Abdominal incision

An incision in the abdomen is an opening or a cut made by the surgeon. An incision in the abdomen is an opening or a cut made by the surgeon. It is done to permit access to abdominal organs for surgery. The selection of an incision depends on. Underlying condition prompting the surgery.

1. Abdominal Incisions Dr. Arjun Patel , MPT , DNHE Assistant Professor

2. Surgical Incision is a cut made through the skin to facilitate an operation or procedure. It should be the aim of the surgeon to employ the type of incision considered to be the most suitable for that particular operation to be performed. In doing so, three essentials should be achieved: 1.Accessibility 2.Extensibility 3.A reliable closure

3. Princip l es Adequate exposure for easy accessibility of organ It should be muscle splitting rather than cutting - Except for the RM which can be cut transversely because of its rich blood supply Nerve should not be divided Incision should extensible

4. Principles Least interference with the function of the abdominal wall Insert DT through a separate incision Close the wound layer by layer

5. Classification Vertical incision Transverse incision Oblique incision Others

6. Vertical incision MEDIAN Supr a -u m b i lical Infra-umbilical PARA-MEDIAN Upper (Rt/Lt) Lower (Rt/Lt)

7. OBLIQUE Mc Burney's Kocher (sub costal) Sir Rutherford Postrolateral

8. TRANSVERSE Lanz Pfannensteil’s Mid abdominal Rt.upper Maylard Transverse

9. Classification According to the muscle No muscle divided Muscle splitting Muscle dividing M e dian Para median Pararectal Through linea semilunaris Para median Lateral Transrectal S u p eri o r Middle Inferior

10. MEDIAN INCISIONS Supra-umbilical Infra-umbilical VERTICAL INCISIONS Supra umbilical Infra umbilical

11. SIGNIFICANCE-it is favoured In diagnostic laparotomy, as it allows wide access to abdominal Cavity. ACCESS Supra umbilical- stomach,duodenum,gall bladder, liver, bile duct, and pancreas Infra umbilical- intestine, appendix, urinary bladder, prostate, rupture and ectopic Pregnancy Mid lines - small and large bowel

12. Advantages Quick and good access for emergency surgery Almost bloodless Very quick to make as well as to close No muscle fibers are divided No nerves are injured Go o d a c c e ss to upper abdo m i n al v i s c era and both side of abd. Can be reached Ca n b e e x ten d e d f u ll le n g t h o f abd o m en cur v ing around umbilical scar. Supra umbilical part heals well as it is thick, strong, and hold suture well

13. Disadvantage Healing in infraumblical region is bad as linea alba is thin and weak there for complication of burst abdomen and incision hernia Injury to the falciform ligament Midline scar Bladder injury

14. PARA-MEDIAN Upper(Rt/Lt) Lower(Rt/Lt) Vertical incisions(cont.)

15. Placed 2 to 5 cm lateral to midline over median aspect of bulging transverse convexity of rectus muscle Rectus retracted 1inch from the midline on either side Access Rt.upper paramedian stomach, duodenum, gallbladder, head of pancreas and Rt.lobe of liver Lt.upper paramedian oesophagus, cardia of stomach, spleen, left lobe of liver

16. Rt.lower parmedian Appendix, female genital organs Lt.lower paramedian sigmoid and descending colon Mid paramedian Exploratory laprotomy Pathology is not known Multiple and extensive pathology

17. Advantage Access and extend up and down Provides access to lateral structures Closer is secure specially in muscle retracting type as muscle comes over it Less chances of incisional hernia

18. Disadvantage Cosmetically bad Tension Hernia More blood loss More time consuming Other quadrant accessibility is less

19. Para rectal (Battle’s incision) Median to outer border of rectus muscle Muscle retracted medially Features Perpendicular to midline 1/3 of spino umbilical line 1/3 above and 2/3 below the line Access Appendix Pelvic with extension Colon with extension

20. Advantages and disadvantages Rectus muscle is not cut Good healing Damage to Nerve supply rectus cause muscle atrophy Accessibility limited Hernia

21. 1. Upper(suitcase incisions) or Chevron (rooftop) modification Transverse incisions

22. The incision may be continued across the midline into double kocher’s incision or rooftop appearance which provide excellent access to upper abdomen particularly in those with broad costal margin Here both recti are cut transversely Uses- Total gastrectomy Total oesophagectomy Extensive hepatic resection Bilateral adrenectomy

23. 2.Lower (Pfannenstiel incision) Transverse incisions(cont.)

24. Used frequently by gynaecologist and urologist for access to pelvic organ, bladder, prostate and for c- section. Is usually 12 cm long and is made in skin fold approximately 5 cm above symphysis pubis. Here rectus sheath and skin is cut transversely along the lower abdominal skin crease, However, rectus muscle are separated in the middle and laterally. This is employed specially for approach to bladder and uterus.

25. Transverse incisions(cont.) 3.Maylard Transverse Muscle Cutting Incision Gives excellent exposure to pelvic organ Skin incision is placed above but parallel to traditional placement of pfannenstiel incision

26. Transverse incisions(cont.) 4. Lanz incision It is a variation of McBurneys incision that is made the same point but in transverse plane. It gives cosmetically good scar

27. Transverse incisions(cont.) 5. Transverse Muscle dividing(mid abdomen) In newborn and infants, this incision is preferred bcs more abdominal exposure is gained per length of incision than with vertical exposure Because infants’ abdomen longer transverse than vertical girth. Also true of short, obese adult

28. 1.Kochers/ sub-costal incisions Oblique incisions

29. It affords excellent exposure to gall bladder and biliary tract and can be made on left side to afford access to spleen. Oblique incision From 1 cm below the xiphoid process to down wards to Rt.and parallel to costal margin and 2 finger breaths below it. 10- 12 cm long Access - Lt.spleen and Rt.liver, gall bladder Advantage & Disadvantage– Good exposure to liver and gall bladder(cholecystectomy) Muscle and nerve cutting - chances of hernia

30. 2.Mc-burney incision Oblique incisions(cont.)

31. Perpendicular to spinoumbilical line At the junction of lateral 1/3 and medial 2/3 of line, and 1/3 above and 2/3 below the line Access- Rt. Appendix, caecum, colostomy, Advantage disadvantage Muscle splitting – no post operative hernia No damage to muscle and nerve Direct approach to appendix Abdomen can not be explored Difficulty in dealing with appendix which is not easily found

32. Rutherford Morison Oblique Muscle Cutting Incision Extension of McBurney incision by division of oblique fossa Can be used for right and left sided colonic resection, or sigmoid colostomy Some other incisions

33. Mercedes benz modification Consists of bilateral low kocher’s incision with upper midline incision upto the xiphisternum. Provides excellent access to the upper abdominal viscera mainly the diaphragmatic hiatuses

34. Thoracic incisions

35. 1.MEDIAN STERNOTOMY Thoracic incisions(cont.)

36. 2.POSTERO-LATERAL INCISION This follows the Vertrebral border of scapula And the line of rib (numbers 5,6,7, or 8) to the Anterior angle or costal margin Thoracic incisions(cont.)

37. ANTERO-LATERAL INCISIONS This start close to the midline in front, follows along the line of the rib below the breast to the posterior axillary line.

38. SOME OTHER INCISIONS

39. COMMON GYNAECOLOGICAL INCISIONS

40. INCISION FOR MASTECTOMY

41. NAME THE NUMBERS…

42. ANSWERS 1. Kocher 2. Midline 3. McBurney 4. Battle 5. Lanz 6. Para median 7. Transverse 8. Rutherford Morison 9. Pfannenstiel