abdominal incisions

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1 : Surgical Abdominal Incision Dr. Ankan Mondal
2 : Definition A cut produced surgically by a sharp instrument that creates an opening into an organ or space in the body. When choosing an incision these three should be achieved Accessibility Extensibility Security, The incision must not only give ready and direct access to the anatomy to be investigated but also provide sufficient room for the operation to be performed .
3 : Ideal Incision The ideal incision should have the following characteristics: Easy to open Minimise damage to tissues Avoid cutting nerves Split rather than transect muscles Limit damage to fascia Easy to close Allow sufficiently strong closure Allow sufficient access Extendable if necessary Factors to Consider Type of surgery Target organ Body habitus Previous operations Speed which the operation needs to be performed Operator preference/experience
4 : In abdominal surgery, wisely chosen incisions and correct methods of making and closing such wounds are factors of great importance. As a badly placed incision, incorrect methods of suturing, or ill-judged selection of suture material, may result in serious complications such as :, An ugly scar, Haematoma formation An incisional hernia, Complete disruption of the wound.
5 : Care must be taken to avoid ‘tramline’ or ‘acute angle’ incisions, which could lead to devascularisation of tissues. Cosmetic end results of any incision in the body are most important from patients’ point of view.
6 : Classification of incisions Vertical incision Midline incisions Paramedian incisions Transverse and oblique incisions Kocher's subcostal Incision Chevron (roof top Modification ) Mercedes Benz Modification Mc Burney’s grid iron or muscle splitting incision. Pfannenstiel incision Maylard Transverse Muscle cutting Incision Transverse Muscle dividing incision Oblique Muscle cutting incision Thoracoabdominal incisions.
7 : Vertical Incisions
8 : Midline incision the most common incision Have three types: Upper Midline Incision From xiphoid to above umbilicus. Skin ? superficial and deep fascia ? linea alba ? extraperitoneal fat ? 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.
9 : . Lower Midline Incision From the umbilicus superiorly to the pubic symphysis inferiorly. Allow access to pelvic organs. The peritoneum should be opened in the uppermost area to avoid possible injury to the bladder. Full Midline Incision From xiphoid to pubic symphysis inferiorly. Great exposure is needed.
10 : Paramedian incision 2 to 5 cm lateral to the midline. Over the medial aspect of the bulging transverse convexity of the rectus muscle. skin ? fascia ? anterior rectus sheath ? 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) ? extraperitoneal fat and peritoneum are then excised allowing entry to the abdominal cavity .
11 : . Advantages Provide an access to the lateral structure such as the spleen or the kidney The closure is theoretically more secure because the rectus muscle can act as a support between the reapproximated posterior and anterior fascial planes so lower risk of dehiscence and hernia as compared to midline incision Disadvantages Takes longer to make and close Incision needs to be closed in layers It tends to weaken and strip off the muscles from it’s lateral vascular and nerve supply resulting in atrophy of the muscle medial to the incision The incision is laborious and difficult to extend superiorly as is limited by costal margin. It does not give good access to contralateral structure Risk of epigastric vessels injury
12 : Transverse And Oblique Incisions
13 : Kocher’s incision Incision parallel to the right 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 It shows excellent exposure to the gallbladder and biliary tract and can be made on the left side to show access to the spleen. .
14 : . Special attention is needed for control of the branches of the superior epigastric vessels which lie posterior to and under the lateral portion of the rectus muscle The small eighth thoracic nerve will almost invariably be divided The large ninth nerve must be seen and preserved to prevent weakening of the abdominal musculature Have two modification: Chevron (Roof Top) Modification. The Mercedes Benz Modification.
15 : Chevron (Roof Top) Modification The incision may be continued across the midline into a double Kocher incision or roof top approach which provide excellent access to the upper abdomen particularly in those with a broad costal margin Used for: Total Gastrectomy. Total oesophagectomy. Extensive hepatic resections. Bilateral adrenalectomy .
16 : The Mercedes Benz Modification consists of bilateral low Kocher’s incision with an upper midline incision up to the xiphisternum. Excellent access to the upper abdominal viscera. (mainly the diaphragmatic hiatuses) .
17 : McBurney Grid Iron (muscle-split incision) first described in 1894 by Charles McBurney Is the incision of choice For most Appendectomies. Made at the junction of the middle third and outer thirds of a line running from the umbilicus to the anterior superior iliac spine. (The McBurney Point) The level and the length of the incision vary according to: The thickness of the abdominal wall. The suspected position of the appendix. If palpation reveals a mass, the incision can be placed directly over the mass. .
18 : .` . Oblique VS Transverse over the skin creases. May be used in the left lower quadrant to deal with certain lesions of the sigmoid colon. (such as .drainage of a diverticular abscess) The Ilioinguinal and Iliohypogastric nerves cross the incision & any accidental injury can predispose the patient to Inguinal hernia. Advantages Good healing. Negligible risk of herniation.
19 : . . Oblique VS Transverse over the skin creases. May be used in the left lower quadrant to deal with certain lesions of the sigmoid colon. (such as .drainage of a diverticular abscess) The Ilioinguinal and Iliohypogastric nerves cross the incision & any accidental injury can predispose the patient to Inguinal hernia. Advantages Good healing. Negligible risk of herniation.
20 : Pfannenstiel incision (smile incision) Used frequently by gynecologists and urologists for access to the pelvis organs, bladder, prostate and for caesarean section. Usually 12 cm long and made in a skin fold approximately 5 cm above symphysis pubis. skin ? fascia ? anterior rectus sheath ? rectus muscle ? transversalis fascia ? extraperitoneal fat ? perineum. .
21 : . Advantages: A convex incision which minimizing muscle parasthesia and paralysis post-operatively.  It also  follows the cleavage lines in the skin resulting in less scarring The incision offers Excellent cosmetic results because the scar is almost always hidden by the pubic hair Disadvantages: Limited exposure of the abdominal organs. Use of incision is therefore restricted to the pelvic organs High risk of injury to the bladder Extension of the incision is difficult laterally .
22 : Maylard Transverse Muscle cutting incision It is placed above but parallel to the traditional placement of Pfannenstiel incision. Gives excellent exposure of the pelvic organs. .
23 : Transverse muscle dividing incision Similar to Kocher’s incision. (but more transverse) Used for: Newborn and infants. Short , obese adults. .
24 : Thoracoabdominal Incision Converts the pleural and peritoneal cavities into one common cavity ? excellent exposure. Left incision ? Resection of the lower end of the esophagus and proximal portion of the stomach. Right incision ? elective and emergency hepatic resections. Upper (midline, paramedian or oblique incision) can be easily extended into either the right or left chest for better exposure. .
25 : .
26 : Postoperative complication POSTOPERATIVE PAIN It has been showed that the patients who received a transverse incision have much less pain compared to patients who received a midline incision WOUND DEHISCENCE Some studies showed that the transverse incision seems to cause less wound dehiscence than the midline and paramedian incisions, but numbers are too small to speak of an actual trend WOUND INFECTION Wound infection is probably an important risk factor for the development of incisional hernia and wound dehiscence
27 : . INCISIONAL HERNIA Incisional hernias occur in 2–19 % of patients after various abdominal incisions A comparison of midline with oblique incisions was performed in two studies, reported a 14 % hernia rate after midline and a 4 % hernia rate after oblique incisions Three prospective randomized clinical trials compared lateral paramedian with midline incisions and found no incisional hernias after the lateral paramedian incision. The difference with the midline incision was significant in all three studies
28 : Abdominal Incisions Kochers /Right Subcostal Open Cholecystectomy Upper Midline Gastric Surgery Duodenal Surgery Cholecystectomy   Roof-Top/ Bilateral Subcostal Pancreatic Surgery   Upper Paramedian Cholecystectomy   Loin/Oblique Renal Surgery   Lanz (McBurneys Point) Appendisectomy   Lower Midline Colonic Surgery Major Modern Gynae “older” Gynae inc Caesarean   Inguinal Inguinal Hernia   Pfannestiel Modern “routine” Gynae   Full midline ( xiphisternum to pubis) Trauma Surgery Aortic Surgery  
29 : Thank you


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