is recommended to momentarily release or adjust the traction on each retractor blade at two hourly intervals throughout surgery to minimise the risk of secondary nerve injury resulting from prolonged compression.