Transcript ABDOMINAL INCISION

‫‪ABDOMINAL INCISION‬‬
‫بإشراف الدكتور‬
‫محمد عبيد‬
‫اعداد الطالب‬
‫علي احمد‬
‫بمشاركة‬
‫سيف ماجد‬
‫ياسر عليوي‬
‫رانيا جودي‬
Introduction
Incision: A cut produced surgically
by a sharp instrument that creates
an opening into an organ or space in
the body.
Abdomen: The part of the trunk
that lies between the thorax and the
pelvis
Considerations in Selecting the
Type of Incision
Certainty of diagnosis
Speed of entry
Body status
Presence of previous scars
Potential for problems with hemostasis
Cosmetic outcome
A well-planned incision has
FOUR essential elements:
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Accessibility: must provide ready
access to the expected pathology and
adequate exposure.
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Extensibility: must be extensible if
the scope of operation needs to be
increased.
Preservation of function: should
interfere minimally with abdominal wall
function muscles must be split in the
direction of its fibers rather than cut
across; and the incision must Not divide
nerves.
Security: should heal with adequate
strength to reduce the risk of wound
disruption and incisional hernia
Skin and muscle incisions
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Langer’s lines. sken incisions made
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Split the muscles in the direction of their
parallel to Langer's lines may heal better
and produce less scarring than those that
cut across.
fibers, rather than transecting them.
Rectus is an exception due to its
segmental innervation and presence of
tendinous intersection
Be careful

Any mistake,
such as a badly placed
incision, worse methods of suturing, or illjudged selection of suture material, may
result in serious complications such as
haematoma formation, an ugly scar, an
incisional hernia, or, worst of all, complete
disruption of the wound
Layers of Abdominal Wall
Skin
Superficial fascia
Deep fascia
Muscles
Transversalis fascia
Extraperitoneal fascia
Peritoneum
RECTUS ABDOMINIS
Origin: Symphysis pubis,
pubic crest
Insertion: 5th, 6th and 7th
costal cartilage and xiphoid
Nerve Supply: Lower six
thoracic nerves
Rectus Sheath:made up of the
aponeuroses of the three
Anterolateral abdominal muscles
as they converge
at the linea alba
External Oblique
Origin: lower 8 ribs.
Insertion: Xiphoid Linea alba
, pubic crest, pubic tubercle,
iliac crest.
Nerve Supply: Lower six
thoracic nerves, iliohypgastric n.
, ilioinguinal n.
Internal Oblique
Origin:Lumbar Fascia,iliac crest,
lateral 2 thirds of inguinal L.
Insertion: Lower three ribs,
costal cartilage,Xiphoid,
Linea alba,symphasis pubis.
Nerve Supply:Lower 6
thoracic nerves, iliohypogastric n.
, ilioinguinal n.
Transversus Abdominis
Origin: lower 6 costal cartilage,
lumbar fascia, iliac crest,
lateral third of inguinal L.
Insertion:Xiphoid process,
Linea alba, symphasis pubis.
Nerve Supply: Lower 6
thoracic nerves, iliohypgastric n.
, ilioinguinal n.
Blood Supply
5 intercostals arteries
subcostal arteries
4 lumbar arteries
Superior epigastric artery,
internal thoracic artery
Inferior epigastric artery –
external iliac artery
Deep iliac circumflex arteryexternal iliac artery.
Innervations

Intercostal n.
• Anterior cutaneous branch
• Lateral cutaneous branch
 T7-12
thoracic n.
 Iliohypogastric n.
 Ilioinguinal n.
 Genitofemoral n.
Classification of incisions
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Vertical incision :
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Transverse and oblique incisions :
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Midline incisions
Paramedian incisions
Kocher's subcostal Incision
Transverse Muscle dividing incision
Mc Burney’s grid iron or muscle splitting incision.
Oblique Muscle cutting incision
Pfannenstiel incision
Abdominothoracic incisions.
Abdominal Regions
Vertical incisions (Midline incisions)
• Upper Midline Incision
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From xiphoid to above umbilicus.
Skin  superficial and deep fascia  linea alba 
extraperitoneal fat (abundant and vascular)  peritoneum.
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
• Lower Midline Incision
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From the umbilicus superiorly to the pubic symphysis
inferiorly.
the peritoneum should be opened in the uppermost area to
avoid possible injury to the bladder.
Allow access to pelvic organs.
• Full Midline Incision
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Great exposure is needed.
Vertical incisions (Midline incisions)
1.
Disadvantages:
1. More painful.
2. Chest complications.
3. Wound
infection……Ugly
scar…… Incisional
hernia…. etc
1.
Advantages:
1. It is almost bloodless.
2. No muscle fibers are
divided.
3. No nerves are injured.
4. Good access to the
upper abdominal
viscera.
5. It is very quick to
make as well as to
close.
Paramedian incisions
• 2 to 5 cm lateral to the midline.
• Over the medial aspect of the
bulging transverse convexity of the
rectus muscle.(linea semilunaris)
• Extra access can be obtained by
sloping the upper extremity of the
incision upwards to the xiphoid.
(Myo-Robson extension)
Paramedian incisions
Disadvantages:
• It doesn’t give good
access to contralateral
structures.
• Difficult to extend
superiorly as is limited
by costal margin.
• atrophy of the muscle
medial to the incision.
(due to weakening the
lateral blood and nerve
supply of the muscle)
Advantages:
• Provide access to the
lateral structures such
as the spleen or the
kidney.
• Lower incidence of
postoperative
incisional hernia.
(rectus muscle??).
Subcostal Incision (Kocher’s
incision)
• Incision parallel with 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 gall
bladder and biliary tract and can be made on
the left side to show access to the spleen.
• Have two modification:
 Chevron (Roof Top) Modification.
 The Mercedes Benz Modification.
Chevron (Roof Top) Modification
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The incision may be continued across the midline
into a double Kocher incision or roof top
approach.
Access to the upper abdomen. (esp. with broad
costal margin)
Used for:
• Total Gastrectomy.
• Operations for renovascular hypertension.
• total oesophagectomy.
• liver transplantation.
• Extensive hepatic resections.
• Bilateral adrenalectomy………etc
The Mercedes Benz Modification
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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)
Disadvantages:
It is a muscle cutting incision.
Dividing the 8th and 9th intercostal ns
leading to weakness of the ant. abd.
wall.
(II)-Transverse muscle dividing
incision
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Its made through rectus sheath and
muscle and through the oblique and
transversus latrally
Its rare to damage more than 1
nerve so post operative abdominal
weakness is minimal
It gives good exposure
Its unnecessary to suture the cut
ends of rectus muscles
(III)- muscle-splitting
McBurney
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Oblique skin incision 5 cm above and medial to
the anterior superior iliac spine
External, internal and transversus muscle are
incised or split to incised fascia transversalis and
peritoneum
No post operative weakness
if palpation reveals a mass, the incision can
be placed directly over the mass.
For most.
Appendectomies ,sigmoid colon
The Ilioinguinal and Iliohypogastric nerves
Inguinal hernia
Good healing.
Cosmetic appearance
(IV)-Pfannenstiel incision (smile
incision)
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It is a generally horizontal (slightly
curved) line just above the pubic
symphysis 5 cm.
It is for obstetric delivery and hernia
repair bladder, prostate .
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Advantages:
• It is a cosmetic incision.
• It does not distort the umbilicus and heals
faster than the traditional vertical incision.
Thoracoabdominal Incision
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It is done for exposing lower thoracic,
upper abdominal & retroperitoneal
compartments.
It converts the pleural and peritoneal
cavities into one common cavity.
On the right side, for hepatic resection,
on the left side for resection of lower
esophagus and upper stomach.
It is done through intercostal space 5
through 9 or by resection of ribs 7-9.
Disadvantages:
•Opening the 2 cavities
increases the mortality and
morbidity rates.
•Anatomic compilations are
encountered, e.g. splenic
and phrenic nerve injuries
and postoperative pain
from transection of costal
arch.
Thank you