Renal incision

Abdominal wall anatomy
Classification of incisions.

1. By Hassaan Ali Gad Assistant lecturer of urology Aswan University, Egypt Surgical approaches to the urinary system

2. Introduction. Abdominal wall anatomy Classification of incisions. Outline

3. Definitions Incision : A cut produced surgically by a sharp instrument that creates an opening into an organ or space in the body. Introduction

4. Skin Superficial fascia Muscles Transversals fascia Extra peritoneal fascia Peritoneum Layers of Abdominal Wall

5. Layers of Abdominal Wall

6. Skin squamous stratified epithelum Superficial fascia: - Camper’s fascia (Fatty Layer) - Scarpa's fascia (Membranous Layer)

7. A. SUPERFICIAL LAYER - move upper extremity Trapezius. Latissimus dorsi . Levator scapulae. Rhomboideus major. Rhomboideus minor. B. INTERMEDIATE LAYER- Respiratory muscles levator costrum Serratus posterior superior. Serratus posterior inferior C. DEEP LAYER - movetrunk and back 1. SPLENIUS 2. ERECTOR SPINAE 3. TRANSVERSO-SPINALIS – deep to Erector Spinae Muscles of Posterior Abdominal Wall

8. Anterior Group Rectus Abdominis Pyramidalis Lateral Group External Oblique Internal Oblique Transversus Abdominal Wall Muscles

9. RECTUS ABDOMINIS Origin : Symphasis pubis, pubic crest Insertion : 5 th, 6 th and 7 th costal cartilage and xiphoid process. Nerve Supply : Lower six thoracic nerves. Rectus Sheath : made up of the aponeuroses of the three anterolateral abdominal muscles as they converge at the linea alba. Linea Alba : fusion of the aponeuroses of the abdominal muscles, and it separates the left and right rectus abdominis muscles.

10. External Oblique Origin : lower 8 ribs. Insertion : Xiphoid process, Linea alba, pubic crest, pubic tubercle, iliac crest. Nerve Supply : Lower six thoracic nerves, iliohypgastric n., ilioinguinal n. Internal Oblique Origin : Lumbar Fascia, iliac crest, lateral two thirds of inguinal ligament. Insertion : Lower three ribs, costal cartilage, Xiphoid process, Linea alba, symphasis pubis. Nerve Supply : Lower six thoracic nerves, iliohypgastric n., ilioinguinal n.

11. Transversus Abdominis Origin : lower six costal cartilage, lumbar fascia, anterior two thirds of iliac crest, lateral third of inguinal ligament. Insertion : Xiphoid process, Linea alba, symphasis pubis. Nerve Supply : Lower six thoracic nerves, iliohypgastric n., ilioinguinal n.

12. SERRATUSPOSTERIOR SUPERIOR - Origin: Vertebrae(cervical and upperthoracic spines) Insert: Ribs Action: Raise ribs ininspiration 3. SERRATUS POSTERIORINFERIOR - Origin: Vertebrae lumbarand lower thoracic spines; Insert: Ribs Action: Lower ribs in expiration Innervation: both muscles by Intercostal Nerves

13. Psoas major Origin: inter vertebral discs T12/L1 to L4,5 bodies of L1-5 transverse prossesL1-5 Insertion: lesser trochanter Nerve supply:L1 ,2,3 Psoas minor Origin: bodies of T12/L1 Insertion: fascia over Psoas major behind inguinal ligament Nerve supply:L1

14. Quadrates lumborum Origin : transverse prossesL5, iliolumber ligament & posterior 1/3 iliac crest Insertion : medial ½ of 12 th rib, transverse prossesL1-4 Nerve supply:T12/L4 iliacus Origin : hollow of iliac fossa I nsertion : psoas tendon below lesser trochanter Nerve supply : femoral(L1,2,3)

15. Extraperitoneal Fascia The thin layer of fascia and adipose tissue between the peritoneum and fascia transversalis. Thoracolumbar Fascia Triangular-shaped sheet of tough connective tissue. Partial site of origin of latissimus dorsi and abdominal oblique muscles.

16. Flank Approaches ELEVENTH RIB INCISION (CLASSIC FLANK) SUBCOSTAL FLANK INCISION DORSAL LUMBOTOMY Anterior Approaches SUBCOSTAL TRANSPERITONEAL INCISION BILATERAL SUBCOSTAL TRANSPERITONEAL INCISION THORACOABDOMINAL INCISION INCISIONS FOR EXPOSURE OF THE UPPER GENITOURINARY ORGANS

17. Twelfth Rib or Modified Flank Incision Midline Abdominal Incisions Gibson’s Incision INCISIONS FOR EXPOSURE OF UPPER AND LOWER URINARY TRACT ORGANS

18. Infra umbilical Incision Lower Abdominal Transverse Incision Inguinal Incision INCISIONS FOR EXPOSURE of LOWER GENITOURINARY AND PELVIC STRUCTURES

19. ELEVENTH RIB INCISION (CLASSIC FLANK)

20. The incision begins posterior at the angle of the11th rib and may extend as far as the border of the rectus abdominus. The skin and subcutaneous tissues are opened Transecting the latissimus overlying the 11 th rib. incision of the periosteum, along the length of the rib .. A periosteal elevator is used to remove the periosteum The Doyen rib instrument slides into the plane between rib and periosteum. to complete the rib dissection. Incised the thoracolumber facia to expouse the kidney ELEVENTH RIB INCISION

21. SUBCOSTAL FLANK INCISION

22. The skin and subcutaneous tissues are opened Incision of the external abdominal oblique muscle and latissimus dorsi. opening the internal oblique muscle The lumbodorsal fascia (the fusion of the internal oblique andtransversalis muscle sheaths posteriorly) is incised to enter the retro peritoneum. Peritoneum is then swept awayfrom the anterior abdominal wall. The transversalis fibers are separated bluntly. SUBCOSTAL FLANK INCISION

23. DORSAL LUMBOTOMY

24. . The incision is limited by the 12th rib superiorly and the iliac crest inferiorly, so there is no option to extend it. DORSAL LUMBOTOMY

25. SUBCOSTAL TRANSPERITONEAL INCISION

26. Incision parallel with the costal margin. ( started at the midline, 2 to 5 cm below the xiphoid and extends downwards, outwards and parallel to and about 2.5 cm below the costal margin ) The external oblique, internal oblique, and transversalis muscles are opened to expose the peritonium SUBCOSTAL TRANSPERITONEAL INCISION

27. BILATERAL SUBCOSTAL TRANSPERITONEAL INCISION

28. Excellent exposure to the upper abdominal cavity andRetroperitoneum The incision may be continued across the midline into a double Kocher incision As with any bilateral incision, care should be taken to assure the incision is symmetrical with respect to the midline and to the costal margins. The abdomen is entered inthe same manner as in the unilateral subcostal transperitoneal incision. Chevron incision

29. THORACOABDOMINAL INCISION

30. Thoracoabdominal incision offers wide exposure of theupper abdomen, chest, and retroperitoneum for largerenal, adrenal, or retroperitoneal tumors or incision is made through the eighth or ninth intercostal space extending inferomedially to or across the midline.. The abdominal portion of the incision is opened first . The costal cartilage between the tips of the two ribs on either side of the incision is then divided with heavy scissorsor rib cutters. Dissection is carried through the intercostalmuscles along the upper border of the adjacentlower rib in order to avoid the neurovascular bundle. The pleura is opened under direct visualization. The diaphragm is incised. With the diaphragm opened, the liver can be retracted into the thorax to maximize exposure of the underlyingstructures THORACOABDOMINAL INCISION

31. Twelfth Rib or Modified Flank Incision

32. A 12th rib incision carries less risk of pleural injur The positioning should be similar to an 11 th rib incision,but the patient should be rotated slightly dorsad. The 12thrib is marked, and the bed developed in the same manner as the 11th rib incision. the incision is angled downwardalong the lateral border of the ipsilateral rectus muscle.If required, 2 cm above the pubis can be made for better bladder exposure. Reflecting the peritoneum medially by blunt dissection gives excellent visualization of the retroperitoneum. Twelfth Rib or Modified Flank Incision

33. Midline Abdominal Incisions

34. Upper Midline Incision From xiphoid to above umbilicus. Skin  superficial and deep fascia  linea alba  extraperitoneal fat (abundant and vascular)  peritonium. Division of the peritoneum is best performed at the lower end of the incision, just above the umbilicus so that falciform ligament can be seen and avoided Lower Midline Incision From the umbilicus superiorly to the pubic symphysis inferiorly. the peritoneum should be opened in the uppermost area to avoid possibleinjury to the bladder. Allow access to pelvic organs. Full Midline Incision Great exposure is needed. Classification Midline Abdominal Incisions

35. Advantages: It is almost bloodless. No muscle fibres are divided. No nerves are injured. Good access to the upper abdominal viscera. It is very quick to make as well as to close. Disadvantages: More painful. Chest complications. Wound infection……Ugly scar…… Incisional hernia…. etc

36. Gibson’s Incision

37. Now used mainly for renal transplantation. In the supine position, an incision is made 2–3 cm medial to the line from the anterior superior iliac spine to the pubis. . The external oblique aponeurosis is exposed. An incisionis made along the lateral border of the rectus abdominus. .

38. If more medial exposure is needed, the rectus maybe transected across its tendinous attachment to the pubis. The inferior epigastric artery may be ligated and divided as it passes along the posterior aspect of therectus. The transversalis fascia is incised to expose the bladder are swept medially to develop the extraperitoneal space The peritoneum and bladder are swept medially to develop the extraperitoneal space

39. Lower Abdominal Transverse Incision

40. The incision is carried through the skin and subcutaneous The rectus fasciais incised. Ending the fascial incision at the lateral borders of therecti limits the risks of injury to the ilioinguinal nerve andcontents of the inguinal canal. .

41. Each leaf of the divided rectus fascia is grasped approx1 cm lateral to the midline with Allis clamps and retracted ventrally. . A curved clamp bluntly separates the two recti, which are retracted laterally. Incising the transversalis fascia, opens the proper plane of dissection. Sweeping the plane between bladder and pelvis exposes the obturator nervesand vessels

42. THANK YOU