Surgical incisions

Surgical incision
By Dr. Somaya Banaei
Resident of General Surgery
Herat-Afghanistan

1. Surgical Incisions
Under observation:
Specialist Dr. Ghulam Reza Riaz
Submitted By:
Dr. Somaya Banaei
Resident of General Surgery
Herat-Afghanistan

2. Introduction
Surgical Incision is a cut made through the skin to facilitate an
operation or procedure.
It should be the aim of the surgeon to employ the type of
incision considered to be the most suitable for that particular
operation to be performed.
By: Dr. Somaya Banaei 2

3. In doing so, three essentials should be achieved:
Accessibility Extensibility Security
By: Dr. Somaya Banaei 3

4. Principles
Incision should be long enough for good exposure
Splitting is better than cutting
Choose the correct position
Avoid cutting of nerves and vessels
Retract muscle, abdominal organs towards neurovascular bundle
Insert DT through a separate incision
Close the wound layer by layer
By: Dr. Somaya Banaei 4

5. Choice of incision
Type of surgery
[elective/emergency]
Target organ
Previous surgery
Grade of patient
Obesity
Surgeons own experience &
preference
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6. Rectus abdominis muscle maybe cut transversely without weakening
the abdominal wall.
The cut passes between two adjacent nerves without injuring the
nerves.
The incision must not divide no nerve
Drainage tubes should be inserted through separate incision like wise
colostomy or ileostomy should be made through a separate incision
The openings made by the incision through different layers of the
abdominal wall must not be superimposed
By: Dr. Somaya Banaei 6
The ideal incision allows:

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8. Lines Of Cleavage
Or
Langer’s Line
The natural lines of cleavage in the skin are constant and run
Downward and forward almost horizontally around the trunk.
If possible, all surgical incisions should be made in the lines of
cleavage, Where the bundles of collagen fibers in the dermis
run in parallel rows.
An incision along a cleavage line will heal as a narrow scar.
By: Dr. Somaya Banaei 8

9. Langer’s Line correspond to the natural orientation of collagen fibers
in the dermis, and are generally parallel to the orientation of the
underlying musclefibers
Incisions made parallel to Langer's lines may heal better and
produce less scarring than those that cut across.
By: Dr. Somaya Banaei 9
Lines Of Cleavage
Or
Langer’s Line

10. Common Abdominal & Pelvic incisions
By: Dr. Somaya Banaei 10
Vertical Incisions
Transverse incisions
Oblique Incisions
•Midline
•Paramedian
•Transverse Muscle Dividing
•Pfannenstiel Incision
•Maylard Incision
•Kocher Subcostal Incision
•Mc Burney Incisions
•Oblique Muscle cutting
•Inguinal incision

11. By: Dr. Somaya Banaei 11
Common Abdominal & Pelvic incisions

12. Vertical Incisions
Medline Incision
vertical incision which follows the lineaalba.
It may be:
Upper Midline Incision
Lower Midline Incision
Single Incision
By: Dr. Somaya Banaei 12

13. Layers of the abdominal wall
•skin, fascia (camper's and scarpa's)
•lineaalba
•transversalis fascia
•extraperitonealfat
•peritoneum
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It is favored In diagnostic laparotomy, as it
allows wide access to abdominal Cavity.
Vertical Incisions
Medline Incision

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Upper medline
•From xiphoid to above umbilicus.
•Division of the peritoneum is best performed at the
lower end of the incision
•just above the umbilicus ,so that the falciform ligament
can be seen and avoided
•Suitable for Upper GI tract operations
Lower medline
•From the umbilicus superiorly to the pubis symphysis
inferiorly
•Allow access to pelvic organs
•the peritoneum should be opened
•in the uppermost area to avoid injury to the bladder

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•Almost bloodless
•No muscle fibers are divided
•No nerves are injured
•Good access to upper abdominal viscera
•Very quick to make as well as to close
•Can be extended full length of abdomen.
•Supine position
Advantage
•Care needs to be taken just above the umbilicus where the
falciform ligament is.
•Midline scar
•Bladder injury
•Incisional hernia
•Adhesions in lower incisions
Disadvantage

16. Modified Makuuchi Incision
A.The modified incision is used for liver and
right-sided abdominal surgery. This incision
begins cephalad to the xiphoid, extends to 1
cm above the umbilicus, and then extends
laterally to the right.
B.The L incision is used for gastric, pancreatic,
and left-sided abdominal surgery. This
incision is a mirror image of the modified
Makuuchi incision.
By: Dr. Somaya Banaei 16

17. placed 2 to 5 cm lateral to midline
It can be extended from costal margin to pubis
Layers of the abdominal wall:
Skin, fascia (camper's and scarpa's) and the anterior rectus
sheath are incised.
The anterior rectus muscle is freed from the anterior sheath and
retracted laterally.
The posterior rectus sheath (if above the arcuate line) or
transversalis fascia (if below the arcuate line)
Extra peritoneal fat and peritoneum are then excised allowing
entry to the abdominal cavity.
By: Dr. Somaya Banaei 17
Vertical Incisions
Para median Incision

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•Provides access to lateral structures
•Avoids injury to nerves, limits trauma to rectus muscle.
•Permits good restoration of abdominal wall function
•Can be extended by slanting the upper end of the incision
medially towards the xiphoid process if required
Advantage
•Time consuming.
•Bleeding & hematoma
•Incision needs to be closed in layers
•Difficult extension superiorly as limited by the costal margin
•Tends to strip the muscles of their lateral blood and nerve
supply resulting in atrophy of the muscle medial to the
incision
Disadvantage

19. Mayo-Robson incision
•This is really a PARAMEDIAN incision that
has been curved towards the xiphoid
process.
•It allows a bigger and wider opening.
•Dissection continues in the same fascial
planes as the paramedian incision.
By: Dr. Somaya Banaei 19

20. This incision is made just above the umbilicus,
dividing one or both of the rectus muscles.
In newborn and infants, this incision is preferred bcz
more abdominal exposure is gained per lenghtof
incision than with vertical exposure
It is useful for:
•Right or left colon
•Duodenum
•Pancreas
•Subhepaticspace.
By: Dr. Somaya Banaei 20
Transverse incision

21. Layers for Transverse incision
a)Skin, fascia
b)Anterior rectus sheath,
c)Rectus muscle (+/-internal oblique,
depending on the length of the
incision),
d)Transvers abdomen
e)Transversalisfascia
f)Extraperitonealfat
g)Peritoneum
By: Dr. Somaya Banaei 21

22. By: Dr. Somaya Banaei 22
•Less pain than a midline incision
•Good access to midline upper GI structures
•Transverse incisions cause the least amount ofdamage
•As the recti have a segmental nerve supply, itcan be cut transversely without
weakening adenervatedsegment
•Muscular segments can be rejoined
•Better scar and good healing.
Advantage
•Limited lateral access in comparison withmidline incisions that can then be
extended
•More wound infections compared to midlinethought to be due to greater
difficulty incontrolling bleeding and haematomaformation
Disadvantage

23. Pfannenstiel Incision
•Used frequently by gynecologist and
urologist for access to pelvic organ,
bladder, prostate and for c.section.
•A convex 5cmto 12cmincision, located a
the suprapubic skin crease about 2cmto
5cmabove the pubic symphysis.
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25. Maylard Transverse (Muscle Cutting Incision)
•Gives Excellent Exposure To
Pelvic Organ
•Skin Incision Is Placed Above But
Parallel To Traditional Placement
Of Pfannenstiel Incision
By: Dr. Somaya Banaei 25

26. By: Dr. Somaya Banaei 26
•3cm below the line that joins spina iliaca ant. Sup.
•Slightly higher Pfannenstiel.
•Subsequent layers open bluntly .
•It necessary extended with scissor and not a knife
This incision associated with
Less:
Pain/fever/Analgesic equipment /blood loss
Shorter:
Duration of surgery/Hospital stay
Joel-Cohen incision

27. The Küstnerincision
Sometimes incorrectly referred to as
modified pfannenstielincision
involves a slightly curved skin incision
beginning below the level of the anterior
superior iliac spine and extending just below
the pubic hairline.
This incision is more time‐consuming and
extensibility is limited.
By: Dr. Somaya Banaei 27

28. By: Dr. Somaya Banaei 28
The Cherney incision involves transection of
the rectus muscles at their insertion on the
pubic symphysis and retraction cephalad to
improve exposure.
This can be used for urinary incontinence
procedures to access the space of Retziusand
to gain exposure to the pelvic side‐wall for
hypogastric artery ligation.
The Cherney incision

29. Kocher (Subcostal) Incision
•It affords excellent exposure to gall bladder
and biliary tract and can be made on left side
to afford access to spleen.
•İs started at midline ,2 to 5 cm below the
xiphoid, and extends downwarda, outwards
and paralelto and about 2.5 cm below costal
margin
•Especially used in cholecystectomy
There are two modifications
Chevron (rooftop)modification
Mercedes Benz modification
By: Dr. Somaya Banaei 29

30. Chevron (rooftop) modification
The incision may be continued across the
midline into double Kocher's incision or rooftop
appearance which provide excellent access to
upper abdomen particularly in those with broad
costal margin
Uses:
Total Gastrectomy
Total Oesophagectomy
Extensive Hepatic Resection
Bilateral Adrenectomy
By: Dr. Somaya Banaei 30

31. Mercedes Benz modification
•Consists of bilateral low kocher’s
incision with upper midline incision up
to the xiphisternum.
•Gives excellent access to the upper
abdominal viscera mainly the
diaphragmatic hiatuses
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33. Thoraco-abdominal Incisions (left / Right)
They convert the pleural and
peritoneal cavities into one.
They allow good access to the lungs,
liver and spleen.
By: Dr. Somaya Banaei 33
Incision is extended along line of
8
th
intercostal space
the space immediately distal to inferior
pole of scapula.

34. By: Dr. Somaya Banaei 34
•Right incision may be
particularly useful in elective
and emergency hepatic
resections
•Left incision may be used in
resection of lower end of
esophagus and proximal
portion of stomach.
Thoraco-abdominal Incisions (left / Right)

35. Flank incision (Retroperitoneal approach)
It commences 1.25cm below and lateral to renal
angle and passes towards the anterior superior
iliac spine.
This extends from kidney angle in oblique
direction down wards and outwards toward the
anterior superior spine.
The kidney angle is formed by the outer border
of sacrospinalismuscles at the junction with the
12th rib.
By: Dr. SomayaBanaei 35

36. Flank incision (Retroperitoneal approach)
By: Dr. SomayaBanaei 36
The incision runs in the direction of the
fibresof external oblique muscle.
This incision for open nephrectomy.
Right lateral region of abdomen has been
exposed.
The outline of three lowest ribs made
visible.

37. Grid iron (muscle splitting) incision
İncision of choice most appendicectomies.
The level and lenghtof incision will
varyaccordingto thickness of abd. Wall and
suspected position of apendix
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Mc Burney point.
Is made at the junction of middle third and
outer third of a line running from umblicus
to,anterior superior iliac spine

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Originally placed the incision obliquely
from above laterallyto below medially.
Also used in left lower quadrant to deal
with certain lesion of sigmoid colon such
as drainage of diverticular abscess.
The level and length of the incision vary
according to thickness of abdominal wall
Suspected position of the appendix
Grid iron (muscle splitting) incision

39. By: Dr. Somaya Banaei 39

40. Lanzincision
•It is a variation of McBurneys
incision that is made the same point
but in transverse plane.
•It gives cosmetically good scar
By: Dr. Somaya Banaei 40

41. Rutherford-Morrison Incision
Oblique muscle cutting incision,Extension
of mcburneyincision by division of oblique
fossa.
Can be used for:
•Right and left sided colonic resection
•Caecostomy
•sigmoid colostomy.
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42. Inguinal incision
Done for
Inguinal hernia
Testicular cancer
Cryptorchidism
Hydrocele
Varicocele
UDT
Orchiectomy
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43. By: Dr. Somaya Banaei 43
In urology, a Gibson incision is used for renal
transplantationor as an extra peritoneal approach
to the distal ureter with low morbidity.
It is started 3cm above and parallel to theinguinal
ligamentand extended vertically 3cm medial to the
anterior superioriliac spineup to theumbilicus
The Gibson incision cannot be extended easily in
case of unexpected intraoperative situations.
Gibson Incision

44. Incisions on posterior abdominal wall
By: Dr. Somaya Banaei 44

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46. Complications of
abdominal incision
Hematoma, Stitch abscess, Wound infection
Wound dehiscence
Burst abdomen
Fistula formation
Wound pain
Incisional hernia
Adhesion and its complications
By: Dr. Somaya Banaei 46
Thanks for your
attention

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British Novelist –Playwright and Poet
1911 -1993
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She multiplies and enlarges what is given to her.
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By: Dr. Somaya Banaei 47