various types of abdominal incisions in gyanecological surgeries

1. BY Dr Gitanjali kumari

2.  SKIN
 SUPERFICIAL FASCIA
 EXTERNAL OBLIQUE MUSCLE
 INTERNAL OBLIQUE MUSCLE
 TRANSVERSE ABDOMINALIS MUSCLE
 FASCIA TRANSVERSALIS
 EXTRAPERITONEAL TISSUE
 PARIETAL LAYER OF PERITONEUM
 RECTUS ABDOMINALIS MUSCLE AND RECTUS
SHEATH IN MIDLINE

8.  Divided into transverse or vertical incision
 McDowell performed first successful
abdominal surgery in 1809

10.  VERTICAL INCISION
 MIDLINE
 PARAMEDIAN
 TRANSVERSE AND OBLIQUE INCISIONS
 KOCHLER SUBCOSTAL INCISION
 MC BURNEY INCISION
 PFANNESTIEL INCISION
 MAYLARD INCISION
 CHERNEY INCISION

11.  Advantages
 Best for cosmetic results
 Low transverse incisions are 30 times
stronger than vertical incisions
 Less painful
 Less interference with post-operative
respirations

12.  Disadvantages
 More time consuming
 more hemorrhagic
 Hematoma or seroma formation are more
common
 Ability to explore the upper abdominal cavity
adequately is compromised

13.  Original/true Pfannesteil incision is described
as a transverse incision that is slightly curved
(concavity upward) and may be made at any
level suitable to the surgeon
 10-15cm long
 The skin and subcutaneous fat and fascia of
the abdominal wall are incised transversely.
 The fascia is separated from the rectus
muscle superiorly, inferiorly and laterally.
 The rectus muscles are then separated and
the peritoneum is incised in the midline

15.  Incorrectly referred as modified Pfannesnteil
incision
 The slightly curved transverse skin incision
begins below the level of anterior superior iliac
spine and extends just below the pubic hairline
,through subcutaneous fat down to the
aponeurosis of the external oblique muscle and
the anterior sheath of the recti musculature
 Midline incision through fascia exposing rectus
and pyramidalis muscle.
 The rectus muscles are retracted laterally and
peritoneum is incised in midline

17.  Skin and fascia are divided transversely
 Rectus muscle is freed at their tendinous
insertion into the pubis symphysis.
 Rectus muscles are then retracted cephalad
to improve exposure
 The transverse Cherney incision is about 25%
longer than a midline incision measured from
the umbilicus to the symphysis.

18.  Excellent exposure to space of Retzius and
excellent exposure of the pelvic side wall.
 In closure of Cherneys incision ,the ends of
rectus tendons are united to the inferior
portion of lower flap of the rectus sheath with
5-6 interrupted delayed sutures in horizontal
mattress configuration
 Femoral nerve can be damaged

19. Developing space of retzius
The hand of the operator
easily separates' the bladder
from the overlying
symphysis in the relatively
bloodless midline

21.  It is a true transverse muscle cutting incision
in which all layers of abdominal wall are
incised transversely
 1st by Ernest Maylard in 1907
 Provides excellent pelvic exposure
 Can be used for radical pelvic surgery
including Radical hysterectomy with pelvic
lymph node dissection and pelvic
exonerations

22.  A transverse incision is made abour 3-8cm
above the pubic symphysis
 Fascia is cut transversely
 Aponeurosis is not detached from underlying
muscle
 The inferior Epigastric arteries are isolated,
sectioned and ligated
 The rectus muscles are incised with a knife or a
Bovie device
 The hand of the surgeon is withdrawn as muscle
is cut

23.  For better approximation of muscles during
closure,suture the underlying muscle to the
underlying fascia before entering peritoneum.
 2-0 delayed U suture is used,and knots are
placed anteriorly to the fascia
 Peritoneum is incised transversely

25.  A 10cm transverse skin incision 3cm below the level of ASIS taken
 The subcutaneous tissue is opened sharply 2-3cm in the midline
 A small transverse incision is made in the fascia & curved Mayo scissors
are pushed laterally on each side & beneath subcutaneous fat to incise
the fascia
 Index finger from both hands are inserted b/w Rectus abdomanis
muscle bellies & benath the fascia
 One finger is moved cranially & the other caudally in opposition to
seperate the muscle
 Peritoneum is entered sharply and the incision is sharply extended to
cephalo caudal
 In Misgav ladach technique the peritoneum is entered bluntly


26.  Affords excellent exposure to gall bladder &
biliary tract
 Used in cholecystectomy

27.  This incision is continued across the midline
into double kocher’s incision or rooftop
appearance which provides excellent
exposure to upper abdomen particularly in
those with broad coastal margin
 Used in- total gastrectomy
 Total oesophagectomy
 Extensive hepatic resection
 Bilateral adrenectomy

28.  EXCELLENT EXPOSURE

29.  Least haemorrhagic
 Ensures rapid entry into abdominal/pelvic
cavity
 Location:
 In midline of abdomen ,can extend from
xiphoid process to just above umbilicus
 It can be continued to below the umbilicus by
curving the incision around umbilicus

30.  Layers of abdomnal wall :
 Skin,fascia,linea alba,transversalis
facia,extraperitonel fat & peritoneum
 Advantages
o Adequate exposure
o Minimal blood loss
o Minimal nerve injury
 Disadvantages
o Midline scar
o Burst abdomen

31.  It is palced lateral to midline and splits rectus
muscle longitudunally
 Excellent exposure & exrensibility
 Increased risk of bleeding & nerve injury
 Modified paramedian incision-retracts the
rectus muscle laterally before incising the
posterior rectus sheath peritoneum

33.  Paramedian incision that has been curved
towards xiphoid process
 Bigger , wider opening

34.  For transperitoneal or extraperitoneal
approach

35.  Obliquely Downwards inwards over Mcburney
point
 McBurneys point- 2/3rd from the umbilicus &
1/3rd rom the right ASIS
 Appendectomy
 Drainage Of pelvic Abscess

36.  Incision is carried through –
skin,subcutaneous fat to the external oblique
muscles
 The fibers of the musclein the direction in
which they run are seperated
 In closing intrnal oblique fibres are
approximated with in figure of 8 no. 0
delayed absorable sutures
 Aponeurosis of external oblique is closed
with continuous or interrupted no. 0 delayed
absorable sutures

38.  Transverse incision placed at the junction of
middle & lower thirds of the line extending
from ASIS to umbilicus
 Ext oblique aponeurosis split in line of fibers
 Internal oblique & transverse muscle fibers
seperated by blunt finger dissection
 Peritoneun is incised transversely

39. HEMATOMA
WOUND INFECTION
WOUND DEHISCENCE
BURST ABDOMEN
FISTULA FORNATION
INCISIONAL HERNIA
ADHESIONS
SCAR

40.  Calculation of suture ( SL to WL ratio –S)/D
 (A- [B+C])/D
 A= LENGTH OF THE SUTURE USED
 B = LENGTH OF THE SUTURE REMNANTS AT
THE STARTING KNOT
 C=LENGTH OF SUTURE REMNANTS AT THE
FINISHING KNOT
 D= LENGTH OF SKIN INCISION

41.  Use a monofilament suture material,slowly
absorable/non absorable
 Use continuous suture technique
 Close the wound in one layer
 Avoid high tension on the suture-adapt but
do not compress the fascial edges
 Place the stitches in the fascia only, 5 to 8mm
from the wound edge and at close intervals
4-5mm apart
 The SL to WL ratio should be greatr than 4

42.  THANK YOU