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Views: 0 Author: Site Editor Publish Time: 2026-05-21 Origin: Site
Many people assume that retracting tissue and closing skin are tasks reserved for junior residents or interns.
But experienced surgeons see things differently:
Exposure is the ticket into the operation. Closure is the surgeon’s signature.
Drawing from modern evidence-based surgical principles, here are several highly practical operating room tips that can immediately improve your surgical technique—and perhaps change the way you think about retractors and suturing altogether.
Retraction is not about “pulling tissues apart.”
It is about overcoming tissue elasticity in a controlled and intelligent way to create safe exposure.
Understand Stress Relaxation
Soft tissues are viscoelastic structures.
When a retractor is first applied, tissue resistance is at its highest. Over time, however, the tissue gradually relaxes under sustained tension—a phenomenon known as stress relaxation or creep.
Practical Surgical Tip
Do not yank aggressively the moment you place a retractor.
Instead:
Apply gentle but steady tension
Allow the tissue several seconds to adapt
Let the tissues “relax” naturally
Forceful retraction only causes:
Microscopic tissue tearing
Increased postoperative swelling
Additional soft tissue trauma
Many junior surgeons pull retractors using only:
Forearm strength
Biceps tension
Wrist grip
This is inefficient and exhausting.
It is also why your hands shake after a long case.
Elbow Adduction Technique
Keep your elbow close to your rib cage while holding the retractor.
This stabilizes the shoulder girdle using the latissimus dorsi rather than relying on smaller arm muscles.
Once your arm is locked in position:
Lean your center of gravity slightly backward
Let your body weight maintain retraction
At that point:
Your skeleton is holding the retractor—not your muscles.
This technique dramatically reduces fatigue during lengthy orthopedic procedures.
Pressure beneath a retractor blade often exceeds capillary perfusion pressure.
Prolonged compression may lead to:
Tissue ischemia
Necrosis
Delayed wound healing
This is one of the hidden causes of postoperative wound complications.
When the primary surgeon moves to another step—such as:
Drilling
Measuring
Implant preparation
—you may not need maximal exposure.
At those moments:
Slightly release the retractor
Allow tissue reperfusion
Restore local blood supply
Even brief reperfusion intervals can significantly reduce soft tissue injury.
The Hohmann Retractor functions as a mechanical lever.
Its tip must always:
Stay in contact with bone
“Walk down” along the cortical surface
Maintain a secure bony purchase
If the tip slips off bone:
The lever loses its fulcrum
Retraction becomes inefficient
Nearby neurovascular structures may be injured
Figure 1.Proper placement of a Hohmann retractor along the cortical bone surface.
Gelpi Retractor and Weitlaner Retractor retractors have extremely sharp tips.
Never place them blindly.
This is especially critical near:
The sciatic nerve
The femoral nerve
Major vascular structures
Always visualize the trajectory of the tips before deployment.
Figure 2.Self-retaining retractors commonly used in orthopedic surgery.
Patients rarely judge the quality of fracture reduction or implant positioning directly.
But they always see the incision.
In many ways, wound closure becomes the most visible representation of surgical quality.
Many beginners believe smooth forceps are less traumatic.
That is not entirely true.
Skin closure should generally be performed using toothed forceps, such as the Adson Forceps.
Why?
Toothed forceps create:
Point contact
Secure grip
Minimal compression injury
In contrast, smooth forceps require greater squeezing force to hold slippery tissue.
This crushes cells across the entire grasped area and may lead to:
Tissue devitalization
Skin edge necrosis
Poor wound healing
Figure 3.Comparison between toothed and non-toothed forceps during skin handling.
The Vertical Mattress Suture is especially valuable for wounds under high tension, including:
Over the patella
Around the olecranon
Prominent bony areas
“Far-Far, Near-Near”
The “far” bites reduce tension
The “near” bites evert the skin edges
Skin edges should protrude slightly outward during closure.
Why?
Because scar contraction naturally flattens the incision over time.
If the wound edges invert inward initially, the final scar may heal as a depressed groove.
Figure 4.Technique illustration of vertical mattress suturing.
Still frustrated by bulky knots at the end of subcuticular sutures?
Learn the Aberdeen Knot.
The Aberdeen knot:
Uses the suture’s own loops to self-lock
Creates an extremely compact knot
Provides excellent security
Minimizes palpable knot prominence
The final step involves:
Passing the needle into deeper tissue
Bringing it out remotely
Cutting the suture
The tail retracts beneath the skin, creating an almost invisible finish.
Figure 5.Demonstration of the Aberdeen knot technique.
Postoperative seroma and hematoma formation commonly originate from unclosed dead space.
Proper closure is not merely about closing the skin.
It is about:
Restoring layered anatomy
Eliminating potential cavities
Reapproximating deep tissues properly
For obese patients or those with thick subcutaneous fat:
Deep-layer closure is often more important than the skin closure itself.
The next time you step into the operating room:
Think of retraction as a sophisticated application of leverage, ergonomics, and tissue biology
Think of wound closure as precise anatomical reconstruction—not merely “closing the skin”
Even if you are currently the assistant at the table, you should approach every task as an active and thoughtful surgeon—not just a passive extra in the operation.
