abdominal incisions and wound healing.pptx

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1. Abdominal incisions and wound healing Presented by ; ngangalya .s .nasser

2. objectives Know the different types of abdominal incisions used in obstetrics Advantages and disadvantages of the different incisions Different phases of wound healing

3. Abdominal incisions Abdominal incisions refers to surgical cuts(incision)made anywhere on the abdomen through the skin to facilitate a procedure or operation. An ideal incision; should allow ease of access to the desired structure Can be extended if needed Muscles should be split rather than cut Should heal quickly with minimal scaring(cosmetic)

4. Choice of incision depends ; Type of surgery(elective/emergency) Target organ or structure Target organ Surgeons experience Previous surgery. Langer’s lines ; correspond to natural orientation of the collagen fibers in the dermis, are parallel to the orientation of the underlying muscle fibers . Importance? Less scaring ,better healing for parallel incisions. The abdominal incisions can be ; Transverse incisions Vertical incisions others

5. Vertical incisions Midline incision Incision follows the Linea alba. Can be upper median ,lower or full median incision. Favored in diagnostic laparotomy as it allows wide access to the abdominal cavity Adv ; almost bloodless No muscle fibers or nerves are damaged Very quick to make and close Good access to upper abdominal viscera Can be extended full length Paramedian incision Incision placed 2-5cm lateral of midline aspect of rectus muscle. Provides access to lateral structures. Advs ; access to lateral structures Avoids injury to the nerves ,limits trauma to the rectus muscle Permits good restoration of abdominal wall function.

6. Ctn; Disadv ; Care needed just above the umbilicus where the falciform ligament is. Midline scar Risk bladder injury Nb; upper-from xiphoid sternum to above the umbilicus.(identify and avoid the falciform ligament) Lower- from the umbilicus superiorly to the pubic symphysis inferiorly. Full-xiphoid to pubic symphysis. Disadv ; Time consuming Difficult extension superiorly limited by coastal margin Muscle atrophy , tends to strip the muscles of lateral supply and innervation(medial muscles affected)

7. Transverse incisions Advantages Better cosmetically Less painful Good access to upper abdominal organs(GI tract) Suitable in children, short stature and obese people (transverse length of the abdomen) Disadvantages Limited exposure to the organs

8. Pfannenstiel incision(“bikini”) A transverse (or horizontal) incision made just above the pubic bone commonly used for cesarean sections and other pelvic surgeries. Known for its cosmetic importance as the scar is hidden within the pubic hairline. Causes less damage to the abdominal wall ,preserving the nerve fibers and blood vessels. Less risk of abdominal hernias compared to the other incisions. Also has a wide application(caesarian section, orthopedic, procedures on the bladder, prostate, ureters other gyn surgeries) Rectus muscles are separated not cut.to maintain integrity of the abdominal wall. Incision can be complicated if unexpected situations arise during surgery and require another intervention.

9. The position for this operation can be lithotomy, supine or modified dorsal supine lithotomy. The incision is made above the mons pubis and is about 12cm. Care should be taken to ensure that hemostasis is complete before entering the peritoneum. Other incisions: Kocher subcostal incision ; affords excellent exposure of the gall bladder, biliary tract and spleen on the left. Starts at the midline 2-5cm below the xiphoid and runs downward, outward and parallel to and about 2.5cm below coastal margin. Modifications; rooftop incision and Mercedes Benz incision. Transverse muscle dividing incision : preferred in newborn and infants ,short stature and in obese because more abdominal exposure is gained per length of exposure than vertical exposure.

10. McBurney incision ; of choice in appendicectomies. Level and length of incision will vary according to the thickness of the abdomen and suspected position of appendix. Modifications: Lanz incision ; made in transverse plane. Rutherford-Morrison incision; extension of McBurney to divide the oblique fossa. Maylard transverse incision ; Incision is placed above the site for Pfannenstiel incision, gives excellent exposure of pelvic organs. Inguinal incision ; done for hernias, testicular cancer, cryptorchidism, hydrocele, varicocele. Thoraco-abdominal incision; either R or L, converts the pleural and peritoneal cavity into one common cavity.

11. Complications of abdominal incision Pain at incision site Hematoma, stitch abscess Infection and sepsis Fistula and burst abdomen Adhesion and its complications Scars(cosmetics) Factors affecting the strength of the scar. Type of incision Ascites Cough Obesity Diabetes immunosuppression

12. Wound healing What is a wound? A break in the integrity of the skin or tissue that is often associated with a disruption in the structure and function. Classification; Rank and Wakefield ; tidy and untidy wounds Based on type: Clean incision wound Bruising and contusion Haematoma Puncture wound Abrasion Crush injury wound Penetrating wound Injury to bone and nerve tissue

13. Based on the thickness : Superficial wound Deep Partial thickness Complicated wound Penetrating wound Classification of surgical wounds a) Clean wound b) Clean contaminated wound c) Contaminated wound d) Dirty infected wound

14. HEALING • Healing is the body’s response to injury in an attempt to restore normal structure and function. The process of healing/repair involves 2 distinct processes: Tissue regeneration Connective tissue deposition(scar formation) • Regeneration : Is when healing takes place by proliferation of parenchymal cells and usually the original results in complete restoration of tissues. • The goal of all surgical procedures should be regeneration which returns the tissues to their normal microstructure and function. • fibrous tissue deposition : It is a healing outcome in which tissues do not return to their normal architecture and function. Labile, stable , permanent tissues.

15. TYPES OF WOUND HEALING • Healing by first intention (wounds with opposed edges) • Healing by secondary intention (wounds with separated edges) Healing by first intention (wounds with opposed edges) Healing of wound with following characteristics :  Clean and uninfected  Surgically incised  Without much loss of cells and tissue  Edges of wound are approximated by surgical sutures.  Wounds with opposed edges  Primary union • The incision causes death of a limited number of epithelial cells and connective tissue cells disruption of epithelial basal membrane continuity • The narrow incisional space immediately fills with clotted blood containing fibrin and blood cells; dehydration of the surface clot forms the well- known scab that covers the wound.

16. By day 5, Incisional space is filled with granulation tissue Neovascularization is maximal .Collagen fibrils become more abundant and begin to bridge incision • The epidermis recovers its normal thickness, and differentiation of surface cells yields a mature epidermal architecture with surface keratinization During the second week Continued accumulation of collagen and proliferation of fibroblasts Leukocytic infiltrate, edema, and increased vascularity have largely disappeared.

17. By the end of the first month, • Scar comprises a cellular connective tissue devoid of inflammatory infiltrate, covered now by intact epidermis. • Dermal appendages that have been destroyed in the line of the incision are permanently lost. • Tensile strength of the wound increases thereafter, but it may take months for the wounded area to obtain its maximal strength.

18. Healing by second intention; For large gaping wounds with significant tissue loss or infection. More inflammation ,abundant granulation tissue, wound contraction. Forms an irregular scar and is slow healing.

19. STAGES OF WOUND HEALING 1. Stage of inflammation. 2. Stage of granulation tissue formation and organization. 3. Stage of epithelialization. 4. Stage of scar formation and resorption. 5. Stage of maturation.

20. PHASES OF WOUND HEALING For soft tissue wound healing: 1.Inflammatory phase: It can be broken down into further a) Clot formation b) Early inflammation c) Late inflammation 2.Proliferative phase 3.Maturation phase

21. Inflammatory phase a) Clot formation: - Begins with three events: i. Blood vessel contraction initiated by platelet degranulation of serotonin, which acts on endothelial cell and increases the permeability of the vessel , allowing a protein rich exudate to enter the wound site ii. A platelet plug formation iii. Activation of extrinsic and intrinsic clotting mechanisms

22. This step is comprised of the typical acute and chronic inflammatory responses. (chemotaxis) Macrophages and neutrophils act to eliminate the offending microorganisms. Cell proliferation;(up to 10 days) Epithelial cells , endothelial cells and fibroblasts proliferate and migrate near the wound. Epithelial-cover the wound, endothelial and vascular cells form new blood vessels.(angiogenesis) and fibroblasts lay down collagen fibres. Collectively form granulation tissue.(pink in colour) Remodeling : the deposited connective tissue by the fibroblasts is rearranged to from a stable fibrous scar.(2-3wks) Angiogenesis: new blood vessels from existing ones.

23. Deposition of ECM proteins by the fibroblasts Remodeling of the connective tissue to increase its strength and contract it. Factors that impair tissue repair Infection Diabetes Nutritional status Steroids Mechanical factors Poor perfusion Location of injury Type and extent of tissue injury

24. Defects in wound healing Venous leg ulcers, arterial ulcers contractures Pressure sores Diabetic ulcers Excessive scaring and keloids