Incisions in Urology.pptx

This presentation is about different incisions used in urology, different abdominal incisions used in general surgery, different lower abdominal surgery, different upper abdominal incisions, different thoracoabdominal incisions, different flank incisions, different incisions used in penile surgery, different incisions used in scrotal surgery, different incisions used in perineal surgery.

1. Incisions in urology surgeries Dr. Rabindra Tamang MCh Resident, TUTH

2. A rich man’s faults are covered with money, but a surgeon’s faults are covered with earth. Abraham Verghese

3. Contents Introduction Abdominal incisions Anterior approaches to retroperitoneum Flank incisions Inguinal incisions Scrotal incisions Penile incisions Perineal incisions Conclusion

4. introduction Incision is a cut produced surgically by a sharp instrument that creates an opening into an organ or space of body. Any incision should achieve three essentials Accessibility Extensibility Security

5. Introduction Open incisions remain unpopular. However, indications for open surgery are based on patient characteristics Prior abdominal surgeries, Prior use of abdominal meshes, and Size and complexity of pathology (e.g., renal mass with caval thrombus)

6. Midline incision Commonly used incision because all 3 spaces are accessible. Advantages: Almost bloodless Very quick to open and close

7. Infraumbilical incision; Indications: Prostatectomy Cystectomy Pelvic lymph node dissection Diverticulectomy Urinary diversions

8. Upper mildline incision: To access retroperitoneal structures including Adrenal glands Kidneys Ureters Retroperitoneal lymph nodes

9. Complete mildline incisions: Trauma nephrectomies RPLND Bilateral nephrectomy for polycystic kidney diseases Large retroperitoneal mass resection Nephroureterectomy

10. Surgical techniques: Incision: along linea alba Avoid rectus muscles Avoid falciform ligament and injury to bladder Closure: In single layer Running or interrupted figure of eight fashion Sutures: 1 cm from midline and 1 cm apart

11. Pfannenstiel incision Indications: Specimen extraction site post nephrectomy Surgical approach to prostate, bladder & distal ureter Surgical techniques: Transverse semilunar incision

12. Pfannenstiel incision Closure: Muscle and peritoneum are approximated Fascia closure: running or figure of eight absorbable suture Modifications: Extend to Gibson incision: ureter Slightly towards the side of surgery: specimen extraction

13. Gibson incision Muscle splitting incisions Provides great extraperioneal access to Lower ureter Bladder Pelvic vessels Surgical techniques: Oblique or curvilinear Muscles are splitted. Peritoneum can be mobilized Closure: two layers with running absorbable sutures.

14. Modifications : J shaped or hockey shaped incision Rectus sheath is intact

15. Anterior approaches to retroperitoneum Thoracoabdominal incision: At cost of large and more morbid incision, it provides excellent exposure. Indications: Level III caval thrombus T4 renal tumors Large upper pole tumors Adrenal tumors Retroperitoneal masses

16. Thoracoabdominal incision continued Incision: Usually made above 9 th or 10 th rib bed depending on pathology, either supracostal or removing a section of rib and extended into abdomen Muscles are incised and pleura opened with care not to injure the underlying lung. Diaphragm can then be opened and the costochondral junction cut. Phrenic nerve

17. Closure: Chest incision is closed after placement of chest tube Diaphragmatic incision is closed in two layers with a running absorbable suture. Use of non absorbable mesh with anchoring figure of eight sutures: Decreased costochondral displacement and discomfort Abdominal wall is then closed.

18. subcostal incision (Kocher) It addresses larger, more anterior tumors where access to hilum may be better controlled than flank subcostal approach. Surgical techniques: Position: supine or modified flank position Incision: two fingerbreadths below costal margin extending laterally as far as the tip of the 11 th rib Anterior rectus sheath is incised and muscle is cut while laterally the muscle layers are divided in sequence

19. Modifications: Chevron (rooftop) modifications Mercedes Benz modifications

20. Flank incisions Flank position: lateral recumbent position with lower leg flexed and upper leg extended, creating a convex extension of the upper side (operative side) of the body. Based on target location and size of renal or retroperitoneal mass, flank incisions can be, 12 th rib supracostal 11 th rib transcostal Subcostal

21. They inherently increase the risk for thoracic complications including pleural injuries. Disadvantage of resection of tip of the ribs: Significant postoperative pain Risk of flank bulge if one goes as high as the 11 th rib Advantage: Allow for more comfortable retroperitoneal access posteriorly: less risk for associated bowel complications

22. Flank incisions

23. Surgical techniques:

24. Neurovascular bundle: Between internal oblique and transversus abdominis In case of pleural injury: Chest tube

25. Inguinal incisions Indications: Cryptoorchidism Inguinal varicocelectomies Oncologic procedures Partial or radical orchiectomy

26. Curvilinear incision Inguinal incision above external inguinal ring Subinguinal approach

27. Incisions above inguinal ligament: Most commonly used for radical orchiectomy Incision: 5 – 7 cm curvilinear transverse incision is made beginning 2 cm cephalad and lateral to the pubic tubercle. Careful dissection to avoid injury to the ilioinguinal ligament and spermatic cord structures. Closure: reapproximate of internal oblique and external oblique to close inguinal canal and create a new external ring.

28. For benign diseases, Incision is usually smaller (2 – 3 cm) and begins 2 fingerbreadths above the symphysis pubis starting at the lateral aspect of the scrotum obliquely along the course of inguinal ligament. The goal is to enter just below the external inguinal ring. Subinguinal approach: Used in obese men or those with prior inguinal surgeries.

29. Incisions for inguinal and/or pelvic lymphadenectomy in penile cancer: Midline – bilateral PLND Vertical incision for superficial and deep LND S shaped for complete ILND and ipsilateral pelvic LN L shaped incision for palpable disease Gibson incision for ipsilateral PLN Subinguinal incision for ipsilateral nodes

30. Incisions for inguinal and/or pelvic lymphadenectomy in penile cancer:

31. Incisions for specific surgeries Posterior lumbodorsal incision or dorsal lumbotomy: Simon performed first nephrectomy using this incision Advantages: Lack of muscle or rib distortion Faster convalescence and decreased intraperitoneal complications.

32. Disadvantages: Limited surgical exposure which resulted in difficult access to vascular control of the kidney.

33. Indications: Pyeloplasty (esp. pediatric population) Upper tract urolithiasis Open renal biopsy Partial nephrectomies

34. Anatomy of lumbodorsal region: Superior: 12 th rib Inferior: Iliac crest Medial: spinous processes of the vertebral column Lateral: an imaginary line between ASIS and the costal margin

35. Dorsal lumbotomy

36. Surgical techniques: Incision: 3 – 5 cm incision two to three fingerbreadths lateral to the spine starting at the costovertebral angle or as high as 11 th rib Incision is made directly over the quadratus lumborum Superficial muscles encountered are: Medial: sacrospinalis Posterior: Latissimus dorsi Anterior: external oblique

37. Modification: Incision can be extended by transecting the costovertebral ligament, mobilizing the 12 th rib, and removing a 2-cm section of 12 th rib as needed.

38. Scrotal incisions Indications: Varicocelectomy Hydrocelectomy Spermatocelectomy Vasectomy Scrotal exploration for testicular torsion Orchiopexy Contraindication: Testicular or intrascrotal malignancy

39. Incision: Transverse or vertical Midline vertical incision in midline raphe if both sides of scrotum are to be operated. Modification: Incision can be extended to base of penis to insert an inflatable penile prosthesis or artificial urinary sphincter.

40. Closure: Easier as scrotal skin is quite elastic. Chances of hematoma or swelling  so dead space must be closed / drain placed. In one or two layers.

41. Penile incisions Indications: Phimosis Penile fractures Peyronie’s disease Phimosis : Two incision sleeve technique

42. 5- 10 mm subcoronal incision Prepucial incision at the level of coronal sulcus

43. Penile fractures: Subcoronal incision and degloving approach Direct longitudinal incision Peyronie’s disease: Subcoronal incision

44. Perineal incisions Indications: Urethroplasties Perineal urethrostomy Male urethral slings Inflatable penile prosthesis Artificial urethral sphincters

45. Incisions: Vertical incision Inverted Y incision  An inverted ‘Y’ incision is made on the perineum with the vertical part on the median raphe extending from the perineo -scrotal junction to about 2.5cm from the anus. The wings of the ‘Y’ are carried on either sides of the anus to a point medial to the ischial tuberosity

46. Inverted U incision: The start and end points at the sides of perineal body (both are about 2-3 cm to perineal body) Apex: mid perineum Total length of incision is 10–15 cm Radical perineal prostatectomy Rectourethral fistula

47. Conclusion Open incisions are still vital in this era of minimal invasive surgeries. Proper incision is with proper principles followed is required for optimal outcomes. Selection of proper incision depends upon surgical pathology.

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