Jalipa,Wilfred Marc A.

Group 19 DIFFERENT INCISION SITES Classification of incisions: The incisions used for exploring the abdominal cavity can be classified as:

(A) Vertical incision: These may be Midline incision Paramedian incisions (B) Transverse and oblique incisions: Kocher's subcostal Incision (a) Chevron (Roof top Modification) (b) Mercedes Benz Modification Transverse Muscle dividing incision Mc Burneys Grid iron or muscle splitting incision Oblique Muscle cutting incision Pfannenstiel incision Maylard Transverse Muscle cutting Incision (C) Abdominothoracic incisions A. Vertical incisions: Vertical incisions include the midline incision, paramedian incision, and the Mayo -Robson extension of the paramedian incision. 1) Midline Incision: Almost all operations in the abdomen and retroperitoneum can be performed through this universally acceptable incision Advantages: (a) It is almost bloodless (b) No muscle fibers are divided, (c) No nerves are injured; (d) it affords goods access to the upper abdominal viscera, (e) It is very quick to make as well as to close; it is unsurpassed when speed is essential ( Clarke, 1989) (f) a midline epigastric incision also can be extended the full length of the abdomen curving around the umbilical scar. 2) Paramedian Incision (white arrow)The skin incision is placed 2 to 5 cm lateral to the midline over the medial aspect of the bulging transverse convexity of the rectus muscle. Extra access can be obtained by sloping the upper extremity of the incision upwards to the xiphoid (Didolkar et al, 1995). Skin and subcutaneous fat are divided along the length of the wound. The anterior rectus sheath is exposed and incised, and its medial edge is grasped and lifted up with haemostats. The medial portion of the rectus sheath then is dissected from the rectus muscle, to which the anterior sheath adheres. Segmental blood vessels encountered during the dissection should be coagulated. Disadvantages : 1. It tends to weaken and strip off the muscles from its lateral vascular and nerve supply resulting in atrophy of the muscle medial to the incision. 2. The incision is laborious and difficult to extend superiorly as is limited by costal margin. 3. It doesnt give good access to contralateral structures. The Mayo-Robson extension of the paramedian incision is accomplished by curving the skin incision towards the xiphoid process. Incision o fthe fascial planes is continued in the same direction to obtain a larger fascial opening .

(B) Transverse Incisions Transverse incisions include the Kocher subcostal incision, transverse muscle dividing, McBurney, Pfannenstiel, and Maylard incisions.

A.Kocher subcostal incision Theodore Kocher originally described the sub costal incision; it affords excellent exposure tothe gall bladder and biliary tract and can be made on the left side to afford access to the spleen. It is of particular value in obese andmuscular patients and has considerable merit if diagnosis is known and surgery. B.Transverse Muscle-dividing incision : The operative technique used to make such anincision is similar to that for the Kocher incision. In newborns and infants, this incision is preferred,because mor e abdominal exposure is gained per length of the incision than with vertical exposure because the infants abdomen has a longer transverse than vertical girth. This is also true of short, obese adults, in whom transverse incision often affords a better exposure. C.McBurney Grid iron or Muscle-split incision The McBurney incision, first described in 1894 by Charles McBurney is the incision of choice for most appendicectomies McBurney, 1894). The level and the length of the incision will vary according to the thickness of the abdominal wall and the suspected position of the appendix (Jelenko &Davis 1973; Watts & Perrone, 1997). Good healing and cosmetic appearance are virtually always achieved with a negligible risk of wound disruption or herniation. D.Oblique Muscle-cutting incision This incision bears the eponym of theRutherford-Morrison incision This is extension of the McBurney incision by division of the oblique fossa and can be used for a right or left sided colonic resection, caecostomy or sigmoid colostomy. E.Pfannenstiel incision The Pfannenstiel incision is used frequently by gynaecologists and urologists for access to thepelvis organs, bladder, prostate and for caesarean section The skin incision is usually 12cm long and is made in a skin fold approximately 5cm above symphysis pubis. The incision is deepened through fat and superficial fascia to expose both anterior rectus sheaths, which are divided along the entire length of the incision. The sheath is then separated widely, above and below from the underlying rectus muscle.

Pfannenstiel Incision The Pfannenstiel incision has become popular in the past decade for cosmetic reasons. This is particularly true in younger women having surgery for benign gynecologic and pelvic problems. If properly placed, it is generally concealed by regrowth of pubic hair. The purpose of the technique is to provide a cosmetic incision for pelvic surgery. Physiologic Changes. The Pfannenstiel incision transects neurovascular pathways in the skin of the abdominal wall and frequently requires partial or compete transection of the rectus abominis muscle. It is rarely associated with incisional her nia, has a low incidence of wound dehiscence, and heals without significant scarring. The latter fact may be due to the copious blood supply in the mons pubis. Points of Caution. A Pfannenstiel incision should never be used in oncologic surgery. It does not give exposure to the upper abdomen and provides only limited exposure to aortic and lymph nodes for their analysis and dissection. Care must be taken to avoid incidental laceration of the inferior epigastric artery and vein on the lateral margin of the rectus muscles. If the mu scles are to be transected, the epigastric artery and vein should be identified, clamped, and ligated prior to transection of the muscle. Hemostasis is particularly important during this incision. The vascularity of the mons pubis increases the risk of hemorrhage, formation of hematoma, and infection. The surgeon should ensure that the incision is dry before closure of the wound. If there is any question, a small suction drain should be left in the incision for 24 -48 hours.

Maylard incision In an effort to improve surgical exposure to the lateral pelvic sidewall with a transverse incision, Maylard proposed a transverse muscle-splitting incision. This incision usually refers to a subumbilical transverse incision. For gynecologic surgery, the incision is made 3-8 cm superior to the pubis symphysis. The anterior rectus sheath is cut transversely. The inferior epigastric vessels are identified under the lateral edge of each rectus muscle and then are ligated.

Cherney incision Cherney described a transverse incision that allows excellent surgical exposure to the space of Retzius and the pelvic sidewall. The skin and fascia are cut in a manner similar to a Maylard incision. The rectus muscles are separated to t he pubis symphysis and separated from the pyramidalis muscles. A plane is developed between the fibrous tendons of the rectus muscle and the underlying transversalis fascia. Using electrocautery, the rectus tendons are cut from the pubic bone. The rectus muscles are retracted and the peritoneum opened. Modified Gibson incision Some gynecologic oncologists perform an extraperitoneal lymph node dissection using a modification of the Gibson incision. This incision can be made on each side of the midline, but often, the skin is cut only on the left. The incision is started 3 cm superior and parallel to the inguinal ligament. Extension is made vertically 3 cm medial t o the anterior superior iliac spine to the level of the umbilicus. The fascia is cut and the peritoneum bluntly dissected, as described mesenteric vessels.