The ideal abdominal retractor occupies minimal space, is quick and easy to set up, and maximizes visualization of the surgical site while protecting vital structures. A variety of retractors exist and surgeon’s preference and surgical need determine which type is used. The framed, oval, or circular Bookwalter retractor is affixed to the surgical table by steel posts and hovers above the incision. Adjustable ratchet mechanisms are attached to the frame and secure a variety of self-retaining blades that expose the surgical site. It has the advantage of occupying minimal abdominal cavity space at the expense of a slightly cumbersome setup (Fig. 4.1 and Tech Fig. 8.1.12). In contrast, the Balfour retractor is a self-retaining, spreadable retractor. Its two blades are placed within the abdominal incision and the two blades are then pushed apart to expose the surgical site. Most commonly, a bladder blade is attached to the most inferior aspect of the retractor set. For increased exposure, additional handheld retractors can be utilized. Options include a right-angle retractor (Fig. 4.2), Dever retractor, and malleable retractor which exist in varying sizes and widths. As the name implies, the malleable retractor is particularly valuable as it can be bent and tailored to fulfill specific needs. Of note, it is important to use correctly sized retractor blades whether they are handheld, or as part of a retractor set; improperly sized retractors can cause injury and inadequately expose the surgical field. For example, oversized lateral blades can cause iatrogenic femoral neuropathy due to the extra pressure placed over the femoral nerve and psoas muscles. In contrast, obese patients may require appropriately longer, specialized bariatric retractor sets.

A variety of clamps are required for grasping tissue. Generally, clamps can be subdivided into atraumatic versus traumatic. Hemostatic clamps are a separate subdivision; however, they may be considered atraumatic due to their use in fine dissection.