Abdominal Access

Dr. Pashi VProf: Munkonge

THE UNIVERSITY TEACHING HOSPITAL.

Relevant anatomy of the abdomenRegion of the trunk between the thorax and the

pelvis

Generally abdomen includes false pelvis

Abdomen proper excludes the false pelvis

Functions of the abdomen:◦ Houses and protects major viscera◦ Assists in breathing◦ Accounts for change in intra-abdominal pressure

SURFACE ANATOMY

ANTERIOR ABDOMINAL WALL

ABDOMINAL MUSCLES

RECTUS SHEATH

Above arcuate line of Douglas

Below arcuate line of DouglasAbove arcuate line of Douglas

The umbilicus and the skin

• In the fetus, the umbilicus transmits the vitelline and umbilical vessels and yolk stalk.

• It is surrounded by the paraumbilical veins that establish connections with both the portal vein and the inferior vena cava (portacaval anastomosis) through a series of venous channels

• It is also the site of attachment of the umbilical ligaments that consist of the median umbilical (remnant of the urachus),medial umbilical (obliterated umbilical arteries) and lateral umbilical (inferior epigastric vessels) ligaments/folds

• The umbilicus may also receive the embryological remnant of the vitelline duct known as Meckel’s diverticulum

• The umbilicus also receives the round ligament of the liver, a remnant of the umbilical vein.

• The umbilical vein remains patent for some time during early infancy and allows blood transfusion or general venous access

• An incision made perpendicular to the direction of Langer’s lines is most likely to gape and result in prominent scarring.

• Since the course of the nerves and vessels that supply the anterolateral abdomen parallels the cleavage lines of the skin, transverse incisions of the abdomen are surgically more favourable,

• They are less likely to gape or cause damage to nerves or vasculature and heal faster without visible scarring

Abdominal incisions• Deciding the right type of surgical incision is

extremely important.• The ideal incision allows:

1. ease of access to the desired structures2. can be extended if needed3. ideally muscles should be split rather than cut4. heals quickly with minimal scarring5. aesthetically pleasing6. The incision must traverse muscle rather than

fascia since the scar left in the peritoneum is best protected by muscles

7. rectus abdominis muscle maybe cut transversely without weakening the abdominal wall. The cut passes between two adjacent nerves without injuring the nerves.

8. The incision must not divide no nerve9. Drainage tubes should be inserted through separate

incision like wise colostomy or ileostomy should be made through a separate incision

10. The openings made by the incision through different layers of the abdominal wall must not be superimposed

Different ways of classifying abdominal incisions

1. Approach to the abdominal cavitya. Incisions through anterior abdominal wallb. Incisions through the Posterior Abdominal wall

2. Orientation of incision to the body axisa. Transverse incisionsb. Vertical incisionsc. Oblique incisions

3. Based on approach to musculature of the abdominal wall

a. Dividing no musclesb. Diving muscles (Transrectal)c. Splitting muscles

Abdominal incision

SURGICAL INCISIONS 1. Kocher’s incision

2. midline incision

3.Gridion muscle splitting

4. Battle incision

5. Lanz incision

6. paramedian

7. transverse

8. Rutherfold Morrison incision

9. Pfannestiel

Vertical incision 1: Midline incisionUse: • 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

Midline incision

Advantages• Adequate exposure of most if not all of the

abdominal viscera• Minimal blood loss as the incision is through the

linea alba• Minimal nerve injury• Minimal muscle injury• Can be quickly made, such as in an emergency and

quickly closed with a mass closure techniqueDisadvantages• Care needs to be taken just above the umbilicus

where the falciform ligament is • Midline scar

Vertical incision 2: Paramedian incisionUse: • 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.

Paramedian incision

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.

Advantages• Provides access to lateral structures• Rectus muscle is not divided• Incisions in anterior and posterior sheath is

separated by muscle which acts as a buttress, therefore closure is more secure

• Can be extended by a curvilinear incision towards the xiphoid process if required

Disadvantages• Takes longer to make and close• Incision needs to be closed in layers• Difficult extension superiorly as limited by the

costal margin• Tends to strip the muscles of their lateral

blood and nerve supply resulting in atrophy of the muscle medial to the incision

Vertical incision 3: Mayo-Robson incision

• 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.

Mayo-Robson incision

Transverse incision 1: Transverse 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

Transverse incision

Advantages• Less pain than a midline incision• Good access to midline upper GI structures• Transverse incisions cause the least amount of

damage• As the recti have a segmental nerve supply, it

can be cut transversely without weakening a denervated segment

• Muscular segments can be rejoined

• Commonly used in children as greater abdominal exposure is gained in comparison with the vertical midline.

• This is due to the longer transverse length of the abdomen in children

Disadvantages• Limited lateral access in comparison with

midline incisions that can then be extended• More wound infections compared to midline

thought to be due to greater difficulty in controlling bleeding and haematoma formation.

Transverse incision 2: Subcostal incisionUse: • 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

Subcostal incision and modifications

Advantages• Greater lateral exposure• Less painful to midline incision• Less post-operative complications such as PE

to a midline incision• Heals well Disadvantages• Longer operation time as the incision is closed

in 2-3 layers

Transverse incision 3: McBurney's incision and the Lanz incision

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.

McBurney's incision and the Lanz incision

Advantages• Aesthetically pleasing incisions as they both

follow Langer's skin lines• A wide range of pathologies in the right and

left lower quadrants can be dealt with, with room for extension if required

• Minimal damage to muscles as muscle splitting techniques can be utilised

• Avoids damage to local nerves

Disadvantages• The ilioinguinal and iliohypogastric nerves

cross the appendicectomy incision and there is a risk of injury.

• This can then predipose to inguinal hernia formation post-operatively.

• This is more evident with the Lanz incision.

Transverse incision 4: Pfannenstiel incision

Use:• Allows exploration of the lower GI and UT, as well

as the pelvic reproductive organs.Location: • A convex 5cm to 12cm incision, located a the

suprapubic skin crease about 2cm to 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.

Advantages• A convex incision is made instead of a

transverse as this parallels the course of the segmental nerves that are cut and so minimising muscle parasthesia and paralysis post-operatively. It also follows the cleavage lines in the skin resulting in less scarring

• Location of incision means it is hidden in the pubic hair line

Disadvantages• Limited exposure of the abdominal organs.• Use of incision is therefore restricted to the pelvic

organs• High risk of injury to the bladder especially because

the fascia thins towards the lower abdomen, leaving the bladder relatively exposed, and if the bladder is not catheterised during surgery

• Extension of the incision is difficult laterally• Exploration of the deep pelvic organs is difficult

making dissection in the obese difficult

Oblique incision: Thoraco-abdominal incisions • 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.

Thoraco-abdominal incisions

INCISIONS THROUGH THE POSTERIOR ABDOMINAL WALL

These usually used to exposure of • Kidney• Ureter• Suprarenal gland

KIDNEY INCISIONS1.Oblique incisions• This is the favourite• This extends from kidney angle in oblique

direction down wards and outwards toward the anterior superior spine.

• The kidney angle is formed by the outer border of sacrospinalis muscles at the junction with the 12th rib.

• The incision runs in the direction of the fibres of external oblique muscle.

Kidney incisions

It divides1.Skin and superficial fascia2.Latissimus dorsi and serratus posterior inferior3.External oblique split in direction of its fibres4.Internal oblique and transverses5.Fascial transversalis6.Extraperitoneal and perirenal fat

• Lateral cutaneous branch of 12th thoracic nerve will be cut and this results in an area of anaesthesia the size of palm over the gluteal region.

• The incision may also cut ilio-hypogastric nerves. The outer border of quadrutus muscles is exposed at the upper part of the incision. Care should be taken not to open peritoneum.

• This incision gives good exposure to kidney and ureter. The advantage of the incision is that it can be extended forward to expose the lower half of the ureter and the base of the bladder.

VERTICAL INCISION• This extends perpendicularly along the outer

border of sacrospinalis muscle from the 12th rib to the iliac crest. This incision divides the following

• Skin and fascia• Latissimus dorsi and serratus posterior inferior• The three layers of lumbodorsal fascia• Fascia transversalis and extraperitoneal fat• This incision does not interfere with the muscles

in this region. It has the biggest disadvantage in that it does not give exposure to ureter and can not be extended.

Kidney incisions

Layers of posterior kidney incisions

HORIZONTAL URETERIC INCISION• A transverse incision a little above the level of

iliac crest extending outwards from the lateral border of the sacrospinalis muscle.

• The ureter is identified so that the divided proximal end is implanted into the skin.

Laporoscopic incisions• 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.

Laporoscopic incisions

summary• Pediatric surgeons utilize several types of

abdominal incision to approach different surgical problems in newborns, infants and children.

• In most children and during the first five years of life transverse incisions are preferred.

• It has been demonstrated that the younger the child, the relatively larger the abdominal cavity and wall.

• In babies a supraumbilical transverse incision is ideal to explore all four quadrants and solve almost every surgical congenital abdominal condition.

• Another advantage of transverse incision over longitudinal incision is the low incidence of fascial dehiscence, hernia formation, and evisceration of transverse incisions.

References

• Askew, A.R. (1975) : The Fowler-Weir approach to appendicectomy. British Journal of Surgery, 62(4): 303-4.

• Brennan, T.G., Jones, N.A., Guillou, P.J. (1987): Lateral paramedian incision. British Journal of Surgery, 74(8): 736-7.

• Burnand, K.G., Young, A.E.: The New Aird’s Companion in Surgical Studies. Churchil Livingstone Edinburgh (1992).

References

• J. Anat. Soc. India 50(2) 170-178 (2001)• Gauderer MW: A rationale for routine use of

transverse abdominal incisions in infants and children. J Pediatr Surg 16(4 Suppl 1):583-6, 1981

• Grantcharov TP, Rosenberg J: Vertical compared with transverse incisions in abdominal surgery. Eur J Surg 167(4):260-7, 2001