Surgical incision

1. ‫تعالی‬ ‫بسمه‬
‫جراحی‬ ‫های‬ ‫برش‬
Alireza Sadeghi Erami
Hanie Mazloumi
Feb 2020

2. SURGICAL INCISION

3. 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.A reliable closure

4. Principles
-Incision should be long enough for good
exposure
-Splitting is better than cutting
-Avoid cutting of nerves and vessels
-Retract muscle, abdominal organs towards
neurovascularbundle
-Insert DT through a separate incision
-Transverse incisions better than vertical
incisions
- Close the wound layer by layer

5. Choice of incision
Depend upon
Type of surgery [elective/emergency]
Target organ
Surgeons own experience and preference
and
Previous surgery.

6. Choice of incision
Depend upon
Type of surgery [elective/emergency]
Target organ
Surgeons own experience and preference
and
Previous surgery.

7. 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.

8. NECK

9. CAROTID ENDARTERECTOMY
An incision is made on
the midline side of the
SCM . The incision is
between 5 and 10 cm
in length.. The lumen
of the internal carotid
artery is opened, and
the atheromatous
plaque substance
removed.

10. CAROTID ENDARTERECTOMY
used to reduce the risk of stroke by
correcting stenosis (narrowing) in the common
carotid artery or internal carotid
artery. Endarterectomy is the removal of
material on the inside of an artery.

12. THYROIDECTOMY INCISION

13. THYROIDECTOMY INCISION
The incision kocher should be created in a
curvilinear fashion within a skin crease
approximately 2 cm or 2 finger-breadths above
the superior edge of the clavicle and sternal
notch.

14. INDICATIONS
 Thyroid cancer
 Toxic thyroid nodule (produces too much thyroid hormone)
 Multinodular goiter (enlarged thyroid gland with many
nodules), especially if there is compression of nearby
structures

15. TRACHEOTOMY INCISION

16. TRACHEOTOMY INCISION
tracheostomy, is a surgical procedure which
consists of making an incision (cut) on
the anterior aspect (front) of the neck and
opening a direct airway through an incision in
the trachea .The resulting stoma (hole) can
serve as an airway or as a site for a tracheal
tube or tracheostomy tube to be inserted; this
tube allows a person to breathe without the use
of the nose or mouth.

17. THORAX

18. STERNOTOMY
 Median sternotomy
 partial sternotomy :
Upper partial-sternotomy
Lower partial-sternotomy

19. MEDIAN STERNOTOMY

20. MEDIAN STERNOTOMY
This procedure provides
access to the heart and lungs
for surgical procedures such
as heart transplant, corrective
surgery for congenital heart
defects, or coronary artery
bypass surgery.

21. UPPER PARTIAL STERNOTOMY

22. UPPER PARTIAL STERNOTOMY

23. LOWER PARTIAL STERNOTOMY

24. THORACOTOMY:
 Posterolateral Thoracotomy (common)
 Anterolateral Thoracotomy
 Bilateral anteriorThoracotomy
 Axillary Thoracotomy

25. POSTEROLATERAL THORACOTOMY

26. ANTEROLATERAL THORACOTOMY

27. AXILLARY THORACOTOMY

28. CLAMSHELL

29. CLAMSHELL

30. Resection of large mediastinal masses
Double-lung Transplantation
Bilateral pulmonary metastasectomy

31. VATS

32. THORACOABDOMINAL INCISION

33. Converts the pleural and peritoneal cavities into one
common cavity /excellent exposure.
Left incision /Resection of the lower end of the
esophagus and proximal portion of the stomach.
Right incision / elective and emergency hepatic
resections.
Incision is extended along line of 8th intercostal
space,the space immediately distal to inferior pole
of scapula.

35. ABDOMEN

36. LAYER OF ANT ABDOMINAL WALL
1.Skin
2.Superficial fascia
Camper's fascia - fatty superficial layer.
Scarpa's fascia - deep fibrous layer.
3.Muscle layer
External oblique abdominal muscle
Internal oblique abdominal muscle
Transverse abdominal muscle
rectus abdominis and pyramidalis muscles.
5.Fascia transversalis
6.Extra peritoneal fascia
7.Parietal Peritoneum

40. SUBCOSTAL INCISIONS
 Kocher Incision
 Chevron Incision
 Mercedes Benz

41. KOCHER INCISION
The Kocher incision
is a subcostal incision
on the right side of
the abdomen used
for open exposure of
the gallbladder and
biliary tree. This
incision is just inferior
and parallel to the
subcostal margin.

42. Incision parallel to the 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 is appropriate for certain operations on the liver,
gallbladder and biliary tract/cholecystectomy/. It
may be mirrored on the contralateral side to
provide access to the spleen or performed
bilaterally as a Rooftop (chevron) incision to
provide efficient access to organs such as the
pancreas and biliary tree /

43. Disadvantages
include the risk of injuring the superior
epigastric vessels,
and lateral extension of the incision risks
disruption of intercostal nerves

44. CHEVRON INCISION
Two modifications and
extensions of the Kocher
incision.It is a sub-costal
incision that extends from the
mid to lateral costal ridge,
across the midline to the
contralateral side . The
average length of the incision
is approximately 24 to 30
inches.

45. CHEVRON INCISION
This may be used for
oesophagectomy,
gastrectomy, bilateral
adrenalectomy,
hepatic resections, or
liver transplantation.

46. MERCEDES BENZ
It is the classic chevron
with a vertical incision
that extends through the
xiphoid and the sternum.
This modification is used
in
liver transplants or any
epigastric pathology that
needs adequate
exposure for total
removal.

48. MIDLINE
Also known as the laparotomy
incision, or celiotomy, this is
the most traditional of surgical
incisions. This location is a
mostly avascular plane and
does not impose a great risk to
the blood supply. There is
rarely nerve damage in this

49. -the most common incision
- three types:
Upper Midline Incision
From xiphoid to above umbilicus.
Lower Midline Incision
From the SUPERIOR umbilicus to INFERIOR
pubic symphysis .
Full Midline Incision
From xiphoid to pubic symphysis inferiorly

50. Advantages:
Adequate exposure of most if not all of the abdominal
viscera
It is almost bloodless.
No muscle fibers are divided.
No nerves are injured.
It is very quick to make as well as to close.
Disadvantages:
Extensive is difficult
More painful.
Chest complications.
Wound infection, Ugly scar, Incisional hernia

51. PARA-MEDIAN INCISION
The incision runs 2-5cm lateral to the
midline.
It was originally used to access much of
the lateral viscera, such as the kidneys,
the spleen, and the adrenal glands.
A paramedian incision can damage the
muscles’ lateral blood and nerve supply,
which may result in the atrophy of the
muscle medial to the incision.

53.  Grid iron Incision (Mc Burney Incision)
 Lanz

55. MCBURNEY GRID IRON
İncision of choice most
Appendicectomies
is made at the junction of middle third and
outer third of a line running from umblicus
to anterior superior iliac spine,McBurney
point.

56. LANZ INCISION
It is a variation of McBurney incision that is
made the same point but in transverse plane.It
gives
cosmetically good scar.

57. RUTHERFORD-MORRISON
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

59. PFANNEISTIEL( KERR) :

60. In the classic Pfannenstiel incision, the skin
and subcutaneous tissue are incised
transversally, but the linea alba is opened
vertically.
Used frequently by gynecologists and
urologists for access to the pelvis organs,
bladder, prostate & caesarean section &
abdominal hysterectomy .
Usually 12 cm long and made in a skin fold
approximately 5 cm above symphysis pubis.
The incision offers Excellent cosmetic results
because the scar is almost always hidden by
the pubic hair

62. Complications of abdominal
incision
Hematoma, Stitch abscess, Wound infection
Wound dehiscence
Burst abdomen
Fistula formation
Wound pain
Incisional hernia
Adhesion and its complications
Unsightly scar

63. Factors affecting the strength of
scar
Types of surgery(acute abdomen, surgery for
malignancy, major surgery)
Types of incision
Obesity
Pregnancy
Straining
Cough
Ascites
Nutrition
Diabetes
Immunosuppression