Abdominal access presentation

post graduate presentation

1. Abdominal Access Dr. Pashi V Prof: Munkonge THE UNIVERSITY TEACHING HOSPITAL.

2. Relevant anatomy of the abdomen Region of the trunk between the thorax and the pelvis Generally abdomen includes false pelvis Abdomen proper excludes the false pelvis Functions of the abdomen: Houses and protects major viscera Assists in breathing Accounts for change in intra-abdominal pressure

3. SURFACE ANATOMY

4. ANTERIOR ABDOMINAL WALL

5. ABDOMINAL MUSCLES

6. RECTUS SHEATH Above arcuate line of Douglas Below arcuate line of Douglas Above arcuate line of Douglas

7. The umbilicus and the skin In the fetus , the umbilicus transmits the vitelline and umbilical vessels and yolk stalk . It is surrounded by the paraumbilical veins that establish connections with both the portal vein and the inferior vena cava ( portacaval anastomosis ) through a series of venous channels

8. It is also the site of attachment of the umbilical ligaments that consist of the median umbilical ( remnant of the urachus ),medial umbilical (obliterated umbilical arteries ) and lateral umbilical (inferior epigastric vessels) ligaments/folds The umbilicus may also receive the embryological remnant of the vitelline duct known as Meckel’s diverticulum

9. The umbilicus also receives the round ligament of the liver, a remnant of the umbilical vein. The umbilical vein remains patent for some time during early infancy and allows blood transfusion or general venous access

10. An incision made perpendicular to the direction of Langer’s lines is most likely to gape and result in prominent scarring . Since the course of the nerves and vessels that supply the anterolateral abdomen parallels the cleavage lines of the skin, transverse incisions of the abdomen are surgically more favourable, They are less likely to gape or cause damage to nerves or vasculature and heal faster without visible scarring

11. Abdominal incisions Deciding the right type of surgical incision is extremely important. The ideal incision allows: ease of access to the desired structures can be extended if needed ideally muscles should be split rather than cut heals quickly with minimal scarring aesthetically pleasing The incision must traverse muscle rather than fascia since the scar left in the peritoneum is best protected by muscles

12. rectus abdominis muscle maybe cut transversely without weakening the abdominal wall. The cut passes between two adjacent nerves without injuring the nerves. The incision must not divide no nerve Drainage tubes should be inserted through separate incision like wise colostomy or ileostomy should be made through a separate incision The openings made by the incision through different layers of the abdominal wall must not be superimposed

13. Different ways of classifying abdominal incisions Approach to the abdominal cavity Incisions through anterior abdominal wall Incisions through the Posterior Abdominal wall Orientation of incision to the body axis Transverse incisions Vertical incisions Oblique incisions

14. Based on approach to musculature of the abdominal wall Dividing no muscles Diving muscles ( Transrectal ) Splitting muscles

15. Abdominal incision

16. SURGICAL INCISIONS 1. Kocher’s incision 2. midline incision 3.Gridion muscle splitting 4. Battle incision 5. Lanz incision 6. paramedian 7. transverse 8. Rutherfold Morrison incision 9. Pfannestiel

17. Vertical incision 1: Midline incision Use: Virtually all abdominal procedures may be performed through this incision.  Location : in the midline of the abdomen, and can extend from the xiphoid process to just above the umbilicus . It can be continued to below the umbilicus by curving the incision around the umbilicus. Layers of the abdominal wall:  skin, fascia  (camper's and scarpa's ), linea alba, transversalis fascia, extraperitoneal fat and peritoneum

18. Midline incision

19. Advantages Adequate exposure of most if not all of the abdominal viscera Minimal blood loss as the incision is through the linea alba Minimal nerve injury Minimal muscle injury Can be quickly made, such as in an emergency and quickly closed with a mass closure technique Disadvantages Care needs to be taken just above the umbilicus where the falciform ligament is  Midline scar

20. Vertical incision 2: Paramedian incision Use: provides laterality to the midline incision, allowing lateral structures such as the kidney, adrenals and spleen to be accessed. Location :  about 2- 5cm to the left or right of the midline incision.  Incision is over the medial aspect of the transverse convexity of the rectus.

21. Paramedian incision

22. Layers of the abdominal wall:  skin, fascia (camper's and scarpa's ) and the anterior rectus sheath are incised.  The anterior rectus muscle is freed from the anterior sheath and retracted laterally.  The posterior rectus sheath (if above the arcuate line) or transversalis fascia (if below the arcuate line) extraperitoneal fat and peritoneum are then excised allowing entry to the abdominal cavity.

23. Advantages Provides access to lateral structures Rectus muscle is not divided Incisions in anterior and posterior sheath is separated by muscle which acts as a buttress, therefore closure is more secure Can be extended by a curvilinear incision towards the xiphoid process if required

24. Disadvantages Takes longer to make and close Incision needs to be closed in layers Difficult extension superiorly as limited by the costal margin Tends to strip the muscles of their lateral blood and nerve supply resulting in atrophy of the muscle medial to the incision

25. Vertical incision 3: Mayo-Robson incision This is really a paramedian incision that has been curved towards the xiphoid process . It allows a bigger and wider opening . Dissection continues in the same fasical planes as the paramedian incision.

26. Mayo-Robson incision

27. Transverse incision 1: Transverse incision Use: right or left colon, duodenum, pancreas, subhepatic space. Location: This incision is made just above the umbilicus, dividing one or both of the rectus muscles. 

28. Layers of the abdomen:  skin, fascia, anterior rectus sheath, rectus muscle (+/- internal oblique, depending on the length of the incision), transversus abdominus , transversalis fascia, extraperitoneal fat and peritoneum.  The medial aspect of this incision will be through the layers just like as in the midline incision

29. Transverse incision

30. Advantages Less pain than a midline incision Good access to midline upper GI structures Transverse incisions cause the least amount of damage As the recti have a segmental nerve supply, it can be cut transversely without weakening a denervated segment Muscular segments can be rejoined

31. Commonly used in children as greater abdominal exposure is gained in comparison with the vertical midline.  This is due to the longer transverse length of the abdomen in children Disadvantages Limited lateral access in comparison with midline incisions that can then be extended More wound infections compared to midline thought to be due to greater difficulty in controlling bleeding and haematoma formation.

32. Transverse incision 2: Subcostal incision Use: gallbladder and biliary tract, spleen.  It is also known as the Kocher subcostal incision, after the person who discovered it.  With the roof top or Chevron modification, access to oesophagus, stomach, kidney and adrenals and liver is also possible.  Another modification is the Mercedes

33. Location:  starts in the midline, 2-5 cm below the xiphoid, extending in parallel with the costal margin at about 2.5 cm below the costal margin.  A rooftop of Chevron incision is a double Kocher incision.  The mercedes incision involves a vertical incision from the rooftop incision, like a mercedes sign. Layers of the abdominal wall: Skin, rectus sheath, rectus muscle, internal oblique, trasnversus abdominus , transversalis fascia, extraperitoneal fat and peritoneum

34. Subcostal incision and modifications

35. Advantages Greater lateral exposure Less painful to midline incision Less post-operative complications such as PE to a midline incision Heals well   Disadvantages Longer operation time as the incision is closed in 2-3 layers

36. Transverse incision 3: McBurney's incision and the Lanz incision Use: This is the incision of most appendicetomies and can be used in the left lower quadrant in left sided colonic pathology.  Location: McBurney's point, as described by Charles McBurney in 1884, is two thirds from the umbilicus and a third from the right anterior superior iliac spine.  The incision is oblique beginning laterally from above and ending medially.

37. If palpation reveals a mass, perhaps an appendiceal abcess , then the incision is made directly over the mass.  Nowadays, the incision is made transverse and placed in a skin crease, the so called transverse Lanz incision as this is more aesthetically pleasing and the scar is hidden in the bikini line. If it is anticipated that the incision will need to be extended, the oblique incision is used with lateral extension and as a muscle splitting (gridiron) surgical technique.   

38. Muscle splitting involves spitting the muscles fibres in a direction that is parallel to the direction of the muscle fibres. Layers of the abdominal wall:  skin, fascia, internal oblique medially and external oblique laterally, transversus abdominus , transversalis fascia, extraperitoneal fat and peritoneum.

39. McBurney's incision and the Lanz incision

40. Advantages Aesthetically pleasing incisions as they both follow Langer's skin lines A wide range of pathologies in the right and left lower quadrants can be dealt with, with room for extension if required Minimal damage to muscles as muscle splitting techniques can be utilised Avoids damage to local nerves  

41. Disadvantages The ilioinguinal and iliohypogastric nerves cross the  appendicectomy incision and there is a risk of injury.  This can then predipose to inguinal hernia formation post-operatively.  This is more evident with the Lanz incision.

42. Transverse incision 4: Pfannenstiel incision   Use: Allows exploration of the lower GI and UT, as well as the pelvic reproductive organs. Location: A convex 5cm to 12cm incision, located a the suprapubic skin crease about 2cm to 5cm above the pubic symphysis.  Once the peritoneum is reached, it is incised vertically, taking care to avoid the bladder.

43. Layers of the abdominal wall: skin, fascia, anterior rectus sheath, rectus muscle, transversalis fascia, extraperitoneal fat, perineum. NOTE: this incision is below the arcuate line and this there is no posterior rectus sheath.

44. EXTRA: MAYLARD INCISION

45. This incision is placed a couple of cm's above the pfannenstiel and also provides good exposure of the pelvic organs.   It cuts through the rectus fascia and muscle as well as external and internal obliques .  Once transverse abdominus and transversalis fascia are reached, a muscle splitting technique is employed.

46. Advantages A convex incision is made instead of a transverse as this parallels the course of the segmental nerves that are cut and so minimising muscle parasthesia and paralysis post-operatively.  It also  follows the cleavage lines in the skin resulting in less scarring Location of incision means it is hidden in the pubic hair line

47. Disadvantages Limited exposure of the abdominal organs . Use of incision is therefore restricted to the pelvic organs High risk of injury to the bladder especially because the fascia thins towards the lower abdomen, leaving the bladder relatively exposed, and if the bladder is not catheterised during surgery Extension of the incision is difficult laterally Exploration of the deep pelvic organs is difficult making dissection in the obese difficult

48. Oblique incision: Thoraco -abdominal incisions   Thoracoabdominal incisions may be located in the RUQ or LUQ.  They convert the pleural and peritoneal cavities into one.  They allow good access to the lungs, liver and spleen.  The left incision can also provide good exposure to the oesophagus and the stomach.

49. Thoraco -abdominal incisions

50. INCISIONS THROUGH THE POSTERIOR ABDOMINAL WALL These usually used to exposure of Kidney Ureter Suprarenal gland

51. KIDNEY INCISIONS Oblique incisions This is the favourite This extends from kidney angle in oblique direction down wards and outwards toward the anterior superior spine. The kidney angle is formed by the outer border of sacrospinalis muscles at the junction with the 12 th rib. The incision runs in the direction of the fibres of external oblique muscle.

52. Kidney incisions

53. It divides Skin and superficial fascia Latissimus dorsi and serratus posterior inferior External oblique split in direction of its fibres Internal oblique and transverses Fascial transversalis Extraperitoneal and perirenal fat

54. Lateral cutaneous branch of 12 th thoracic nerve will be cut and this results in an area of anaesthesia the size of palm over the gluteal region. The incision may also cut ilio-hypogastric nerves. The outer border of quadrutus muscles is exposed at the upper part of the incision. Care should be taken not to open peritoneum. This incision gives good exposure to kidney and ureter. The advantage of the incision is that it can be extended forward to expose the lower half of the ureter and the base of the bladder.

55. VERTICAL INCISION This extends perpendicularly along the outer border of sacrospinalis muscle from the 12 th rib to the iliac crest. This incision divides the following Skin and fascia Latissimus dorsi and serratus posterior inferior The three layers of lumbodorsal fascia Fascia transversalis and extraperitoneal fat This incision does not interfere with the muscles in this region. It has the biggest disadvantage in that it does not give exposure to ureter and can not be extended.

56. Kidney incisions

57. Layers of posterior kidney incisions

58. HORIZONTAL URETERIC INCISION A transverse incision a little above the level of iliac crest extending outwards from the lateral border of the sacrospinalis muscle. The ureter is identified so that the divided proximal end is implanted into the skin.

59. Laporoscopic incisions These incisions are small cuts in the skin made in the abdominal wall to allow the instruments of laparoscopy access to the contents of the abdominal cavity. Their location will depend on the organ being operated on.  Generally there will be 3-4.  One is always at the umbilicus to allow a port for the camera.  The other incisions will be located in one of the 4 quadrants for tools such as the griper, cutting and dissecting scissors and so on.

60. Laporoscopic incisions

61. summary Pediatric surgeons utilize several types of abdominal incision to approach different surgical problems in newborns , infants and children. In most children and during the first five years of life transverse incisions are preferred . It has been demonstrated that the younger the child , the relatively larger the abdominal cavity and wall.

62. In babies a supraumbilical transverse incision is ideal to explore all four quadrants and solve almost every surgical congenital abdominal condition. Another advantage of transverse incision over longitudinal incision is the low incidence of fascial dehiscence , hernia formation, and evisceration of transverse incisions.

63. References Askew, A.R. (1975) : The Fowler-Weir approach to appendicectomy . British Journal of Surgery, 62(4) : 303-4 . Brennan, T.G., Jones, N.A., Guillou , P.J. (1987): Lateral paramedian incision. British Journal of Surgery, 74(8) : 736-7 . Burnand , K.G., Young, A.E.: The New Aird’s Companion in Surgical Studies. Churchil Livingstone Edinburgh (1992).

64. References J. Anat. Soc. India 50(2) 170-178 (2001 ) Gauderer MW: A rationale for routine use of transverse abdominal incisions in infants and children. J Pediatr Surg 16(4 Suppl 1):583-6, 1981 Grantcharov TP, Rosenberg J: Vertical compared with transverse incisions in abdominal surgery. Eur J Surg 167(4 ):260-7, 2001