Surgical Incisions

Stj.Dr. Aylin Mert0902110019

Surgical Incision is a cut made through the skin to facilitate an operation or precedure.

It should be the aim of the surgeon to employ the type of incision considered to be the most suitable for that particular operation to be performed. In doing so, three essentials should be achieved:

1.Accessibility 2.Extensibility 3.Security

Langer’s Line

Langer’s Line correspond to the natural orientation of collagen fibers in the dermis, and are generally parallel to the orientation of the underlying muscle fibers

 Incisions made parallel to Langer's lines may heal better and produce less scarring than those that cut across.

Skin Subcutaneous tissue Superficial Fascia -Camper’s Fascia-fatty superficial layer -Scarpa’s Fascia-deep fibrous layer Deep Fascia(Gallaudet’s Fascia) Musculoaponeurotic Layer -External Oblique Muscle -Internal Oblique Muscle -Transverse Abdominal Muscle -Rectus Abdominis-Pyramidalis Muscle Fascia Transversalis Preperitoneal Fatty Tissue Peritoneum

Layer of Anterior Abdominal Wall

Abdominal & Pelvic incisions

VerticalIncisions

-Midline-Paramedian

Transverse & Oblique Incisions Abdominothoracic

Incisions

-Kochler Subcostal Incision-Transverse Muscle Dividing-McBurney Incisions-Oblique Muscle cutting-Pfannenstiel Incision-Maylard Incision

Vertical Incisions1)Midline Incision Almost all operations in the

abdomen and retroperitoneum

Advantages: -almost bloodless -no muscle fibers are

divided -no nerves are injured -good access to upper

abdominal viscera -very quick to make as

well as to close -can be extended full

lenght of abdomen curving around umblical scar.

Vertical Incisions2)Paramedian

Incisions Has 2 theoretical

advantages: -it offsets vertical

incision to right or left,providing access to lateral str. such as spleen or kidney.

-closure is theoretically more secure because rectus muscle can act as a buttress between reapproximated posterior and anterior fascial planes.

is placed 2 to 5 cm lateral to midline over median aspect of bulging transverse convexity of rectus muscle.

2)Paramedian Incision (cont’d) 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 laborius and difficult to extend superiorly as is limited by costal margins.

3. It doesn’t give good access to contralateral structures.

Vertical Incisions

Transverse Incisions1)Kocher Subcostal

Incision It affords excellent

exposure to gall bladder and biliary tract and can be made on left side to afford access to spleen.

İs started at midline ,2 to 5 cm below the xiphoid,and extends downwarda, outwards and paralel to and about 2.5 cm below costal margin

Especially used in cholecystectomy

1)Kocher Subcostal Incisions(cont’d) is divided into : -Chevron (Roof Top) Modification -The Mercedes Benz Modification

Transverse Incisions

Transverse Incisions

2)Transverse Muscle dividing In newborn and infants, this incision is

preferred bcs more abdominal exposure is gained per lenght of incision than with vertical exposure

Because infants’ abdomen longer transverse than vertical girth.

Also true of short, obese adult

Transverse Incisions

Transverse Incisions3)McBurney Incision(muscle

split) İncision of choice most

appendicectomies The level and lenght of incision

will vary according to thickness of abd. wall and suspected position of apendix.

is made at the junction of middle third and outer third of a line running from umblicus to anterior superior iliac spine,McBurney point.

Originally placed the incision obliquely from above laterally to below medially.

Also used in left lower quadrant to deal with certain lesion of sigmoid colon such as drainage of diverticular abscess.

Transverse Incisions

4)Oblique Muscle Cutting Incision Eponym of Rutherford-Morrison Incision Extension of McBurney incision by division

of oblique fossa Can be used for right and left sided colonic

resection, caecostomy or sigmoid colostomy

Transverse Incisions

Transverse Incision

5)Pfannenstiel Incision Used frequently by gynecologist and

urologist for access to pelvic organ, bladder, prostate and for c-section.

is usually 12 cm long and is made in skin fold approximately 5 cm above symphysis pubis.

Transverse Incisions

6)Maylard Transverse Muscle Cutting Incision

gives excellent exposure to pelvic organ Skin incision is placed above but parallel to

traditional placement of Pfannenstiel incision

Transverse Incisions

Thoracoabdominal Incisions

Either right or left Converts pleural and peritoneal cavities into

one common cavity Thereby gives excellent exposure Right incision may be particularly useful in

elective and emergency hepatic resections Left incision may be used in resection of

lower end of esophagus and proximal portion of stomach.

Incision is extended along line of 8th intercostal space,the space immediately distal to inferior pole of scapula.

Thoracoabdominal Incisions

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

2. Ayers, J.W., Morley, G.W. (1987): Surgical incision for caesarean section. Obstetrics Gynaecology, 70(5): 706-8.

3. Brand, E. (1991): The Cherney incision for gynaecologic cancer. American Journal of Obstetrics and Gynaecology, 165(1): 235.

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

5. Brodie. T.E., Jackson, J.T., McKinnon, W.M. (1976): A muscle retracting subcostal incision for cholecystectomy. Surgery Gynaecology Obstetrics 143(3): 452-3.

6. Brooks, M.J., Bradbury, A., Wolfe, H.N. (1999) : Elective repair of type IV thoraco-abdominal aortic aneurysms; experience of a subcostal (transabdominal) approach. European Journal of Vascular Endovascular Surgery, 18(4): 290-3.

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

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