Abdominal incisions in Gynaecology and obstetrics

1. ANATOMY OF ANTERIOR ABDOMINAL
WALL AND ABDOMINAL INCISIONS FOR
GYNAECOLOGICAL SURGERIES AND
LAPAROTOMY PORT SITES
Dr. Tanya Das
Moderator:Dr. Rosina Manandhar

2. ANATOMY OF ANTERIOR ABDOMINAL
WALL
Why important?
-To avoid injury to vessels and nerves
-To close any incision with minimal chance of
dehiscence.

3. Boundary
Superiorly-the costal cartilage of 7th,8th,9th ribs
Laterally-iliac crests
Inferiorly-inguinal ligament,the pubic crests and
superior border of the symphysis pubis

4. Anatomy of Anterior Abdominal wall

5. Musculature of Abdominal Wall

6. Rectus Sheath

7. MAJOR ARTERIAL SUPPLY

8. ARTERIAL AND VENOUS SUPPLY

9. NERVE SUPPLY

10. LYMPHATIC DRAINAGE

11. Abdominal incisions for most gynecologic
procedures can be divided into:
1.Transverse Incision
2.Vertical Incision
3. Oblique Incision

12. TRANSVERSE INCISION
ADVANTAGES:
1.Best cosmetic results
2.30 times stronger than midline incisions
3.Less painful
4.Results in less interference with postoperative
respirations
5.Less wound dehiscence

13. DISADVANTAGES:
1.More time consuming
2.More hemorrhagic
3.Less exposure
4.Division of multiple layers of fascia and muscle
–formation of potential spaces-hematoma and
seroma formatiom.

14. TRANSVERSE INCISION
Pfannenstiel incision
Maylard Incision
Kustner incision
Cherney incision

15. Pfannenstiel incision
-Transverse incision that are slightly curved
-10-15cm long,about 2cm above the symphysis
pubis
-Excellent cosmetic results
-Exposure is limited
-If extended laterally-injury to hypogastric and
ilioinguinal nerves

17. KUSTNER INCISION
-Modified Pfannenstiel incision
-slightly curved transverse incision below the level
of Anterior superior iliac spine and extends just
below the pubic hairline,through subcutaneous fat
down to the aponeurosis of external oblique muscle
and the anterior rectus sheath
-Inferior epigastric artery may be encounter in
subcutaneous fat at the lateral margin of the
incision

18. - Fascia cleared superiorly and inferiorly to
create space to permit adequate vertical
incision in linea alba
- Separation of rectus muscle and entrance into
peritoneum similar to other transverse
incisions

20. CHERNEY INCISION
-The Rectus muscles are transected at their
tendinous insertion into the symphysis pubis
-Provide excellent access to the space of Retzius
and pelvic side wall
-Bleeding is negligible

22. MAYLARD INCISION
-Transverse muscle cutting incision
-Provide excellent pelvic exposure
-Used for radical pelvic surgery,including radical
hysterectomy with pelvic lymph node dissection
and pelvic exenteration
-Inferior epigatric vessels must be ligated before
incising the rectus muscle to avoid tearing of the
vessels, vessel retraction and hematoma
formation

25. VERTICAL INCISIONS
Advantages
-Excellent exposure
-Easily extended
-Rapid entry to the abdominal cavity
-Minimal nerve damage
-Least hemorrhagic

26. Disadvantages:
-Wound dehiscence and hernia are more
common
-Poor cosmetic results
-Higher infection rates, hemorrhage and
operating time with paramedian incision.

27. MIDLINE(median) INCISION
-Least hemorrhagic
-Rapid entry to abdominal cavity
-Minimal nerve damage
-Dehiscence and hernia are more common

29. PARAMEDIAN INCISION
-Lateral to midline
-Splits the rectus muscle longitudinally
-Risk of bleeding and nerve injury increased
-Greater strength than midline incision
-Modified paramedian incision retracts the
rectus muscle laterally before incising the
posterior rectus sheath and peritoneum

30. Oblique Incisions
-Can be used for transperitoneal or
extraperitoneal approach.
1.Gridiron(muslce splitting Incision)Incision
-appendectomy
-extraperitoneal drainage of an abscess
from pelvic inflammatory disease.
Made obliquely downward and inward over the
McBurney point

32. 2.Rockey-Davis Incision
-Alternative to McBurney incision
-transverse incision placed at the junction of
middle and lower thirds of a line extending from
the anterior superior iliac spine to the umbilicus.
-medially extends to the border of rectus muscle

34. Incisions Used for Cesaerean section
• Pfannenstiel Incision
• Joel cohen Incision
• Misgav Ladach Incision

35. LAPAROTOMY PORT SITES

38. THANK YOU