ABDOMINAL INCISIONS

A cut produced surgically by a sharp instrument that creates an opening into the abdomen When choosing an incision these three should be achieved: Accessibility Extensibility Security Re-entry into the abdominal cavity is best done through the previous laparotomy incision. This minimizes further loss of tensile strength of the abdominal wall by avoiding the creation of additional fascial defects

CLASSIFICATIONS: 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. Rutherford morison incision Pfannenstiel incision Maylard Transverse Muscle cutting Incision Transverse muscle dividing incision Thoracoabdominal incisions.

Upper Midline Incision -the most common incision three types: Upper Midline Incision From xiphoid to above umbilicus. Skin  superficial and deep fascia  linea alba  extraperitoneal fat  peritonium. Lower Midline Incision From the SUPERIOR umbilicus to INFERIOR pubic symphysis . Full Midline Incision From xiphoid to pubic symphysis inferiorly. Advantages: Adequate exposure of most if not all of the abdominal viscera It is almost bloodless. No muscle fibers are divided. No nerves are injured. It is very quick to make as well as to close. Disadvantages: Extensive is difficult More painful. Chest complications. Wound infection, Ugly scar, Incisional hernia, etc.

PARAMEDIAN Advantages Disadvantages 2 to 5 cm lateral to the midline. skin  fascia  anterior rectus sheath    The posterior rectus sheath or transversalis fascia  extraperitoneal fat and peritoneum are then excised allowing entry to the abdominal cavity 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 results in atrophy of the muscle medial to the incision The incision is laborious and difficult to extend superiorly as is limited by costal margin. Risk of epigastric vessels injury

TRANSVERSE AND OBLIQUE INCISIONS 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. 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 MERCEDEZ BENZ consists of bilateral low Kocher’s incision with an upper midline incision up to the xiphisternum. MCBURNEY GRID IRON 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) RUTHERFORD-MORRISON INCISION This is extension of the McBurney incision by division of the oblique fossa

PFANNESTIEL INCISIONP (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. 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 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

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. TRANSVERSE MUSCLE DIVIDING INCISION The operative technique used to make such an incision is similar to that for the Kocher incision. In newborns and infants, this incision is preferred. Also in obese patients

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.

SURGICAL PROCEDURES Vagotomy Jejunostomy Gastrectomy Pancreatomy Midline Para median Transverse & oblique thoracoabdominal Vagotomy Jejunostomy Gastrectomy Pancreatomy Hysterectomy Cystotomy Cystectomy Salphingo oopherectomy   Right Cholecystectomy Pyroplasty Left Splenectomy pancreadectomy Kocher Cholecystostomy Heptectomy chevron Esophagectomy Adrenalectomy Mercedez benz Liver transplant Pancreatic transplant McBurney Appendectomy Rutherford-morison caecostomy or sigmoid colostomy Pfannestiel Caesarean section Prostatectomy Hepatic resections SURGICAL PROCEDURES

8-Rutherford Morison: 9-PfannenstieL: 1-Kocher Incision:  2-Midline: 3-McBurney: 5-Lanz: 6-Paramedian: 7-Transverse: MUSCLE DIVIDING 8-Rutherford Morison: 9-PfannenstieL: