In the intricate world of general surgery, visibility is everything. A clear view of the operative field is essential not only for efficiency but also for patient safety and successful outcomes. Retractors are indispensable tools that allow surgeons to hold back tissues, organs, or incisions, creating the necessary exposure to perform surgical procedures with precision.

Retractors fall into two main types of retractors: manual retractors, which require continuous assistance from a surgical assistant, and self-retaining retractors, which maintain tension and position independently after being set in place. Each type has its advantages and ideal use cases. This article delves deep into the differences between manual and self-retaining retractors, with a special focus on some of the most commonly used retractors in general surgery: Gelpi, Weitlaner, and Army-Navy retractors.

Recognizing Different types of Retractors in General Surgery

Retractors have been used for surgeries for thousands of years. Surgical retractors can be as simple as a hook, or there are really cool retractors with ratcheting devices, but the function is the same: retract tissue to gain proper visualization/access to a target area.

• Manual Retractors (e.g., Richardson retractors) require a person to hold them and can be treated in a highly dynamic and flexible manner, yet these manual retractors do require precise manipulation to keep in position.
• Self-Retaining Retractors (e.g., Bookwalter retractors) lock in place once they are deployed and free up aides in the operating room while providing device-automated continual retraction through a period of fatigue (due to the length of the surgery).
  

Manual Types of Retractors: Use of the human hand

Manual retractors can be very reliable because of their ability to adapt and control. They have a relatively simple design with a handle and blade or hook, so it’s not uncommon to see them together in less invasive and more superficial procedures.

Army-Navy

The Army-Navy is one of the most recognizable manual retractors. It is a double-ended retractor with flat, curved blades on both ends. The double-ended design means you can alternate ends based on the depth and size of the incision.

Features:

• Double ended for greater versatility
• Flat blades with slight curve for wide retraction
• Non-ratcheted design allows smooth handling

Common Uses:

• Abdominal wall retraction
• Orthopedic exposure
• Soft tissue dissection

Advantages:

• Lightweight and easy to use
• Perfect for shallow incisions or small openings of wounds
• Easy to manipulate in small working spaces

The Army-Navy is very easy to use and probably the most basic manual retractor, and as a result, it is a staple in most general surgery sets. However, it is a manual retractor so only one hand is always occupied and that can become limiting with lengthy procedures.

Self-retaining Types of Retractors: Retraction without Another Hand

Self-retaining retractors use locking mechanisms such as springs, screws, or ratchets to remain in place after they have been opened. They are helpful for cases in deep areas or longer cases that need the field exposed for long periods of time.

Two of the most common self-retaining retractors are Gelpi and Weitlaner retractors.

Gelpi Retractor

The Gelpi retractor is a self-retaining instrument with sharp, curved tips that separate the surgical site and hold tissue apart through a ratcheted mechanism. It is especially useful in smaller, deeper incisions where precision is necessary.

Features:

• Pointed blades that curve outward
  
• Ratchet locking mechanism
  
• Narrow profile, ideal for tight operative fields

Common Uses:

• Neurosurgery
  
• Orthopedic procedures
  
• Perineal surgery
  
• Spine surgeries

Benefits:

• Provides excellent exposure with minimal movement
  
• Frees up assistants for other tasks
  
• Minimal trauma due to small contact surface
  

Despite its usefulness, care must be taken to avoid tissue damage with the sharp points, especially in delicate anatomical areas.

Weitlaner Retractor

The Weitlaner retractor is another self-retaining tool but has more prongs on each blade (either sharp or blunt) than the Gelpi. Since the prongs grip the tissue a bit more all-encompassingly, it tends to work better for muscular retraction and larger openings.

Features:

• Multiple prongs, e.g. 2×3 or 3×4 (on circumferential blades)
• Blunt or sharp tips
• Ratcheting handle for consistent separation

Common uses:

• Soft tissue surgery
• Wound debridement
• Orthopedic surgery
• Back and shoulder incisions

Benefits:

• Broad and even retraction
• Reduced risk of localized tissue trauma
• Outstanding option for surgeries/cases requiring moderate to wide exposures

The Weitlaner is preferred in general and orthopedic surgery as it provides an even distribution of pressure on the retracted tissue and lessens the risk of tearing tissue or ischemia.

Selecting the Optimal Retractor for the Job

The retractors a surgeon selects will depend on the following main factors:

• Size of the Surgical Field: Larger fields will require longer, and sometimes, self-retaining retractors.
• Tissue Type: More delicate tissue will require less traumatic and blunt-tipped retractors.
• Length of Surgical Procedure: Longer surgeries will benefit from self-retaining retractors to prevent fatigue.
• Available Personnel: In cases with limited assistance, self-retaining retractors offer autonomy.

Surgeons often use a combination of retractors during a procedure. For example, an Army-Navy might be used initially to open a small incision, followed by a Gelpi or Weitlaner to hold the field open during the procedure.

Guidelines for Using Surgical Retractors

Regardless of the type of retractor being used, there are general best practices that all surgeons and surgical assistants need to remember:

• Avoid stressing tissue with constant retraction pressure. Excessive pressure from retraction can cause adverse effects, including bruising or necrosis.
• Be mindful of damaging Fascial or connective nerve tissues next to the surgical field. This is particularly important for orthopedic and spinal surgery, in which adjacent nerves can be severely damaged or transected.
• Make sure the retractors are properly sterilized and maintained. They must be clean and undamaged.
• Don’t take retractors for granted. Slight damage to purchase retractors is often overlooked. Periodically check retractors for misalignment, inconsistency, loss of prong sharpness, and/or malfunction in the ratchet mechanism.
• Know how to use them. All surgical personnel should be reasonably good at putting on and taking off all different styles of retractors and be able to perform this quickly and safely.

Conclusion

Retractors, both manual and self-retaining, are part and parcel of general surgery today. With manual retractors like the Army-Navy, there is the ability to manipulate tissue with precision and ease in superficial or simple procedures. With self-retaining retractors like the Gelpi and Weitlaner, there exists the ability to offer needed support and holding capability in deeper and more complex surgeries.

Ultimately, the determination of choosing a manual versus self-retaining retractor is most likely situational, based on the type of procedure performed, preferences of the surgeon, and the support of the OR team. Any retractor used, the surgeon’s singular aim does not change: to maximize surgical visibility and minimize surrounding tissue trauma while ensuring the best possible outcome for the patient.

At Hasni Surgical, we manufacture a wide range of surgical retractors crafted from high-grade stainless steel for durability, performance, and precision. From trusted manual instruments like the Army-Navy to precision-engineered self-retaining options like the Gelpi and Weitlaner, our instruments are built to support excellence in the operating room.

Contact us today to learn more about our retractors and how we can support your surgical needs.