By Peter Kim, MD

No act of kindness, however small, is wasted.

—Aesop, 600 bc

John Bookwalter, MD, inventor of the Bookwalter retractor.

When surgeons need to convert from a laparoscopic case to open abdominal surgery, they often shout, “Get the Bookwalter!” The Bookwalter retractor is the most popular retractor system for holding open abdominal incisions. The man who invented and promotes the retractor system is John Bookwalter, MD, and I had the good fortune to sit next to him by chance at a dinner meeting of the New York Surgical Society last winter. It was quite an honor talking to the man who developed a surgical instrument that has been used in almost every American hospital for the past 25 years.

At the meeting, I spoke with Dr. Bookwalter about my acceptance to the Master of Medical Management program at USC Marshall School of Business, and he was very encouraging of my desire to learn about entrepreneurship. We spoke about his efforts 30 years ago to create the surgical device that bears his name. Because of my interest in developing surgical devices and working with instrument-manufacturing companies, I decided to take the opportunity to interview Dr. Bookwalter at his home in Vermont. We sat at a large wooden table in his kitchen and spoke for five hours about his life, his family and his mentors.

Personal Mentors

Dr. Bookwalter’s main mentor was his father, a general practitioner at Case Western Reserve University in Youngstown, Ohio. When he was 12 years old, Dr. Bookwalter’s father took him on house calls, and one day he said to him, “It is a privilege to take care of sick people.” That was the moment Dr. Bookwalter distinctly remembers he wanted to become a doctor. His grandfather also was a doctor who delivered about 5,000 babies during his career, and taught his grandson to “take care of any patient as if they were a member of your family.”

The Bookwalter retractor being used in an open surgical case.

There were many illnesses in Dr. Bookwalter’s family that shaped his memories. Just after he received his driver’s license at age 16 years, Dr. Bookwalter’s father asked him to drive his grandfather to the hospital one day. His grandfather died there of pancreatic cancer. On another occasion, after he had graduated from medical school, his father asked him to operate on his uncle for lung cancer. Dr. Bookwalter’s uncle survived the operation but later died of a ruptured abdominal aortic aneurysm. His mother, who was a nurse, died of breast cancer. “The key to success in innovation is the unconditional love from our mothers,” Dr. Bookwalter said. Throughout his life, he recognized that “the opportunity for improvement occurs when something is difficult.”

After graduating from Amherst College in Massachusetts, Dr. Bookwalter went to Harvard Medical School and trained at Boston City Hospital (now Boston Medical Center) as a general surgeon. There, he learned from his heroes like Cornelius E. Sedgwick, MD, who, as his mentor, told him “good judgment comes from experience; good experience comes from bad judgment.”

Inventing the Bookwalter Retractor

The idea for the retractor first occurred to Dr. Bookwalter in the middle of a night in 1964, when he fell asleep in the operating room (OR) while holding a retractor during an emergency operation. When he awoke he found that it hadn’t mattered he had fallen asleep, and he began to think about the possibility of replacing hand-held retractors with a mechanical device. He went into active duty in the U.S. Army at Fort Bragg, N.C., during 1970 to1972, where the idea germinated further. To make the retractor, he took what was called a Smith ring—a smooth, flat metal ring—and he created notches at the edges with a metal cutter. The Smith retractor fastened to the table at two points and retractor blades could be moved and tightened around the perimeter. However, one day in the OR, there was only one bar available for the Smith retractor instead of two, so he decided to try it with only one bar and it worked. Dr. Bookwalter said luck played a part in this major development of the invention, but it also was his willingness to try something different to help his surgical patients that led to the creation of the device.

Luck and Strategy: Dealing With Start-Up Risks

At that time, Dr. Bookwalter was working with Codman & Shurtleff, Inc., a medical device manufacturer, on another device called a pistol grip needle holder, so he was able to show company representatives his new invention: the notched, uniform, single-post retractor. Tom Jones, CEO of Johnson & Johnson, who had just purchased the company, wanted to expand product lines, so he invested a lot of money in research and development that helped Dr. Bookwalter financially to develop and ultimately manufacture his retractor.

Over the next three years, from 1975 to 1978, Dr. Bookwalter worked on developing the retractor and attributes some of his greatest ideas to the time he spent driving on the I-91 highway and country roads in Vermont. One night at Exit 3, he had the idea to develop a tilt-ratcheted system that originally had come from the Bailey-Gibbon Rib Approximator. He called Allen West, who worked at the metal shop at Codman, and nine days later he had the prototype. Dr, Bookwalter attributes this success to the relationship he had with the machinists and people in the central sterile units at the company. In 1991, the tilt ratchet mechanism was modified so the release was on the side instead of the back. These ratchets were easier to deploy with one hand by the operating surgeon. The entire retractor was successful because it freed the hands of the senior surgeon, so he could delegate more of the surgery to the junior surgeon learning how to operate. “Good exposure is the key to good surgery,” his mentor, Dr. Sedgwick, told him.

An early ad for the Bookwalter retractor, circa 1981, when the first tilt ratchet was introduced. Note the single screw post coupling and the 1" diameter of both the table post (formerly 7/8") and the horizontal bar. The quote is from Dr. Cornelius Sedgwick, Dr. Bookwalter's mentor.

Traits of an Entrepreneur: Don’t Ask Why, Ask Why Not

Dr. Bookwalter succeeded because he worked in the field of surgery—an established industry—that allowed him to follow his passion for helping people and that also compensated him while he proceeded to innovate. By partnering with a well-known instrument company, such as Codman & Shurtleff that was interested in supporting innovation, he decreased the start-up risks and took advantage of its sales and distribution expertise. This allowed him to continue to practice surgery, and at the same time improve the eponymous retractor.

“It is easier to make an improvement than to make it from scratch,” Dr. Bookwalter said of successful innovation, and this was his approach to creating the Bookwalter retractor.

To administrators and doctors, the concept of error is unpleasant, demoralizing and misleading. Dr. Bookwalter said we should eliminate the term “trial and error” and instead use “trial and evaluation,” when we strive to innovate.

Since this interview, Dr. Bookwalter and I have kept in touch, exchanging ideas, phone calls and introductions to more and more people. “No act of kindness, however small, is wasted,” Dr. Bookwalter said to me, quoting Aesop: words to remember for this young surgeon in the age of burnout and regulopathy, where shower caps replace surgical hats. Regardless of the type of head covering, let’s remember the head, the heart and the hands underneath.

Dr. Kim is associate professor of surgery, Albert Einstein College of Medicine, New York City.