Anatomy & Incisions General Surgery

Incisions A variety of incisions are used The type chosen is dependent on a number of factors Access desired Procedure Surgeon Extensibility (can we make it bigger?) Wound security

Layer by layer… Abdominal wall layers: Skin Subcutaneous Fascia Muscles Preperitoneal fat Peritoneum

Tissue Layers of the Abdominal Wall (Redrawn from Ethicon: Wound closure manual, Somerville, NJ, 2002, Ethicon, Inc.)

Organs by Quadrants

Incisions, continued Abdominal incisions (Modified from Rothrock JC: Alexander's care of the patient in surgery, ed 12, St Louis, 2003, Mosby.)

The good, the bad and the scar tissue Each incision type has advantages and disadvantages Adequacy of exposure Closure time Disruption of blood and nerve supplies Muscle damage Wound hernia Effect pulmonary function

Other Factors Other things may influence choice Patient condition Need for speed Previous surgery Minimize bleeding and trauma Postop discomfort Room to roam

And yet more pain… Cosmetics Changes in the blood supplies to the anterior wall Limit choices for future surgeries and reconstruction

Vertical Midline Incision Simple to perform Good exposure to all of the abdominal cavity Can be extended from the sternal notch to the symphysis pubis

Paramedian Vertical incision that is placed 2” off of the midline Same indications as the vertical with the exception of trauma Longer to create and close Bleed more readily Prone to herniation

Oblique Incisions Allow access to specific structures Strong However, Splits muscles Bleeding Nerve damage

Muscle-Splitting Incisions Surgical options for muscle (Redrawn from Ethicon: Wound closure manual, Somerville, NJ, 2002, Ethicon, Inc.)

McBurney Used most commonly for open appendectomy Quick and easy to close Firm closure Poor exposure

Oblique Inguinal From the pubic tubercle to the iliac crest above the inguinal crease Used for Inguinal Herniorraphy repair May also be used for urologic, transplant or vascular procedures in this region

Subcostal Usually made on the right side (kocher) Used for open gall bladder procedures Left sub costal used for spleenectomy Strong but painful Limited exposure Good cosmetic closure

Transverse Incisions Used to expose either the upper or lower regions of the abdomen Same issues as the oblique incision

Pfannenstiel Used for pelvic surgery Approximately ½” above the symphysis pubis Most commonly used for OB/GYN Excellent exposure Cosmetic

Midabdominal Used for retroperitoneal approaches Colectomy or colostomy

Thoracoabdominal Used for proximal stomach, distal esophagus, and anterior spine Patient is in a lateral position Begins at midpoint between xiphoid and umbilicus and extends to midscapular line into the chest