ABDOMINAL INCISIONS AND LAPAROTOMY-1.pptx

The theoretical advantage of a paramedian over a midline incision is
a diminished risk of wound dehiscence and incisional hernia

In practice, when these incisions are reopened, the medial edge of the rectus muscle is frequently adherent to the anterior or posterior sheath incision and does not effectively buttress the wound.

A “lateral paramedian incision” refers to a vertical incision created several centimeters lateral to the location of the traditional paramedian incision.
In the patient who has had prior abdominal surgery, the cosmetic advantages of reentering the abdomen through a preexisting scar must be balanced against the challenges associated with dissection in a reoperative field. Close proximity of a new incision to an old one should be avoided in order to minimize the risk of ischemic necrosis of intervening skin and fascial bridges.

Mass closure of the abdominal wall is usually advocated, using large bites and short steps in the closure technique and either non-absorbable (e.g. nylon or polypropylene) or very slowly absorbable suture material (e.g. polydioxanone suture (PDS)). It has been estimated that, for abdominal wall closure, the length of the suture material should be at least four times the length of the wound to be closed to minimise the risk of abdominal dehiscence or later incisional hernia.

1. ABDOMINAL INCISIONS AND LAPAROTOMY Nanma Thara

2. INCISIONS An incision must provide : Access to the site of abdominal pathology and allow ready extension if greater exposure is required. A larger incision or even, on occasion, a second incision, should be created without hesitation if exposure is inadequate. The incision should be executed in a fashion that anticipates a secure wound closure. It should interferes as little as possible with the function and cosmesis of the abdominal wall.

3. 3 Abdominal incisions can be vertically, transversely, or obliquely oriented. The avascular linea alba affords the vertical midline its superior flexibility. When optimal exposure of the entire abdominal cavity is necessary ( eg , exploration for abdominal trauma), the vertical midline incision is preferred and can be extended superiorly to the xiphoid process and inferiorly to the symphysis pubis. Resection of the xiphoid may afford even better superior exposure when needed. Alternatively, vertical incisions may be placed in a paramedian position Transverse and oblique incisions can be placed in any of the 4 quadrants of the abdomen depending on the site of pathology.

4. Anatomy of anterior abdominal wall 4

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12. Types of abdominal incisions 12

13. EXAMPLES OF ABDOMINAL INCISIONS 13 Right subcostal incision -for biliary surgery Left subcostal incision Upper midline Right upper paramedian Subumbilical Left lower paramedian Lower mid line

14. 14 08. Left thoracoabdominal 09. Roof-top -(Chevron) incision 10. Upper horizontal 11. Left lumbar sympathectomy incision 12. Lower horizontal 13. Lanz Incision 14. McBurney's incision 15. Pfannensteil incision 16. Incision for inguinal hernia

15. MERIT OF TRANSVERSE INCISION . Transverse incisions have a more secure closure than vertical incisions. The fascial fibers of the anterior abdominal wall are oriented transversely or obliquely. Transverse incisions, therefore, parallel this orientation and allow for ready reapproximation with sutures placed perpendicular to the fibers . In contrast, vertical incisions disrupt fascial fibers and must be reapproximated with sutures placed between fibers As well as the absence of an anatomic barrier may predispose to tearing of tissues, resulting in dehiscence or hernia formation. Transverse incisions are superior to vertical incisions with regard to long-term and short-term outcomes ( eg , postoperative pain, pulmonary complications, and frequencies of incisional hernia and dehiscence). 15 VERTICAL V/S TRANSVERSE INCISION - MERITS AND DEMERITS

16. DEMERIT OF TRANSVERSE INCISION. Larger transverse incisions obligate division of muscle fibers with greater functional consequences and leave fewer options for remediation when hernias do develop More wound infections were seen with transverse incisions. 16

17. MIDLINE V/S PARAMEDIAN INCISIONS The theoretical advantage of a paramedian over a midline incision is a diminished risk of wound dehiscence and incisional hernia owing to the presence of rectus muscle interposed between layers of divided fascia. In practice, when these incisions are reopened, the medial edge of the rectus muscle is frequently adherent to the anterior or posterior sheath incision and does not effectively buttress the wound. A “lateral paramedian incision” refers to a vertical incision created several centimeters lateral to the location of the traditional paramedian incision. 17

18. In the patient who has had prior abdominal surgery, the cosmetic advantages of reentering the abdomen through a preexisting scar must be balanced against the challenges associated with dissection in a reoperative field. Close proximity of a new incision to an old one should be avoided in order to minimize the risk of ischemic necrosis of intervening skin and fascial bridges. Mass closure of the abdominal wall is usually advocated, using large bites and short steps in the closure technique and either non-absorbable (e.g. nylon or polypropylene) or very slowly absorbable suture material (e.g. polydioxanone suture (PDS)). It has been estimated that, for abdominal wall closure, the length of the suture material should be at least four times the length of the wound to be closed to minimise the risk of abdominal dehiscence or later incisional hernia. 18

19. COMPLICATIONS OF ABDOMINAL INCISION Wound infection. Burst abdomen Fistula formation. Wound pain. incisional hernia. Adhesion and its complication. 19

20. 20 Laparotomy

21. INDICATIONS The decision to use Laparotomy is usually taken by the surgeon in cases of emergency, an unstable patient or the case where a large incision is required. Some of these cases are: Repairing hernias within the abdominal wall. Removing the diseased tissue and diseased organs. If a large leak is demonstrated or the patient experiences peritonitis Laparotomy is indicated for life-threatening hemorrhage 21

22. Standard open laparotomy allows rapid determination of the etiology and more expeditious management of the disorder. Suspicion of gallbladder malignancy mandates that standard open resection be undertaken. This is because of persistent concerns regarding adequacy of resection and the possibility of gallbladder perforation (occurring in 20%-30% of laparoscopic cholecystectomies) with intraperitoneal dissemination of cancer. 22

23. Open laparotomy allows the additional tool of manual palpation and haptic sensation and should be performed when the anatomy cannot be delineated because of inflammation, adhesions, or anomalies. Fistulae between the biliary system and bowel are rare, but may require laparotomy for optimal management. The demonstration of potentially resectable gallbladder carcinoma also dictates an open exploration. Finally, CBD stones that cannot be removed laparoscopically and are unlikely to be extracted endoscopically because of Billroth II anastomosis, previously failed ERCP, should be converted to open operation without hesitation. 23

24. The role of open surgical treatment of infected pancreatic necrosis is reserved for those who fail minimally invasive intervention and for when a laparotomy is required for additional reasons, such as abdominal compartment syndrome and intestinal infarction/perforation. in the case of acute abdominal complications such as bowel ischemia, bowel perforation, and abdominal compartment syndrome, emergency laparotomy is required. Adhesive bowel obstruction warrants a period of expectant management and supportive care, as the majority of these problems will resolve spontaneously. Most surgical texts recommend that the waiting period can be extended to 14 days. If the early bowel obstruction lasts longer than 14 days, less than 10% resolve spontaneously, and exploratory laparotomy is indicated. 24

25. Midgut volvulus is a surgical emergency. Once the diagnosis of malrotation is made in the symptomatic patient, immediate laparotomy is indicated even if radiologic and clinical signs of volvulus are absent. Incase of a strangulated groin hernia - If the initial physical examination yields signs of ischemic bowel that may necessitate resection, a midline laparotomy can be performed and the hernia repaired in the inguinal canal using a tissue repair after the laparotomy is closed. 25

26. Patients with bleeding refractory to endoscopic management or those with significant hemodynamic instability may require urgent operative intervention. In these patients, an exploratory laparotomy is performed with attempts made to determine the location of blood within the GI tract. In a trauma laparotomy - A staged celiotomy (“damage control” laparotomy) might be necessary if the patient becomes acidotic, hypothermic, develops coagulopathy, or is hemodynamically compromised. 26

27. ABSOLUTE INDICATIONS FOR EXPLORATORY LAPAROTOMY IN PENETRATING ABDOMINAL INJURIES A. Peritonitis B. Evisceration C. Impaled object D. Hemodynamic instability E. Associated bleeding from natural orifice F. Documented pneumoperitoneum 27

28. PROCEDURE A Laparotomy procedure is typically performed under general anesthesia . Provide good access to the whole abdomen. The linea alba may be divided from xiphisternum to symphysis pubis,although commonly a shorter incision is made and only extended if necessary. A large xiphisternum can be excised if it is restricting access. Troublesome bleeding would then occur from the terminal branches of internal thoracic artery and this will require diathermy coagulation. 28

29. The main disadvantage of a midline incision is that it crosses the natural crease line of the skin and a hypertrophic scar is common ,especially in young children. In addition to the cosmetic issues,thickening and shortening of the scar at the waist crease may be irritated by the clothes. 29

30. The umbilicus presents an additional cosmetic challenge. A straight incision through the umbilicus is favoured by some, while most surgeons prefer to curve the incision around it, taking care to cut the skin perpendicular on the curve. Forceps placed on the umbilical skin, retracting it to one side and holding the skin taut while making the incision may be helpful. The incision is deepened through the subcutaneous fat, and any bleeding vessels controlled, until linea alba is exposed throughout the length of the incision. 30

31. At the umbilical cicatrix, the peritoneum is in close apposition to the linea alba, and is often the easiest and safest place to gain access to the peritoneal cavity. The linea alba is lifted upwards while the fascia is carefully incised. As the incision is extended, it is possible to encounter no muscle fibres, if it is in the midline, but below the arcuate line, there is no posterior sheath, also line alba is narrow, and pyrimidalis may be obvious, hence presence of muscle fibres do not mean that the incision is strayed. 31

32. The rectus muscle may be separated right down to pubic symphysis,but care must be taken, as an inadvertent incision may be made on the bladder. The peritoneal division may be lateralised if further low division is required for access. 32

33. Closure as mentioned before ,is a mass closure(a single layer with a continuous suture). Peritoneum may be included, but not necessary as it will naturally appose as fascia is closed. Some people may need a stoma, a temporary arrangement to allow the bowel time to heal, after an emergency laparotomy. The healing can take three to six months, after which time the patient will have to undergo another operation to rejoin the bowel and have the stoma removed. 33

34. Complications Hemorrhage Infection Damage to internal organs Formation of internal scar tissue Bowel blockages or abdominal pain caused by adhesions 34

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