Deciding the right type of surgical incision is extremely important.
The ideal incision allows:
It is also important that incisions are placed in the direction of lines of cleavage of the skin (Langer's lines) so that a hairline scar is the outcome. These lines correspond to the direction of collagen fibres in the dermis and epidermis.
Incisions should also be placed as far as possible from stoma sites in order to avoid interfering with the stoma site and causing complications such as retraction and prolapse of the stoma.
Surgical incisions on the abdomen can be divided into transverse, vertical and oblique incisions.
Use: Virtually all abdominal procedures may be performed through this incision.
Location: in the midline of the abdomen, and can extend from the xiphoid process to just above the umbilicus. It can be continued to below the umbilicus by curving the incision around the umbilicus.
Layers of the abdominal wall: skin, fascia (camper's and scarpa's), linea alba, transversalis fascia, extraperitoneal fat and peritoneum.
Use: provides laterality to the midline incision, allowing lateral structures such as the kidney, adrenals and spleen to be accessed.
Location: about 2- 5cm to the left or right of the midline incision. Incision is over the medial aspect of the transverse convexity of the rectus.
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), extraperitoneal fat and peritoneum are then excised allowing entry to the abdominal cavity.
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 fasical planes as the paramedian incision.
Use: right or left colon, duodenum, pancreas, subhepatic space.
Location: This incision is made just above the umbilicus, dividing one or both of the rectus muscles.
Layers of the abdomen: skin, fascia, anterior rectus sheath, rectus muscle (+/- internal oblique, depending on the length of the incision), transversus abdominus, transversalis fascia, extraperitoneal fat and peritoneum. The medial aspect of this incision will be through the layers just like as in the midline incision.
Use: gallbladder and biliary tract, spleen. It is also known as the Kocher subcostal incision, after the person who discovered it. With the roof top or Chevron modification, access to oesophagus, stomach, kidney and adrenals and liver is also possible. Another modification is the Mercedes
Location: starts in the midline, 2-5 cm below the xiphoid, extending in parallel with the costal margin at about 2.5 cm below the costal margin. A rooftop of Chevron incision is a double Kocher incision. The mercedes incision involves a vertical incision from the rooftop incision, like a mercedes sign.
Layers of the abdominal wall: Skin, rectus sheath, rectus muscle, internal oblique, trasnversus abdominus, transversalis fascia, extraperitoneal fat and peritoneum.
Use: This is the incision of most appendicetomies and can be used in the left lower quadrant in left sided colonic pathology.
Location: McBurney's point, as described by Charles McBurney in 1884, is two thirds from the umbilicus and a third from the right anterior superior iliac spine. The incision is oblique beginning laterally from above and ending medially.
If palpation reveals a mass, perhaps an appendiceal abcess, then the incision is made directly over the mass.
Nowadays, the incision is made transverse and placed in a skin crease, the so called transverse Lanz incision as this is more aesthetically pleasing and the scar is hidden in the bikini line.
If it is anticipated that the incision will need to be extended, the oblique incision is used with lateral extension and as a muscle splitting (gridiron) surgical technique. Muscle splitting involves spitting the muscles fibres in a direction that is parallel to the direction of the muscle fibres.
Layers of the abdominal wall: skin, fascia, internal oblique medially and external oblique laterally, transversus abdominus, transversalis fascia, extraperitoneal fat and peritoneum.
Use: Allows exploration of the lower GI and UT, as well as the pelvic reproductive organs.
Location: A convex 12cm incision, located a the suprapubic skin crease about 5cm above the pubic symphysis. Once the peritoneum is reached, it is incised vertically, taking care to avoid the bladder.
Layers of the abdominal wall: skin, fascia, anterior rectus sheath, rectus muscle, transversalis fascia, extraperitoneal fat, perineum.
NOTE: this incision is below the arcuate line and this there is no posterior rectus sheath.
EXTRA: MAYLARD INCISION
This incision is placed a couple of cm's above the pfannenstiel and also provides good exposure of the pelvic organs. It cuts through the rectus fascia and muscle as well as external and internal obliques. Once transverse abdominus and transversalis fascia are reached, a muscle splitting technique is employed.
Thoracoabdominal incisions may be located in the RUQ or LUQ. They convert the pleural and peritoneal cavities into one. They allow good access to the lungs, liver and spleen. The left incision can also provide good exposure to the oesophagus and the stomach.
These incisions are small cuts in the skin made in the abdominal wall to allow the instruments of laparoscopy access to the contents of the abdominal cavity.
Their location will depend on the organ being operated on. Generally there will be 3-4. One is always at the umbilicus to allow a port for the camera. The other incisions will be located in one of the 4 quadrants for tools such as the griper, cutting and dissecting scissors and so on.
Surgical incisions may be closed with sutures, staples, steri-strips or local tissue glue.
It is important to keep the wound site clean and incisions are often covered with a protective dressing. Patients are encouraged to keep the wound as dry as possible to limit wound infection. Showering and bathing can resume after a couple of days. Wounds that are closed with nonabsorbable sutures and staples require removal of these materials first.
While gentle exercise is encouraged, it is important to avoid pressure, pulling and stretching on wounds.
As wounds heal, it is common for patients to see their wounds becoming itchy, red, swollen and wounds may even ooze sero-sangiunous fluid. These all represent the healing process. It is important to know what is normal so that abnormalities in wound healing that may represent infection, wound dehiscence, hypertrophic and keloid scars may be detected.
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