Principles Governing Abdominal Incisions
Adequate exposure for easy accessibility to the organ.
Incision should be extendible.
It should be a muscle splitting rather than muscle cutting except for the rectus muscle which can be cut transversely because of its rich segmental nerve supply.
Nerves should not be divided.
Opening through the different layers of the abdominal wall should not be superimposed.
Least interference with the functions of abdominal wall
Closure should be strong and secure
Factors governing the choice of Incision
1) Patient related -
Thickness of abdominal wall and tone
2) Pathology -
Benign / malignant
Solitary / Multiple
Diagnosis not confirmed (e.g. hemoperitoneum)
A) Operating conditions -
Degree of relaxation -
A)Anterior abdominal wall Posterior abdominal wall
No muscles divided -
Through linea semilunaris (damages nerves)
Muscle splitting -
Muscle dividing - Transrectal -
1) Vertical -
Position of Umbilicus -
Supraumbilical / Infraumbilical Incision -
Upper / central / lower
Muscle retracting / splitting
Upper / central / lower
2) Oblique -
Sir Rutherford Morrison's
A. No muscles divided
Median / midline (Supraumbilical / Infraumbilical / Mid midline)
Supraumbilical - Stomach, duodenum, gall bladder, liver, bile ducts and pancreas
Infraumbilical - Intestine, appendix, urinary bladder, prostate, ruptured ectopic pregnancy
Mid midline - Small and large bowel
Quick, good access for emergency surgery.
Both sides of abdomen can be readied.
Supraumbilical part heals well as it is thick, strong and holds sutures well.
Healing in infraumbilical region is bad as linea alba is thin and weak. Therefore complications - burst abdomen & incisional hernia.
Injury to falciform ligament / urinary bladder. For an incision through the whole length of the anterior abdominal wall a median supraumbilical and paramedian infraumbilical incision is preferred. Opening of peritoneum -
Above - below upwards to avoid damaging falciform ligament.
Below - above downwards-to avoid damaging the urinary bladder.
Procedure of closure of layers -
Skin 3-0 / 2-0 Ethilon, vertical mattress / simple sutures
Superficial fascia 2-0/3-0 chromic catgut, interrupted
Linea alba 1-0 Ethilon, interrupted-non absorbable
Extraperitoneal fat 2-0/3-0 chromic catgut / vicryl, continuous interlocking
Types of Closure -
Monolayer closure - Rectus sheath and muscle. extraperitoneal fat, peritoneum with 1-0 ethilon & skin as usual.
Wilkie's closure - Rectus sheath flaps closed over peritoneum.
Pauchet and Reid's closure - Steel wire closure. Entire thickness, interrupted.
Figure of 8- All layers in figure of 8 fashion. 1-0 ethilon.
Rectus retracted 1 inch from the midline on either side.
Right upper paramedian - Stomach and duodenum, gall bladder, head of pancreas, right lobe of liver
Left upper paramedian - Esophagus, cardia of stomach, spleen, splenic flexure of colon, left lobe of liver
Right lower paramedian - Appendix, cecum, female genital organ
Left lower paramedian- Sigmoid and descending colon
Mid paramedian (more towards Right)
Exploratory laprotomies - Pathology not known Multiple pathologies Extensive pathology
Layers cut -
Anterior rectus sheath
Rectus muscle retracted laterally as nerve supply is from lateral side
Post rectus sheath
Access-up and down
Extend-up and down
Closure is secure especially in muscle retracting type as muscle comes over it
Less chances of incisional hernia Disadvantages -
Perpendicular to Langer's lines, cosmetically bad
Post-operative pain more than transverse
More blood loss
More time consuming
Other quadrants accessibility bad
Pararectal (also called as BATTLE'S incision)
Medial to the outer border of rectus muscle
Muscle is retracted medially
Perpendicular to middle 1/3' of spinoumbilical line 1/3" above and 2/3" below the line
Same as above except rectus muscle is retracted medially Access -
Pelvis with extension
Colon with extension Advantages -
Rectus not cut
Nerve supply to rectus damaged. Therefore, muscle atrophy.
B. Muscle splitting Paramedian (MAYO ROBSON)
Same as paramedian (vide supra) except that here the muscle is split.
Split should be as medial as possible because it damages nerve supply.
Gall bladder easily reached
Lateral - (Mc Burney / Lanz / Rocky Davis)
a. McBurney's grid iron incision
Pezpendicular to spinoumbilical line
At the junction of lateral 1/3 and medial 2/3 of the line, 1/3 above and 2/3 below the line
Right - Appendix - only if diagnosis is confirmed, cecum, colostomy
Left - Colostomy
Layers cut -
External oblique split in the direction of it's fibers
Internal oblique same as above
Peritoneum-direction of skin incision
Lines of opening not superimposed
Artificial sphincteric action through left side (adequately controlled by abdominal muscles) Disadvantages -
Very limited exposure
Difficult to extend. Advantages are lost.
May lead to ilio-inguinal and ilio-hypogastric nerve damage causing hernia
Abscess drainage cannot be done between the internal oblique and transversalis just below the incision.
b. Lanz incision (Bikini incision)
Modification of McBurney's
Passes through McBurney's point along the skin creases. Used in elective appendicectomy for cosmesis.
c. Rocky Davis incision
1 finger breadth below the umbilicus 3 cm long with mid point at mid davicular line.
Hernia (also testis, cord, tunica vaginalis) 1 inch above the inner half of inguinal ligament Ureter (also external iliac vessels) 1 inch above the lateral half of inguinal ligament
c. Muscle cutting/dividing (Transrectal) Superior (Subcostal / Kocher's)
Xiphoid process, downwards, to right & parallel to costal margin, two finger breadths below it. Layers cut and closure
Skin - 3-0/2-0 ethilon
Superficial fascia - 2-0 catgut
Anterior rectus sheath - No. 1 vicryl
Rectus - No. 1 vicryl
Posterior rectus sheath - Transversalis fascia 2-0 catgut! vicryl
Peritoneum -2-0 catgut
Intercostal nerves, which passes perpendicular to the incision must be carefully preserved (especially T3 & T4) Access -
Left - Spleen
Right— Liver, gall bladder
Good exposure of gall bladder
As an extension of supraumbilical midline incision. Access
Right — Liver, gall bladder, bile ducts
Left - Spleen
Umbilicus-to tip of 10th costal cartilage, Raise-large triangular flap.
Rutherford Morrison's Incision
Gall bladder Bile duct
1 inch below the tip of 12th rib to the upper part of the middle 1/3 of the line from the xiphoid to umbilicus. Inferior (transrectal) Pfannensteil's incision
Transverse incision on the lower abdominal wall 5 cm above the pubic symphysis 12 cm in length. Usually along the skin crease.
Rectus muscle divided along the line of incision (may also be retracted.)
Uterus, ovary, fallopian tube, urinary bladder
Complications of Abdominal Incisions
Infection of abdominal incision Grades -
Stitch abscess — Superficial / Deep
Subcutaneous. abscess Treatment - cut stitches, observe, antibiotics
Dehiscence - Burst abdomen
Keloid in supraumbilical incision from xiphisternum.