Abdominal Incision Barasima G_121502.pptx

Abdominal incisions

1. ABDOMINAL INCISIONS By Dr. BARASIMA TSHILUNGU Guelord SHO – Orthopedics Surgery Department (KIU, 2024) Supervisor : Prof OGBU 1

2. CONTENTS Basic principles Longitudinal incisions Oblique incisions Transverse incisions Special considerations : Reentry incisions and patient with obesity 2

3. BASIC PRINCIPLES Choice of incision The most important goal when choosing an abdominal incision is to provide adequate exposure for the anticipated procedure  Taking into account the possibility that the planned procedure may change depending upon intraoperative findings or complications  The incision should interfere minimally with abdominal wall function by preserving important abdominal structures and heal with adequate strength to reduce the risk of wound disruption and subsequent incisional hernia 3

4. BASIC PRINCIPLES Choice of incision: other considerations Need for rapid entry Certainty of the diagnosis Body habitus Location of previous scars Potential for significant bleeding Minimizing postoperative pain Cosmetic outcome 4

5. BASIC PRINCIPLES Measures to control surgical site infection   : skin antisepsis, prophylactic antibiotics, proper hand hygiene, and surgical technique 5

6. BASIC PRINCIPLES Skin incision  : Controversy persists regarding the choice of scalpel or electrosurgery for making abdominal wall incisions   Analysis found no significant differences: in the rate of postoperative wound infection. About the blood loss and the time to perform the incision, the was not clinically relevant. Postoperative pain scores (visual analog scale) were significantly lower for the diathermy group in the early postoperative period (<24 hours) 6

7. BASIC PRINCIPLES Control of superficial bleeding  : Small subcutaneous vessels that are divided during the course of making the incision will constrict, minimizing blood loss. Persistently bleeding vessels can be managed with electrocautery. The control of larger vessels ( eg , inferior epigastric artery) is best accomplished by isolating the vessel through dissection, clamping it with a hemostat , and suture ligating it. 7

8. LONGITUDINAL INCISIONS 8

9. LONGITUDINAL INCISIONS Longitudinal incisions are almost always placed in the midline . Paramedian and pararectus incisions are uncommonly used. 9

10. Midline incision  The midline abdominal incisions take advantage of the fact that only terminal branches of the abdominal wall blood vessels and nerves are located at the linea alba, thereby limiting the potential for bleeding or nerve injury A systematic review comparing midline with transverse incisions found that analgesia use, pulmonary compromise, and wound dehiscence may be increased with midline incisions One of the main indications for a midline incision is an exploratory laparotomy : trauma, sepsis 10

11. Midline incision  The midline incision provides the most rapid entry, which is especially important if the patient is hypotensive due to bleeding or septic shock T he midline incision provides the greatest abdominal exposure and can easily be extended The midline incision provides ready access to the abdominal viscera, liver, spleen, inferior vena cava, aorta, renal pedicles, kidneys, pelvic organs, and vasculature  However, exposure of the posterolateral retroperitoneum, including the posterior renal hilum and retrohepatic vena cava, can be more difficult to achieve. 11

12. Midline incision The midline incision provides ready access to the abdominal viscera, liver, spleen, inferior vena cava, aorta, renal pedicles, kidneys, pelvic organs, and vasculature. However, exposure of the posterolateral retroperitoneum, including the posterior renal hilum and retrohepatic vena cava, can be more difficult to achieve. The incision is made in the skin with a scalpel and carried through the subcutaneous fat sharply or using electrocautery. The midline fascia can be identified as the point where the fibers of each anterior rectus sheath join each other. 12

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14. Paramedian incision  A paramedian incision is made 2 to 5 cm to the left or right of the midline The anterior rectus sheath is incised vertically, and the rectus muscle is dissected from the medial fascial edge The muscle is retracted laterally, exposing the posterior sheath, which is incised vertically along with the peritoneum.  Lateral paramedian incisions are placed at the junction of the outer one-third and inner two-thirds of the rectus muscle. These incisions take longer to perform, restrict access to the contralateral pelvis, and risk injury to the epigastric vessels , nerve… 14

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16. Pararectus incision ( Battle's incision) : is placed at the lateral border of the rectus muscle, which is retracted medially This infrequently utilized incision was used primarily for appendectomy or drainage of pelvic abscesses  It causes denervation of the rectus, resulting in paralysis and, ultimately, muscle atrophy. The length of this incision must be restricted to no more than two dermatomes to prevent weakness of the abdominal wall 16

17. OBLIQUE INCISIONS 17

18. OBLIQUE INCISIONS Several oblique incisions are used for specific anatomic exposures 18

19. McBurney's incision:  McBurney's incision is an oblique muscle-splitting incision located one-third of the way from the iliac spine to the umbilicus  It is commonly used for an open appendectomy or surgeries in which exposure to the right or left lower quadrant is required An oblique incision is made in the skin along Langer's lines The fibers of the external oblique, internal oblique, and transversus abdominis are sequentially separated along their fibers The peritoneum and transversalis fascia are exposed and incised parallel to the skin incision. 19

20. McBurney's incision: McBurney's incision provides excellent access to the ipsilateral lower quadrant, making it ideal for appendectomy. The incision may be placed lower for extraperitoneal drainage of a pelvic abscess. It is easily expanded, and cosmesis is excellent 20

21. Subcostal:  The subcostal and bilateral subcostal (chevron) incisions are used to access the upper abdomen and flank   can be used for open cholecystectomy, bile duct surgery, liver resection, liver transplant, duodenal surgery, adrenalectomy, and open nephrectomy, among other surgeries The subcostal or chevron incision can also be extended to a sternotomy incision (also known as the Mercedes-Benz incision ) when cardiopulmonary bypass or liver mobilization is needed. 21

22. Subcostal: The skin incision is placed approximately 3 cm below and parallel to the costal margin. The fascia of the rectus muscle and the external oblique muscles are initially divided  Next, the rectus muscle and the external oblique, internal oblique, and transversalis muscles are divided. When dividing the rectus muscle, the superior epigastric vessels should be identified and divided between clamps and ligated. 22

23. Thoracoabdominal: The thoracoabdominal approach is a transthoracic intra- or extraperitoneal approach that provides exposure to the kidney, adrenal, lung, and inferior vena cava (IVC; right) and aorta (left).  It is the preferred approach for open thoracoabdominal aortic surgery and for intravenous tumor thrombus extending into the IVC since it allows mobilization of the liver and complete IVC exposure up to the heart  The disadvantages of the thoracoabdominal approach include the potential for thoracic complications (hernia, phrenic nerve injury, pneumothorax), postoperative chest tube requirement, and a prolonged operative time. 23

24. TRANSVERSE INCISIONS 24

25. TRANSVERSE INCISIONS Transverse incisions were initially developed to minimize likelihood of fascial dehiscence and incisional hernias. Since these incisions follow Langer's lines, less tension exists across transverse incisions, and the cosmetic result is enhanced. 25

26. TRANSVERSE INCISIONS Transverse incisions above or below the umbilicus are occasionally used in adults to access the abdominal organs but are more commonly used in the pediatric population A transverse extension of a midline incision may also be used to gain additional exposure. 26

27. Rockey -Davis or Elliot incision: Modified from the McBurney's incision Elliot incision is a transverse incision that is centered at the McBurney's point Medially, the incision extends to the lateral border of the rectus abdominis muscle; laterally, the incision extends an equal distance as it does medially This incision is thought to be cosmetically superior to the McBurney's incision, and indications for its use are like those of McBurney's incision 27

28. Flank  : The flank incision is a retroperitoneal approach that provides good exposure to the retroperitoneal structures without the need to open the peritoneum and is an excellent approach for radical, simple, and partial nephrectomy. It is useful for avoiding contamination of the peritoneum when active infection of the kidney is present ( eg , emphysematous pyelonephritis). The flank incision is performed at the superior margin of the 10 th , 11 th , or 12 th  rib and extended toward the midline. The latissimus dorsi, intercostal, external oblique, internal oblique, and transversalis muscles are divided using electrocautery 28

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30. Lumbotomy : Lumbotomy is used mainly for nephrectomy involving small nonfunctional kidneys and for pediatric pyeloplasty  A transverse incision is placed between the 12 th  rib and the iliac crest perpendicular to the sacrospinalis muscle  The main advantages of the lumbotomy include avoidance of muscle, decreased postoperative pain, and direct access to the renal pelvis and ureter. Disadvantages include poor access to the renal vessels and difficult dissection in the face of renal masses 30

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32. Incisions for pelvic operations: The greatest disadvantages of transverse incisions are the limited exposure provided to the upper abdomen, limited extensibility, increased surgical time, and relatively larger blood loss  Low transverse incisions can also be problematic if the pannus is large  However, when a planned operation is likely going to be confined to the pelvis, low transverse incisions are often used. All of the incisions described below begin with a transverse skin incision centered above the symphysis pubis. 32

33. Incisions for pelvic operations: Placing the incisions in the pubic hair line or in a natural skin crease may enhance the cosmetic result. However, the incision should not be placed in a deep skin fold of a large panniculus where maceration of the skin can increase the risk of infection. Transverse incisions for pelvic surgery are of four types: Pfannenstiel's incision, a muscle-separating operation (most common) Cherney's incision, a tendon-detaching operation Maylard's incision, a true muscle-cutting incision Küstner's incision, a median incision using a transverse skin incision Turner-Warwick's incision, a low midline incision for retropubic exposure 33

34. Pfannenstiel's incision:  Pfannenstiel's incision, the most popular transverse incision for pelvic surgery, is placed 2 to 5 cm above the pubic symphysis and usually is 10 to 15 cm in length After the skin is entered, the incision is carried through the subcutaneous tissue to the anterior rectus sheath, which is incised transversely. Pfannenstiel's incision provides excellent strength and cosmesis, and exposure is adequate for procedures limited to the pelvis; however, there is minimal opportunity to extend the incision if wider exposure is desired. 34

35. Pfannenstiel's incision: After the skin is entered, the incision is carried through the subcutaneous tissue to the anterior rectus sheath, which is incised transversely. The upper and lower fascial edges are grasped with a heavy toothed clamp, such as a Kocher, elevated, and dissected bluntly and sharply off the underlying rectus muscle from the umbilicus to the symphysis. The rectus muscle is separated along the midline raphe, exposing the transversalis fascia (and the posterior rectus sheath above the arcuate line). These layers and the peritoneum are incised vertically. 35

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37. Pfannenstiel's incision: Like all other incisions, the Pfannenstiel does have its limitations, however. Since several tissue planes must be opened, speed of entry is restricted and the risk of seroma, hematoma, and wound infection may be increased. Because of these considerations, this incision is relatively contraindicated in the presence of active abdominal infection or if speed is of the essence. Additionally, the rectus muscle is not routinely divided, so exposure is more limited than in the Maylard or Cherney incisions. 37

38. Cherney's incision: Cherney's incision is similar to the Pfannenstiel incision, except it involves incising the rectus tendons and is placed slightly lower on the abdomen Like Pfannenstiel's incision, the anterior rectus sheath is incised in transverse fashion and may be dissected from the muscle superiorly and inferiorly.  The tendons of the rectus and pyramidalis muscles are incised at their insertion to the symphysis following blunt separation from the underlying bladder and adventitial tissue. A half- centimeter segment of tendon is left on the symphysis for reattachment. The muscles and tendons are retracted caudad, and the peritoneum is incised longitudinally. 38

39. Cherney's incision provides excellent exposure to the retropubic space of Retzius , making it a good choice for retropubic urethropexy. A Pfannenstiel incision may be converted to a Cherney incision to enhance exposure. 39

40. Maylard's incision ( Mackenrodt incision ) :  is a transverse incision through all layers of the abdominal wall, usually at the level of the anterior iliac spine Following wide transverse incision in the aponeurosis, the rectus muscles are incised transversely with a scalpel, electrosurgery, or surgical stapler. Prior to transection of the muscles, the deep inferior epigastric vessels are identified on their lateral undersurface. The vessels are isolated, clamped, transected , and ligated. The Maylard incision can provide adequate abdominal and pelvic exposure for complex gynecologic surgery  40

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42. Küstner's incision  : This incision is uncommonly used. Küstner's incision is begun with a transverse skin incision approximately 5 cm above the symphysis and just below the anterior iliac spine A vertical midline incision is then made in the linea alba. The procedure for the midline incision is subsequently followed. Küstner's incision combines the disadvantages of both midline and transverse incisions and therefore has limited utility  It was developed to reduce the risk of evisceration; however, the incidence of herniation is similar to that of midline incisions. 42

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44. Turner-Warwick's incision: Turner-Warwick's incision is centered 2 to 3 cm above the symphysis and placed within the lateral borders of the rectus muscles The lower pole of the rectus muscles from below the symphysis is separated from the overlying sheath. The aponeurosis incision is usually 2 cm below the symphysis and 4 cm across. The rectus sheath incision is angled upward to the lateral border of the rectus but remains medial to the internal oblique and transversus abdominis muscle bellies. 44

45. A Kocher clamp can be placed on the aponeurosis for traction as it is separated from the muscle by blunt and sharp dissection. The pyramidalis muscles usually remain attached to the aponeurosis. The rectus muscles are separated from the transversalis fascia, and the peritoneum is incised in the midline. The Turner-Warwick incision provides excellent exposure to the retropubic space, but upper pelvis and abdominal exposure is severely limited. 45

46. REENTRY INCISIONS For patients who have had prior surgery at the same planned incision site, it is preferable to make the incision through the previous scar If the prior scar is cosmetically unacceptable, it may be excised at the beginning or end of the procedure. This is easily accomplished by elevating the old scar with Allis clamps and making an elliptical incision around the old scar. As noted above, it is usually preferable to extend the skin and fascial incision a few centimeters above the previous incision so the peritoneum can be opened where it is relatively free of adhesions. 46

47. OBESITY: ABDOMINAL INCISIONS Incisions should not be placed within the overlapping fold of a panniculus, due to the anaerobic bacterial load The panniculus can be grasped with towel clamps and pulled down.  The skin incision is then placed in a paramedian or midline location extending above the umbilicus. Although the topography of the abdomen is distorted, the fascial anatomy is not. A protocol utilizing this technique has been shown to lower the rate of wound infection from 42 to 3 percent  47

48. OBESITY: ABDOMINAL INCISIONS PANNICULECTOMY An alternative approach is surgical removal of the panniculus The advantage of this procedure is that by removing the panniculus, the depth of the surgical field is significantly reduced  Unfortunately, complication rates of panniculectomy are high, with wound healing problems occurring in 40 to 50 percent of patients The simplest approach to panniculectomy is a pair of curvilinear transverse incisions across the abdomen, widest apart at the midline and tapering to meet laterally over the iliac spines, creating a pointed oval ( ie , "football") piece of tissue, which will be removed 48

49. Many surgeons are adding a second wedge resection perpendicular to the transverse one, using a "fleur-de-lis" incision The surgeon can preserve the umbilicus by separately dissecting a cone of tissue around it to be brought out from a new site in the abdominal skin, maintaining its position relative to the pubic symphysis. However, for very large panniculi , the umbilicus may need to be sacrificed. 49

50. REFERENCE Jason S Mizell et al, Incisions for open abdominal surgery, Uptodate , feb 2024 available on https://www.uptodate.com/contents/incisions-for-open-abdominal-surgery?source=autocomplete&index=1~10 50