Incisions
Done by /Mogahed AL_Someeai.
Abdominal incision. .
criteria of professional incision
1. Safety: The incision should have minimal damage to muscles, blood vessels and
nerves.
2. Muscle splitting incisions are preferable than muscle cutting ones
3. Accessibility: The incision should provide good exposure of the diseased area.
4. Extensibility; If needed, it should be possible to enlarge the incision to give more
exposure.
5. Support by muscles
6. Not time consuming
7. Good cosmetic
8. Minimal scar.
9. Rapid healing
Type of abdominal incisions
1. Vertical Incisions
• Midline incision
• Paramedian incision
• Paramedian transrectal
• Para umbilical
2. Transverse Incisions
• Upper transverse epigastric
• low transverse suprapubic (Pfannensteil)
• Lanz incision
• Upper Rt. Horizontal
• Upper Lt. Horizontal
• Transverse epigastric incision
3. Oblique Incisions:
• Subcostal incision Left and right (Kocker's incision)
• Grid iron incision
• Inguinal incision
• McBurney's incision
• Rutherford Morrison
• Mercedes Benz
🔅According to their relation to the underling
museles :
[Link] splitting incision :
a) Grid-iron incision "See appendectomy".
b) Lanz incision.
2. Mttscle cutting incision :
a) Subcostal incision ""
b) Lumbar incision for nephrectomy.
3. Muscle reflecting incision :
@ Paramedian incision
[Link] Incisions
Midline incision
⭕Method and open
This incision passes through the linea alba
Open :
• Skin.
• SuperficiaFascia.
• Linea alba.
• - pretonum
Advantage;
• Low incidence of incisional hernia.
• - Exploratory (allowing access to both sides of the abdomen)
• Rapid
• Less bleeding
• Extensable
• They do not interfere with muscles or nerves.
Disadvantage
• Healing capacity is poor, so disruption of the wound & incisional hernia are
common.
• Bad cosrnosis
Indication
• Emergency
Paramedian incision
Indication
• It may be upper and lower and right or left.
• Right upper for—biliary tract, liver, duodenum, small bowel and
upper part of large intestine.
• Right lower for—Rt ureter, appendix, caecum, part of small bowel,
Fallopian tubes
• Left lower for—Left ureter, lower colon
Steps
The incision is made to the midline, at a distance of 2 to 3 cm from it.
The anterior rectus sheath is divided in the line of the skin incision. The
rectus is then displaced laterally to expose the posterior sheath. This is
incised in the line of the skin incision, together with transversalis fascia
and peritoneum.
Open
- Skin.
- Superficial fascia.
- Ant rectus sheath"
- Retract the nectus m. laterally (nerve [Link] csmes frsm tateral side).
- Posterior rectus sheath
Peritoneum
Advantage
• Low incidence af incisional hernia.
• Safe and the healing power is strong.
• . Extensible.
• Give exposure to any abdominal organ
Disadvantage
• Time consuming and is, therefore, not recommended in emergency situations.
• Not passing with Langer's lines,see fiuger
• More bleeding than midline
Langer's lines
Paramedian transrectal incision
Method
• Similar to the classic paramedian incision but the rectus muscle is split longitudinally in
thesame line of incision in the anterior rectus sheath.
Advantage
It done in emergency
Disadvantage
The sacr is not strong as that of para median incision due to devitalization of the
medial part of the rectus muscle
[Link] Incisions
A. Subcostal incision :left or Right (kochar
incision )
On the right side it is called Kocker's incision.
► Method: It is a muscle cutting incision, one inch below and parallel to
the costal margin. In
its medial part the rectus muscle and the anterior and posterior rectus sheaths are
divided. Laterally, the three abdominal muscles may be divi ded
Indication
• Used for operations on—gallbladder
• Right side—gallbladder (biliary tract), liver in patient with subcstal angel is wide
and obese ptn.
• Left side—spleen
► Advantages: Very good exposure to the biliary apparatus or the spleen
especially in obese &
patients with wide costal angle.
. Cosmetlcally better
Disadvantage
• More bleeding (= blood loss).
• Injury to 8, 9, 10th nerveS
• Time consuming
• Not exploratory
• It is not extensible.
• Not used in patients with narrow subcostal angle.
B. McBurney's incision: (Grid iron incision)
This is the incision most commonly used for removal of appendix.
Incision lies at right angle of lower 1/3 point of spino-umbilical line. A
line that joins the right anterior superior iliac spine to umbilicus. It is
arbitrarily divided into three parts. Lateral 1/3 point is known as
Mc Burney’s point. At this point, the supposed base of appendix is lies.
Skin is incised then external oblique aponeurosis in the line of skin
incision, then muscles are splitted with the help of scissor or handle of
knife to expose the peritoneum. Now peritoneum is opened in the line
of skin incision
► Indication: Used in case with sure diagnosis of appendicitis
Advantage
• The scar is small & cosmetic.
• Direct approach to the appendix.
• Needs little time to do and to close.
• Incisional hernia is uncommon.
Disadvantage
1. It is not an exploratory incision, used only in sure diagnosis.
2. Any change in the position of the appendix makes it difficult to be exposed
except by enlarging the
wound as a muscle cutting one.
4. Injury to ilia-inguinal nerve leads to paralysis of conjoint tendon leading to
direct inguinal hernia.
5. Its extension (Rutherford Morison'E) 4' rnuscle cutting.
[Link] incision
For total gastroctomy & total esophgyoctomy
D. Roof top incision
Indication
Trauma
pancreatic and hepatic major injury and gastroctomy
[Link] beens incision
In liver transplant
E. Rutherford Morrison
Above the grid iron incision
Indication
Renal transport
For appendectomy for obses pt. & pregnancy
Also used for colonstctomy or sigmoid
.INGUINAL INCISION
This incision is for inguinal hernia. It is an oblique incision, made 2.5 cm
above and parallel to the medial 3/5th of the inguinal ligament.
In children for herniotomy
3. Transverse Incisions
A. .Lanz incision like grid iron but 2cm
Iindication
Done when cosmosis is hlghly indicated {e.9. in
children}.
Advantage :More cosmetic
Disadvantage : Difficult access
B. low transverse suprapubic (Pfannensteil)
In Pfannensteil incision in which the anterior
rectus sheath is cut transversely, then the two
recti are separated.
• Finally the posterior rectus sheath and
peritoneum are opened
Advantage
1. The scar is cosmetic as the wound lies in Langer's lines & hidden in the pubic hair.
2. The muscular tension on the suture line is minimal, and the patient can cough in the
post-operative period.
Disadvantage
1. It is time consuming.
2. Excessive bleeding.