AIPT

TYPES OF INCISIONS

surgery- 1

PRESENTED BY:
Bhavya – A1106621081
Simran – A1106621100
(Sem- 5B)
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INCISIONS
• A surgical incision is a cut made through the skin and soft tissue to aid an operation
or treatment in surgery.
• Multiple incisions are frequently possible during an operation.
• To promote safe and timely operating conditions, surgical incisions are created as
small and unobtrusive as feasible.
• Surgical incisions are chosen based on the estimated level of exposure required for
the procedure and several other factors as well .
• the incision must provide sufficient room for the procedure to be performed. The
incision should (if possible):
• be capable of easy extension (to allow for any enlargement of the scope of the
operation)
• interfere as little as possible with the strength and function of the abdominal wall.
• Abdominal surgery is also know as LAPAROTOMY.

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Factors to be considered while selecting an Incision

The are several factors on which the surgeon relies on to choose the incision best suited
for the planned procedure based on the following most essential and crucial factors :
• Accessibility to the Affected Organ or Anticipated pathology
• Extensibility of the incision
• Preservation of the Abdominal wall function
• A reliable and secured closure of the incision
• Type of surgery ( Elective or Emergency)
• Demand for a swift entry in to the belly

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• The certainty of the diagnosis of the disease

• Target Organ
• Any kind of previous surgical scars and it’s location
• Body measurements including – ( weight & height of the patient )
• Possibility of significant bleeding
• Surgeons experience and preference
• Choice must be Accurate and well executed for example :

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• A serious emergency (e.g. ruptured abdominal aortic aneurysm, closed abdominal

injury) should be approached through a midline incision because it gives rapid
access and can be enlarged to the whole length of the abdomen in a matter of
seconds.
• A subcostal (Kocher) incision gives excellent access for open biliary surgery in the
obese patient with a wide subcostal angle.
• The Pfannenstiel incision is a beautiful cosmetic procedure for elective pelvic
surgery (including open access to the prostate) but is time-consuming .
• A lower midline incision is needed for an emergency Caesarean section (where
minutes may be crucial for baby and mother).

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 ANATOMY OF ABDOMEN AIPT

• The Abdomen is the lower part of the trunk and lies below the diaphragm.
• The is bounded by the muscles and other layers .
• The abdomen contains greater parts of digestive and urogenital systems . It also
contains the spleen , suprarenal glands , and numerous lymph nodes, vessels and
nerves .
• The Abdominal wall is made up of the following six layers :
Skin
Superficial fascia
Muscles ( bones at places )
Continuous layer of fascia
Extra-peritoneal Connective Tissue
Peritoneum

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Abdominal Cavity
• Abdominal Cavity is the largest cavity, enclosing peritoneal cavity between
its parietal and visceral layers .
• The Abdominal Cavity is divided into 4 Quadrants and 9 Regions by the two
horizontal planes and two vertical planes .
• 4 Quadrants – 2 right quadrants and 2 left quadrants –( Upper and Lower) .
• 9 Regions – Hypochondrium
Lumbar
Iliac Fossa
• These 3 regions are divided into both Right and Left sides

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• From above downwards the Median regions comprises of the following :

Epigastric , Umbilical, Hypogastric .

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• The names of the two horizontal planes are :
Trans pyloric plane
Transtubercle plane
• The names of the two vertical Planes are :
Right Lateral Plane
Left Lateral Plane

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• RECTUS SHEATH : The rectus sheath is described as a aponeurotic sheath

covering the rectus abdominis muscle. It consist of Anterior and Posterior
Wall .
• Anterior Wall : covers the muscle from end to end . Firmly adherence to the
tendinous intersection of rectus muscle .
• Posterior Wall : Free from the muscle and is incomplete being deficient .

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• PERITONEUM : Peritoneum is the large serous membrane lining the

abdominal cavity .
Consist of three layers :
 Parietal peritoneum
 Visceral Peritoneum
 Folds of peritoneum by which the viscera are suspended .

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 LANGER’S LINE AIPT

• It corresponds to the natural orientation of collagen fibres in the

dermis and are generally parallel to orientation of the underlying
muscle fibres. Incision made parallel to langers line may heal better
and produce less scarring than cut across.

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TYPES OF INCISION:
Abdominal incisions are broadly categorised into three main types:
1. TRANSVERSE INCISION
2. VERTICAL INCISION
3. OBLIQUE INCISION

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TRANSVERSE INCISION:
A transverse incision, also known as a horizontal incision or transverse
laparotomy incision, is a type of surgical incision made horizontally
across the body. It is called "transverse" because it runs perpendicular to
the body's long axis .Transverse incisions are commonly used in various
surgical procedures, especially in abdominal surgeries. They have several
advantages, such as:
1. Less tension on the wound: Transverse incisions are often placed in
regions with less tension, which can result in better wound healing and
reduced risk of wound complications.

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2. Better cosmetic outcome: Due to their placement, transverse

incisions may result in less noticeable scars compared to vertical
incisions, which are more prominent and visible.
3. Reduced risk of wound complications: Because transverse incisions
are typically made in areas with lower tension, there is a reduced risk of
wound dehiscence (when the wound edges separate) and hernias.
4. Easier access to certain organs: In some surgeries, a transverse
incision can provide better access to specific organs or structures, which
may be difficult to reach with a vertical incision.

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TYPES OF TRANSVERSE INCISION

• Pfannenstiel incision: It is a curved incision that is approximately
10-15 cm long and 2 cm above the pubic symphysis. It is commonly
used for pelvic surgeries.

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• Kustner incision: It involves a slightly curved skin incision that

extends just below the pubic hairline.
Also called as modified Pfannenstiel incision.

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• Cherney incision: It involves a cross section of the abdominal muscle

at the insertion in the pubic area. It’s a transverse incision of rectus
sheath and allows larger areas to operate. Mainly used for
gynaecological procedures.

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• Maylard incision: It is a muscle cutting incision 3-8 cm above the

pelvic region in which all layers of the lower abdominal wall are
penetrated and cut to get access to pelvic structures.

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• Mouchel incision: It runs lower than a maylard incision (runs at the

upper limit of pubic hair). Used in obstetrics procedures.
• Joel – cohen incision: It is mainly used for hysterectomy and
caesarean delivery.

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• Modified Gibson incisions: These incisions are specially made

during surgeries related to women reproductive system and cancer
surgeries. Cuts are made on the side of the midline of the abdomen
specially on the left. Mainly used in cases of urological and
gynaecological surgeries.

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Disadvantages
 Time consuming
 Can lead to haematoma ( collection of blood at the incision sight)
 Restricts the exploration of the abdominal cavity.

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 Vertical incision: AIPT

A vertical incision is a type of surgical cut made vertically along the midline
of the body, dividing it into two symmetrical halves. This incision runs just
below the sternum (breastbone) to the pubic bone. Vertical incisions are
commonly used in various surgical procedures, particularly in abdominal
surgeries. Here are some advantages of using vertical incisions:
1. Direct access to abdominal organs: Vertical incisions provide excellent
access to the abdominal cavity and its organs, including the intestines,
liver, spleen, and kidneys. This direct access allows surgeons to perform
complex procedures and manipulate organs more effectively.
2 . Reduced risk of injury to major blood vessels: Compared to some
other types of incisions, vertical incisions have a lower risk of accidentally
damaging major blood vessels. The path of the incision avoids critical blood
vessels in most cases.

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3 . Better visualization: The vertical incision allows surgeons to have a

clear and unobstructed view of the surgical site. This improved
visualization is particularly important in procedures where precision is
crucial.
4 . Flexibility: Vertical incisions can be extended if needed without
creating additional incisions. This flexibility is advantageous in
situations where a larger incision is required due to unexpected
complications or difficulties during the surgery.
5 . Commonly used for exploratory surgeries: When the exact location
of the problem is uncertain, surgeons may opt for a vertical incision to
explore the abdominal cavity thoroughly and identify the issue.

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5 . Suitable for various procedures: Vertical incisions are used in a

wide range of surgeries, including abdominal explorations, bowel
surgeries, and certain gynecological procedures. They are a versatile
option for accessing different areas within the abdominal region.
Despite these advantages, vertical incisions may have some drawbacks,
such as increased pain and a longer recovery period compared to smaller
incisions used in minimally invasive surgeries. Additionally, vertical
incisions can lead to more noticeable scars.

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Types of vertical incision:

• Midline incision: These incisions are made on the midline of the
abdomen and is mostly favoured in open surgery for diagnostic
procedures. It allows a wide access to all the areas of the abdomen
and organs. It allows almost bloodless surgery with minimum risk of
injury to blood vessels and nerves. E.g. median sternotomy and
thoracotomy allows access to most thoracic organs.

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• Paramedian incision: They are made 2-5 cm beside the midline of the
trunk on our abdomen. It provides access to structures such as stomach,
liver and spleen. It avoids any injury to the nerves and limits trauma to
rectus and permits good restoration of functions later. It is used to
access lateral viscera like kidneys , spleen and adrenal glands.

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 OBLIQUE INCISION AIPT

An oblique incision is a type of surgical cut or wound made at an angle

rather than perpendicular to the body's longitudinal axis or the direction
of the muscle fibers. In medical terminology, "oblique" refers to
something that is neither parallel nor at a right angle. Therefore, an
oblique incision is made diagonally, forming an angle with the surface of
the skin or the anatomical structure being operated on.
Surgeons may choose to use an oblique incision for various reasons,
depending on the specific case and surgical objectives. Some potential
advantages of oblique incisions include:
[Link] access to specific anatomical structures: In certain surgeries,
an oblique incision can provide better visibility and access to targeted
areas that might be challenging to reach with a straight incision.

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2. Improved cosmetic outcome: Depending on the location of the

incision, an oblique approach may lead to a more aesthetically pleasing
result, as the resulting scar can sometimes be less noticeable compared to
a straight incision.
[Link] risk of wound complications: In some cases, an oblique
incision might reduce the risk of wound dehiscence (when the wound
edges separate) or other wound-related complications.

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TYPES OF OBLIQUE INCISION:

• McBurney’s incision: These are specially used for appendectomy
(appendix removal operation). They are made at the junction of 1/3rd
of the line running from the umbilicus to the ASIS . Made in the right
iliac quadrant of abdomen. Also called Grid Iron incision.

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• Subcostal incision: These start at the midline and are 2-5 cm

incisions below the lower part of the sternum that extends down
outward parallel to the lower edge of the chest rib. They provide easy
access to the gall bladder and spleen. Mainly used in gallstone
removal operations.
• Also called as Kocher incision.

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 DIFFERENT OTHER AIPT

• INCISIONS:
Lanz incision: Also called Rockey-Davis. It is a type of gridiron
incision and is useful for open appendectomies and is made at the
McBurney point with the same anatomical layers and blood supply.
However, the lanz incision is horizontal while gridiron is oblique.

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• Thoracoabdominal incision: It is a unique incision that connects the

pleural and peritoneal cavity. Right sided incision may expose hepatic
region as well as right kidney while the left sided incision exposes
stomach as well as distal eosophagus.

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• Chevron incision: It crosses the midline of the abdomen. It is

subcostal incision that extends from the mid to lateral costal ridge .
This provides exposure for hepatic, pancreatic , upper GIT region,
adrenal or renal surgeries.

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• Mercedes-Benz incision: It is a modification of the chevron incision

with a vertical incision that extends through the xiphoid and the
sternum. This is used in liver transplant or any epigastric pathology

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• Clamshell incision: It is a large transverse incision that spans across

the entire chest wall. It is also known as bilateral thoracotomy and is
used during chest trauma , lung transplant or resection of tumours in
the chest.

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• Laparoscopic incisions
• Tracheostomy
• Inguinal incisions
• Para-rectus
• Supra/infra – umbilical
• Trapdoor incision

It's worth mentioning that advances in minimally invasive surgical

techniques, such as laparoscopy and endoscopy, have significantly
reduced the need for large incisions in many cases. These techniques
involve using specialized instruments and cameras through small
incisions or natural body openings, leading to faster recovery times and
reduced scarring for patients.
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• COMPLICATIONS
Early Generic early Specific early Late
Complications Complications Complications Complications

 Anaesthetic  Post- operative  Reactionary  Incisional hernia

difficulties pneumonia haemorrhage  Intra- abdominal
 Haemodynamic  UTI  Intra-abdominal adhesions
instability  Oliguria collection
 Primary  Bedsores  Post operative
haemorrhage  DVT ileus
 Iatrogenic injury  Wound infection

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• WOUND DEHISCENCE :
Following the midline laparotomy is a particularly complained.
Yellow coloured fluid ooze out from the wound site particularly
seen after 7 -10 days post operative .
Risk factors :
• Patient specific : ( immunocompromised, smoking, obesity,
jaundice , diabetes , steroid use , history of radiotherapy ,
vascular disease )
• Procedure specific : ( surgical technique, site , orientation
of incision , intra- operative contamination, length
procedure)

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THANK
YOU!
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