SURGICAL ABDOMINAL INCISIONSAND THEIR CLOSURE

Presented by: Dr akshay Presented by: Dr akshay sharmasharma

Dr Vikrant Ranjan

BACKGROUND

INCISION Definition A cut produced surgically by a sharp instrument that

creates an opening into an organ or space in the body.

When choosing an incision these three should be achieved

Accessibility Extensibility Security

INTRODUCTION Planning of an abdominal incision, Preoperative diagnosis The speed with which the operation needs to be

performed, as in trauma or major haemorrhage.

Previous abdominal operation.

In general, re-entry into the abdominal cavity is best done through the previous laparotomy incision. This minimizes further loss of tensile strength of the abdominal wall by avoiding the creation of additional fascial defects

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WHAT ARE THE LAYERS OF ANTERIOR ABDOMINAL WALL

Skin

Fascia Camper's fascia - fatty superficial

layer. Scarpa's fascia - deep fibrous

layer.

Muscle Rectus abdominis External oblique muscle Internal oblique muscle Transverse abdominal muscle

Transversalis fascia

Extraperitoneal fascia

Parietal Peritoneum

.

Skin

Superficial Fascia Camper's fascia - fatty

superficial layer. Scarpa's fascia - deep fibrous

layer.

Deep fascia : Thin layer of C.T covering the muscle

ABDOMINAL WALL MUSCLES

Rectus Abdominis

Pyramidalis

External Oblique

Internal Oblique

Transversus abd

Anterior Group Lateral Group

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External Oblique Origin lower 8 ribs.

Insertion Xiphoid process, Linea alba,

pubic crest, pubic tubercle, iliac crest.

Aponeurosis of this muscle lies superficial to rectus abdominis.

Nerve Supply Lower six thoracic nerves, iliohypogastric n., ilioinguinal n.

External oblique runs mainly downwards, forwards and medially

.

Internal Oblique Origin Lumbar Fascia, iliac

crest, lateral two thirds of inguinal

ligament. Insertion Lower three ribs,

costal cartilage, Xiphoid process, Linea alba, symphysis pubis.

The lowest tendinous fiber are joined to transversus abdominis to form conjoint tendon.

Nerve Supply Lower six thoracic nerves, Iliohypogastric n., ilioinguinal n.

Internal oblique runs mainly in a slightly upward and medial direction

.

Transversus Abdominis

Origin lower six costal cartilage, lumbar fascia, anterior two

thirds of iliac crest, lateral third of inguinal ligament.

Insertion Xiphoid process, Linea alba, symphesis pubis.

Transversus abdominis is the deepest muscle,runs mainly horizontally under the internal olblique

Nerve Supply Lower six thoracic nerves,

iliohypogastric n., ilioinguinal n.

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RECTUS ABDOMINIS

OriginSymphysis pubis, pubic crest

Insertion 5th, 6th and 7th costal cartilage

and xiphoid process. Nerve Supply

Lower six thoracic nerves.

Rectus abdominis lies alongside the linea alba

RECTUS SHEATH

• This is formed by the aponeuroses of external oblique, internal oblique and the transversus abdominis

• The anterior sheath is complete from rib margin to pubis.

---In its upper three-quarters it is formed by external oblique and by the anterior lamina of internal oblique.

---In the lower one-quarter it is formed by all three aponeuroses

• The posterior sheath is complete only as far down as a point midway between umbilicus and pubis, where it ends as a free border, the arcuate line

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. Linea Alba fusion of the aponeurosis of the abdominal muscles, and it

separates the left and right rectus abdominis muscles.

Transversalis fascia a thin layer of fascia that lines the Transversus Abdominis

muscle & continue to diaphragm & iliac muscle.

Extraperitoneal Fascia The thin layer of C.T and adipose tissue between the

peritoneum and fascia transversalis.

Parietal peritoneum It is a thin serous membrane Continuous below with the parietal peritoneum lining the pelvis.

BLOOD SUPPLY

Superior epigastric artery: Branch of internal thoracic artery. Supplying the upper central part of abdomen &

anastomoses with inferior epigastric a.

Inferior epigastric artery: Branch of external iliac artery. Supplying the lower central part of abdomen &

anastomoses with superior epigastric a.

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Deep circumflex iliac artery branch of external iliac artery. Run upward and lateral toward ASIS & Supplying the

lower lateral part of abdomen.

Lower two posterior intercostal arteries

& the four lumber arteries Supplying the lateral part of abdominal wall.

NERVE SUPPLY Nerve supply to the anterior

abdominal wall is derived from Lower 5 Intercostal and

subcostal nerve• Anterior cutaneous branch• Lateral cutaneous branch

Dermatomes T7 (over xiphoid) T10 (umbilicus)

Iliohypogastric n.

Ilioinguinal n.

Genitofemoral n.

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CLASSIFICATION OF INCISIONS Vertical incision

Midline incisions Paramedian incisions

Transverse and oblique incisions Kocher's subcostal Incision

Chevron (roof top Modification ) Mercedes Benz Modification

Mc Burney’s grid iron or muscle splitting incision. Pfannenstiel incision Maylard Transverse Muscle cutting Incision Transverse Muscle dividing incision Oblique Muscle cutting incision

Thoracoabdominal incisions.

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VERTICAL VERTICAL INCISIONSINCISIONS

MIDLINE INCISION the most common incision Have three types:

Upper Midline IncisionUpper Midline Incision From xiphoid to above umbilicus.

Skin superficial and deep fascia linea alba extraperitoneal fat peritonium.

Division of the peritoneum is best performed at the lower end of the incision, just above the umbilicus so that falciform ligament can be seen and avoided.

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.Lower Midline IncisionLower Midline Incision

From the umbilicus superiorly to the pubic symphysis inferiorly.

Allow access to pelvic organs. The peritoneum should be opened in

the uppermost area to avoid possible injury to the bladder.

Full Midline IncisionFull Midline Incision

From xiphoid to pubic symphysis inferiorly.

Great exposure is needed.

MIDLINE INCISION Advantages:

Adequate exposure of most of all abdominal viscera

It is almost bloodless. No muscle fibers are divided. No nerves are injured. It is very quick to make as well as to close.

Disadvantages: Extensive is difficult More painful. Chest complications. Wound infection, Ugly scar, Incisional hernia,

etc.

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Paramedian incision 2 to 5 cm lateral to the midline.

Over the medial aspect of the bulging transverse convexity of the rectus muscle.

skin fascia anterior rectus sheath 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

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Advantages Provide an access to the lateral structure such as the spleen or the

kidney

The closure is theoretically more secure because the rectus muscle can act as a support between the reapproximated posterior and anterior fascial planes so lower risk of dehiscence and hernia as compared to midline incision

Disadvantages Takes longer to make and close

Incision needs to be closed in layers

It tends to weaken and strip off the muscles from it’s lateral vascular and nerve supply resulting in atrophy of the muscle medial to the incision

The incision is laborious and difficult to extend superiorly as is limited by costal margin.

It does not give good access to contralateral structure

Risk of epigastric vessels injury

TRANSVERSE AND OBLIQUE INCISIONS

KOCHER’S INCISION

Incision parallel to the right costal margin. started at the midline, 2 to 5 cm below the xiphoid and extends downwards, outwards and parallel to and about 2.5 cm below the costal margin

It shows excellent exposure to the gallbladder and biliary tract and can be made on the left side to show access to the spleen.

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Special attention is needed for control of the branches of the superior epigastric vessels which lie posterior to and under the lateral portion of the rectus muscle

The small eighth thoracic nerve will almost invariably be divided

The large ninth nerve must be seen and preserved to prevent weakening of the abdominal musculature

Have two modification: Chevron (Roof Top) Modification. The Mercedes Benz Modification.

CHEVRON (ROOF TOP) MODIFICATION

The incision may be continued across the midline into a double Kocher incision or roof top approach which provide excellent access to the upper abdomen particularly in those with a broad costal margin

Used for: Total Gastrectomy. Total oesophagectomy. Extensive hepatic resections. Bilateral adrenalectomy

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THE MERCEDES BENZ MODIFICATION

Consists of bilateral low Kocher’s incision with an upper midline incision up to the xiphisternum.

Excellent access to the upper abdominal viscera. (mainly the diaphragmatic hiatuses)

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MCBURNEY GRID IRON (MUSCLE-SPLIT INCISION)

first described in 1894 by Charles McBurney

Is the incision of choice For most Appendectomies.

Made at the junction of the middle third and outer thirds of a line running from the umbilicus to the anterior superior iliac spine. (The McBurney Point)

The level and the length of the incision vary according to: The thickness of the abdominal wall. The suspected position of the appendix.

If palpation reveals a mass, the incision can be placed directly over the mass.

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. Oblique VS Transverse over the skin creases.

May be used in the left lower quadrant to deal with certain lesions of the sigmoid colon. (such as .drainage of a diverticular abscess)

The Ilioinguinal and Iliohypogastric nerves cross the incision & any accidental injury can predispose the patient to Inguinal hernia.

Advantages Good healing.

Negligible risk of herniation.

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PFANNENSTIEL INCISION (SMILE INCISION)

Used frequently by gynecologists and urologists for access to the pelvis organs, bladder, prostate and for caesarean section.

Usually 12 cm long and made in a skin fold approximately 5 cm above symphysis pubis.

skin fascia anterior rectus sheath rectus muscle transversalis fascia extraperitoneal fat perineum.

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Advantages: A convex incision which minimizing muscle

parasthesia and paralysis post-operatively.  It also  follows the cleavage lines in the skin resulting in less scarring

The incision offers Excellent cosmetic results because the scar is almost always hidden by the pubic hair

Disadvantages: Limited exposure of the abdominal organs. Use of incision

is therefore restricted to the pelvic organs

High risk of injury to the bladder

Extension of the incision is difficult laterally

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MAYLARD TRANSVERSE MUSCLE

CUTTING INCISION

It is placed above but parallel to the traditional placement of Pfannenstiel incision.

Gives excellent exposure of the pelvic organs.

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TRANSVERSE MUSCLE DIVIDING INCISION

Similar to Kocher’s incision. (but more transverse)

Used for: Newborn and infants. Short , obese adults.

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THORACOABDOMINAL INCISION Converts the pleural and peritoneal cavities into

one common cavity excellent exposure.

Left incision Resection of the lower end of the esophagus and proximal portion of the stomach.

Right incision elective and emergency hepatic resections.

Upper (midline, paramedian or oblique incision) can be easily extended into either the right or left chest for better exposure.

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Abdominal Wall Closure

CLOSURE OF THE ABDOMINAL INCISION

The goal of wound closure is to restore function of the abdominal wall after a surgical procedure.

It should leave the patient with a reasonably aesthetic scar, and most importantly, it should minimize the frequency of wound rupture, incisional hernia, wound infection, and sinus formation.

CLOSURE OF THE PERITONEUM

It is concluded that closure of the peritoneum is unnecessary and not recommended. It is associated with a slightly longer operative time and more postoperative pain, and there are some suggestions that it may cause increased formation of adhesions

CLOSURE OF THE FASCIA

Rates of wound sepsis and sinus formation have been studied in randomized trials and do not depend on closure technique

CONTINUOUS VS INTERRUPTED

Continuous suture Interrupted suture

WHAT SHOULD WE DO?

Depends on choice of surgeon,though continuous is preffered by almost all.

Clinical evidence, however, demonstrates that continuous and interrupted closures of the abdomen are responsible for similar incidences of wound dehiscence, incisional hernia, wound infection, wound pain, and suture fistula.

RESORBABLE VERSUS NONRESORBABLE SUTURE IN CLOSING THE FASCIA

Nonresorbable Resorbable

MONOFILAMENT VERSUS MULTIFILAMENT SUTURE

Less incidence of wound sepsis.

higher incidence of wound sepsis when compared to monofilament suture

monofilament multifilament

IN BRIEF

optimal surgical method of closing the abdominal wound is a continuous mass closure. This technique appears to reduce the incidence of wound rupture, is considerably less time consuming, is less expensive, and does not increase the incidence of incisional hernia, wound infection, or sinus formation.

prefer to use a resorbable suture with delayed degradation, such as polydioxanone.

catgut should not be used. Among nonresorbable sutures,

monofilament suture is recommended.

METHOD OF MASS CLOSURE OF THE ABDOMEN

Whether the incision is vertical or transverse, the steps for closure are more or less the same

For closure of the midline laparotomy incision, we employ two size 0 looped polydioxanone (PDS) sutures. One loop is used at the upper extremity and one at the lower extremity of the wound so that only one knot need be tied at the middle of the incision.

If the first stitch is inserted from under the fascia, the knot will lie deep to the fascia. Each suture should be placed so that it lies no more than 1 cm advanced from the previous suture and the needle should be inserted 1 cm from the cut edge . If the incision has entered the rectus sheath, the anterior sheath may retract, and great care must be taken to include it in the sutures as this is the most important layer for the strength of the wound.

MIDLINE INCISION

Closure of a midline incision is perfectly adequate in a single layer (mass closure), with a continuous suture.

The peritoneum may be included in the closure, but this is not essential as it will appose naturally when the fascia is closed.

A strong (gauge 1 or 0) monofilament nylon or polydioxanone (PDS) suture is therefore suitable. Closure is started at one end and a knot formed. If the first stitch is inserted from under the fascia, the knot will lie deep to the fascia. Each suture should be placed so that it lies no more than 1 cm advanced from the previous suture and the needle should be inserted 1 cm from the cut edge (Fig. 12.6). If the incision has entered the rectus sheath, the anterior sheath may retract, and great care must be taken to include it in the sutures as this is the most important layer for the strength of the wound.

Closure of a paramedian incision is undertaken in two layers.

After the posterior sheath has been repaired, the rectus muscle is released back into its original position before the anterior sheath is sutured. The muscle lies between the two suture lines and may give some strength to the closure

APPENDIX MUSCLE-SPLITTING INCISIONS

Closure of appendix incisions is performed in layers. The peritoneum is closed first with a continuous absorbable suture. One or two loose absorbable sutures appose the muscles, and finally the external oblique is closed with a continuous or interrupted absorbable suture (Fig. 12.10). Even when catgut was routinely used for these wounds incisional herniae were very rare.

PFANNENSTIEL INCISIONS

Closure of Pfannenstiel incisions is in layers, and particular care must be taken over the fascial closure at the upper extremity or an incisional hernia may develop at the umbilicus.

Closure of all muscle-cutting incisions is usually in two layers, using a continuous suture. The inner layer consists of peritoneum, transversalis fascia, transversus and internal oblique muscles – or the more posterior equivalents – along with the posterior rectus sheath. Most surgeons prefer to use an absorbable suture for this layer

ANTERIOR THORACO-ABDOMINAL INCISIONS

Closure of thoraco-abdominal incisions must include careful attention to diaphragmatic closure in order to prevent an iatrogenic diaphragmatic hernia. The use of a chest drain is usually indicated.

Following closure of the peritoneum and the linea alba, Scarpa's fascia may be approximated with 3/0 absorbable suture.

The skin may be closed with interrupted fine 3/0 or 4/0 nonabsorbable sutures using a curved cutting needle .

The sutures are spaced such that the distance between them is approximately equal to their width.

The skin may also be closed with interrupted fine 4/0 or 5/0 synthetic absorbable subcuticular sutures.

FIG1 SCARPA’S FASCIA. FIG 2 SKIN CLOSURE

SUBCUTICULAR SUTURE

STAPLES CLOSURE AND REMOVAL

RECONSTRUCTION

IF FASCIAL DEFECT REMAINS:-CAN PLACE PROSTHETIC MESH (EG. DUALMESH)-RELAXING INCISIONS IN THE EXTERNAL OBLIQUEAPONEUROSIS LATERAL TO RECTUS SHEATH

RECONSTRUCTIONCOMPONENTS SEPARATION METHOD- FOR LARGER DEFECTS-INTERNAL OBLIQUE INCISED LATERAL TO RECTUS AND POSTERIORRECTUS SHEATH INCISED DOWN TO ARCUATE LINE-LATERAL CUT EDGE OF POST SHEATH BROUGHT ANTERIORLY AND SUTURED TO THE LATERAL ANTERIOR FASCIAL LAYER

COMPLICATIONS FROM ABDOMINAL WOUNDS

Wound infections --Deep wound infections within the abdominal muscles often require formal re-exploration for drainage of pus.

Burst abdomen --now almost exclusively an indication of faulty technique. A poorly tied knot may have slipped, or the knot may have damaged the suture material, which subsequently fractured. The suture may have been pulled too tight and cut through the tissue, or the suture may have been carelessly sited and the fascia not included in the bites.

INCISIONAL HERNIA

Incisional herniae may become apparent during the early months after surgery when there has almost certainly been some deep wound dehiscence in the postoperative period.

TEMPORARY ABDOMINAL CONTAINMENT ANDLAPAROSTOMY

problem may be due to oedematous bowel or a retroperitoneal haematoma, or there may be packs to control bleeding which have reduced the available intra-abdominal capacity.