Optimal exposure for hepatobiliary operations using the Bookwalter self-retaining retractor

With the increasing application of hepatic resections for both primary and metastatic tumors and the growth of liver transplantation, safe and reliable exposure to all surfaces of the liver is routinely required. In the past, many surgeons thought the resection of hepatic lesions, especially those located in the posterior right lobe of the liver, required a thoraco-abdominal incision for adequate exposure. However, the Bookwalter retractor, together with the bilateral subcostal incision with extension in the midline to the xiphoid, provides outstanding exposure to the upper quadrants of the abdomen and all surfaces of the liver. We found that certain technical details of its use provided superior exposure during more than 158 hepatic resections and orthotopic liver transplantations in a 36 month period at Vanderbilt University Medical Center. No thoracotomies were required. Only a few patients noted transient postoperative costal pain, and there have been no significant complications with the use of this system. This retractor provides optimal exposure for hepatic operations without the need for thoracotomy. It is versatile and easy to use, decreasing manpower use, time, and cost. By providing steady, unobstructed exposure to all surfaces of the liver, this system facilitates the procedure and increases safety for the patient.