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Viscera Retainer

A flexible single-purpose shield placed beneath the fascial edges during laparotomy closure to protect underlying bowel from inadvertent needle puncture or suture strangulation. The two devices in common use are the FISH Viscera Retainer (a fish-shaped flexible plastic / silicone shield) and the Glassman Visceral Retainer (a metal alternative). Both serve the same purpose; both share the same defining limitation — they must be withdrawn before the last sutures are placed, leaving the bowel unprotected for the final portion of the closure.[1]

Design​

  • FISH Viscera Retainer — fish-shaped flexible plastic / silicone shield with a tapered tail. Slides easily between the fascial edges and the underlying bowel; the broad body covers the closure zone, the narrow tail trails out of the wound for retraction by an assistant during sequential bite placement.
  • Glassman Visceral Retainer — rigid / semi-rigid metal alternative serving the same function.
  • Malleable (ribbon) retractor — the most common improvised alternative when neither dedicated device is on the field; see Malleable Retractor.
  • Laparotomy pads can serve in a pinch but lack the rigidity to deflect a curved needle reliably; see Laparotomy Pads.

Reconstructive-Urology and Urogyn Uses​

The viscera retainer earns its keep at the moment of greatest needle-strike risk — fascial closure after open abdominal RU / urogyn procedures, particularly when the bowel is protuberant, distended, or adherent:

  • Open radical cystectomy, urinary diversion, augmentation cystoplasty — bowel is mobilized, distended, and adherent to the closure zone.
  • Open abdominal sacrocolpopexy and large prolapse repairs — extended Pfannenstiel or low midline closure with bowel often crowding the wound.
  • Re-operative abdomen — adhesive bowel disease, prior radiation, prior mesh, or prior diversion makes inadvertent enterotomy at closure a real and morbid risk.
  • Obese patients with a deep wound and shortened operative-arm reach — visibility is the worst exactly where the closure needle is moving fastest.
  • Pediatric augmentation, Mitrofanoff, and bladder-exstrophy closure — small-volume abdomen with thin abdominal wall.

Defining Limitation — and Modern Alternatives​

The viscera retainer must be withdrawn before the last suture is tied, leaving the underlying bowel unprotected during placement of the final fascial bites. This is the moment at which the most-publicized inadvertent-enterotomy cases occur. Mitigations include:

  • Withdraw incrementally as the closure progresses — pull the device out by one body-length as each pair of bites is tied; never pull the device entirely until the second-to-last bite is set.
  • Direct visualization of the bowel edge with a handheld retractor for the final 1–2 bites.
  • A second assistant maintaining bowel-side counter-retraction as the last bites are placed.
  • Biodegradable in-situ alternatives — Kaymakcalan 2017 described a biodegradable polycarbonate elastomer (CC-DHA) that can be placed over the viscera and left in situ during closure, undergoing a controlled solid-to-liquid phase transition and degrading without toxicity or intraabdominal scarring. The mechanistic appeal is continuous puncture-resistant protection through the entire closure including the final bites. Not yet in routine clinical use; signals an active development area.[1]

Evidence Gap — Outcomes Data Are Absent​

There are no clinical trials or comparative studies demonstrating that viscera retainers reduce inadvertent enterotomy, surgical-site infection, reoperation, or mortality at fascial closure. The case for their use rests on surgical logic and biomechanical principles, not outcomes data. That gap matters because the morbidity of inadvertent enterotomy is well documented:

  • 1.9% incidence at ventral hernia repair (AHSQC, n = 5,916) — enterotomy associated with SSI (OR 2.20), reoperation, readmission, and mortality.[2]
  • 12.8% during abdominal-wall repair requiring adhesiolysis, with adhesiolysis time as the strongest independent predictor.[3]
  • Up to 19–20% in reoperative abdominal surgery, especially when dividing lower-abdominal / pelvic adhesions.[4][5]

The WSES 2023 ECLAPTE guideline explicitly noted that there are too few data even on blunt-vs-sharp needle selection at emergency laparotomy closure to make a recommendation.[6] Viscera-retainer outcome data sit in the same evidence vacuum.

Bottom line. Continue using viscera retainers — the mechanistic rationale is sound and the downside is negligible — but recognize that the device-vs-no-device comparison is an unanswered question. For the broader operative-strategy options that do have outcome data (gentle bowel handling, sharp adhesiolysis, energy-device selection, anastomosis-vs-diversion decisions for iatrogenic injuries), see Intraoperative Bowel Handling & Injury Management.

References​

1. Kaymakcalan OE, Jin JL, Sun Z, et al. Transient phase behavior of an elastomeric biomaterial applied to abdominal laparotomy closure. Acta Biomater. 2017;58:413-420. doi:10.1016/j.actbio.2017.05.055

2. Krpata DM, Prabhu AS, Tastaldi L, et al. Impact of inadvertent enterotomy on short-term outcomes after ventral hernia repair: an AHSQC analysis. Surgery. 2018;164(2):327-332. doi:10.1016/j.surg.2018.04.003

3. ten Broek RP, Schreinemacher MH, Jilesen AP, et al. Enterotomy risk in abdominal wall repair: a prospective study. Ann Surg. 2012;256(2):280-7. doi:10.1097/SLA.0b013e31826029a8

4. Van Der Krabben AA, Dijkstra FR, Nieuwenhuijzen M, et al. Morbidity and mortality of inadvertent enterotomy during adhesiotomy. Br J Surg. 2000;87(4):467-71. doi:10.1046/j.1365-2168.2000.01394.x

5. van Goor H. Consequences and complications of peritoneal adhesions. Colorectal Dis. 2007;9(Suppl 2):25-34. doi:10.1111/j.1463-1318.2007.01358.x

6. Frassini S, Cobianchi L, Fugazzola P, et al. ECLAPTE: Effective closure of laparotomy in emergency — 2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings. World J Emerg Surg. 2023;18(1):42. doi:10.1186/s13017-023-00511-w