Surgical incisions

Surgical Incisions
Under observation:
Specialist Dr. Ghulam Reza Riaz
Submitted By:
Dr. Somaya Banaei
Resident of General Surgery
Herat-Afghanistan

Introduction
Surgical Incision is a cut made through the skin to facilitate an
operation or procedure.
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.
By: Dr. Somaya Banaei 2

In doing so, three essentials should be achieved:
Accessibility Extensibility Security

Principles
Incision should be long enough for good exposure
Splitting is better than cutting
Choose the correct position
Avoid cutting of nerves and vessels
Retract muscle, abdominal organs towards neurovascular bundle
Insert DT through a separate incision
Close the wound layer by layer

Choice of incision
Type of surgery
[elective/emergency]
Target organ
Previous surgery
Grade of patient
Obesity
Surgeons own experience &
preference

Rectus abdominis muscle maybe cut transversely without weakening
the abdominal wall.
The cut passes between two adjacent nerves without injuring the
nerves.
The incision must not divide no nerve
Drainage tubes should be inserted through separate incision like wise
colostomy or ileostomy should be made through a separate incision
The openings made by the incision through different layers of the
abdominal wall must not be superimposed
The ideal incision allows:

Lines Of Cleavage
Or
Langer’s Line
 The natural lines of cleavage in the skin are constant and run
Downward and forward almost horizontally around the trunk.
 If possible, all surgical incisions should be made in the lines of
cleavage, Where the bundles of collagen fibers in the dermis
run in parallel rows.
 An incision along a cleavage line will heal as a narrow scar.

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.
Lines Of Cleavage
Or
Langer’s Line

Common Abdominal & Pelvic incisions
Vertical Incisions
Transverse incisions
Oblique Incisions
• Midline
• Paramedian
• Transverse Muscle Dividing
• Pfannenstiel Incision
• Maylard Incision
• Kocher Subcostal Incision
• Mc Burney Incisions
• Oblique Muscle cutting
• Inguinal incision

Common Abdominal & Pelvic incisions

Vertical Incisions
Medline Incision
vertical incision which follows the linea alba.
It may be:
 Upper Midline Incision
 Lower Midline Incision
 Single Incision

Layers of the abdominal wall
• skin, fascia (camper's and scarpa's)
• linea alba
• transversalis fascia
• extraperitoneal fat
• peritoneum
It is favored In diagnostic laparotomy, as it
allows wide access to abdominal Cavity.
Vertical Incisions
Medline Incision

Upper medline
• From xiphoid to above umbilicus.
• Division of the peritoneum is best performed at the
lower end of the incision
• just above the umbilicus ,so that the falciform ligament
can be seen and avoided
• Suitable for Upper GI tract operations
Lower medline
• From the umbilicus superiorly to the pubis symphysis
inferiorly
• Allow access to pelvic organs
• the peritoneum should be opened
• in the uppermost area to avoid injury to the bladder

• Almost bloodless
• No muscle fibers are divided
• No nerves are injured
• Good access to upper abdominal viscera
• Very quick to make as well as to close
• Can be extended full length of abdomen.
• Supine position
Advantage
• Care needs to be taken just above the umbilicus where the
falciform ligament is.
• Midline scar
• Bladder injury
• Incisional hernia
• Adhesions in lower incisions
Disadvantage

Modified Makuuchi Incision
A. The modified incision is used for liver and
right-sided abdominal surgery. This incision
begins cephalad to the xiphoid, extends to 1
cm above the umbilicus, and then extends
laterally to the right.
B. The L incision is used for gastric, pancreatic,
and left-sided abdominal surgery. This
incision is a mirror image of the modified
Makuuchi incision.

placed 2 to 5 cm lateral to midline
It can be extended from costal margin to pubis
Layers of the abdominal wall:
 Skin, fascia (camper's and scarpa's) and the anterior rectus
sheath are incised.
 The anterior rectus muscle is freed from the anterior sheath and
retracted laterally.
 The posterior rectus sheath (if above the arcuate line) or
transversalis fascia (if below the arcuate line)
 Extra peritoneal fat and peritoneum are then excised allowing
entry to the abdominal cavity.
Vertical Incisions
Para median Incision

• Provides access to lateral structures
• Avoids injury to nerves, limits trauma to rectus muscle.
• Permits good restoration of abdominal wall function
• Can be extended by slanting the upper end of the incision
medially towards the xiphoid process if required
Advantage
• Time consuming.
• Bleeding & hematoma
• Incision needs to be closed in layers
• Difficult extension superiorly as limited by the costal margin
• Tends to strip the muscles of their lateral blood and nerve
supply resulting in atrophy of the muscle medial to the
incision
Disadvantage

Mayo-Robson incision
• This is really a PARAMEDIAN incision that
has been curved towards the xiphoid
process.
• It allows a bigger and wider opening.
• Dissection continues in the same fascial
planes as the paramedian incision.

This incision is made just above the umbilicus,
dividing one or both of the rectus muscles.
In newborn and infants, this incision is preferred bcz
more abdominal exposure is gained per lenght of
incision than with vertical exposure
It is useful for:
• Right or left colon
• Duodenum
• Pancreas
• Subhepatic space.
Transverse incision

Layers for Transverse incision
a) Skin, fascia
b) Anterior rectus sheath,
c) Rectus muscle (+/- internal oblique,
depending on the length of the
incision),
d) Transvers abdomen
e) Transversalis fascia
f) Extraperitoneal fat
g) Peritoneum

• Less pain than a midline incision
• Good access to midline upper GI structures
• Transverse incisions cause the least amount of damage
• As the recti have a segmental nerve supply, it can be cut transversely without
weakening a denervated segment
• Muscular segments can be rejoined
• Better scar and good healing.
Advantage
• Limited lateral access in comparison with midline incisions that can then be
extended
• More wound infections compared to midline thought to be due to greater
difficulty in controlling bleeding and haematoma formation
Disadvantage

Pfannenstiel Incision
• Used frequently by gynecologist and
urologist for access to pelvic organ,
bladder, prostate and for c.section.
• A convex 5cm to 12cm incision, located a
the suprapubic skin crease about 2cm to
5cm above the pubic symphysis.

Maylard Transverse (Muscle Cutting Incision)
• Gives Excellent Exposure To
Pelvic Organ
• Skin Incision Is Placed Above But
Parallel To Traditional Placement
Of Pfannenstiel Incision

• 3cm below the line that joins spina iliaca ant. Sup.
• Slightly higher Pfannenstiel.
• Subsequent layers open bluntly .
• It necessary extended with scissor and not a knife
This incision associated with
Less:
Pain/fever/Analgesic equipment /blood loss
Shorter:
Duration of surgery/Hospital stay
Joel-Cohen incision

The Küstner incision
 Sometimes incorrectly referred to as
modified pfannenstiel incision
 involves a slightly curved skin incision
beginning below the level of the anterior
superior iliac spine and extending just below
the pubic hairline.
 This incision is more time‐consuming and
extensibility is limited.

The Cherney incision involves transection of
the rectus muscles at their insertion on the
pubic symphysis and retraction cephalad to
improve exposure.
This can be used for urinary incontinence
procedures to access the space of Retzius and
to gain exposure to the pelvic side‐wall for
hypogastric artery ligation.
The Cherney incision

Kocher (Subcostal) Incision
• It affords excellent exposure to gall bladder
and biliary tract and can be made on left side
to afford access to spleen.
• İs started at midline ,2 to 5 cm below the
xiphoid, and extends downwarda, outwards
and paralel to and about 2.5 cm below costal
margin
• Especially used in cholecystectomy
There are two modifications
Chevron (rooftop)modification
Mercedes Benz modification

Chevron (rooftop) modification
The incision may be continued across the
midline into double Kocher's incision or rooftop
appearance which provide excellent access to
upper abdomen particularly in those with broad
costal margin
Uses:
Total Gastrectomy
 Total Oesophagectomy
 Extensive Hepatic Resection
 Bilateral Adrenectomy

Mercedes Benz modification
• Consists of bilateral low kocher’s
incision with upper midline incision up
to the xiphi sternum.
• Gives excellent access to the upper
abdominal viscera mainly the
diaphragmatic hiatuses

Thoraco-abdominal Incisions (left / Right)
They convert the pleural and
peritoneal cavities into one.
They allow good access to the lungs,
liver and spleen.
Incision is extended along line of
8th intercostal space
the space immediately distal to inferior
pole of scapula.

• Right incision may be
particularly useful in elective
and emergency hepatic
resections
• Left incision may be used in
resection of lower end of
esophagus and proximal
portion of stomach.
Thoraco-abdominal Incisions (left / Right)

Flank incision (Retroperitoneal approach)
 It commences 1.25cm below and lateral to renal
angle and passes towards the anterior superior
iliac spine.
 This extends from kidney angle in oblique
direction down wards and outwards toward the
anterior superior spine.
 The kidney angle is formed by the outer border
of sacro spinalis muscles at the junction with the
12th rib.

Flank incision (Retroperitoneal approach)
The incision runs in the direction of the
fibres of external oblique muscle.
This incision for open nephrectomy.
Right lateral region of abdomen has been
exposed.
The outline of three lowest ribs made
visible.

Grid iron (muscle splitting) incision
İncision of choice most appendicectomies .
The level and lenght of incision will
varyaccording to thickness of abd. Wall and
suspected position of apendix
Mc Burney point.
Is made at the junction of middle third and
outer third of a line running from umblicus
to, anterior superior iliac spine

Originally placed the incision obliquely
from above laterally to below medially.
Also used in left lower quadrant to deal
with certain lesion of sigmoid colon such
as drainage of diverticular abscess.
The level and length of the incision vary
according to thickness of abdominal wall
Suspected position of the appendix
Grid iron (muscle splitting) incision

Lanz incision
• It is a variation of McBurneys
incision that is made the same point
but in transverse plane.
• It gives cosmetically good scar

Rutherford-Morrison Incision
Oblique muscle cutting incision, Extension
of mcburney incision by division of oblique
fossa.
Can be used for:
• Right and left sided colonic resection
• Caecostomy
• sigmoid colostomy.

Inguinal incision
Done for
 Inguinal hernia
 Testicular cancer
 Cryptorchidism
 Hydrocele
 Varicocele
 UDT
 Orchiectomy

In urology, a Gibson incision is used for renal
transplantation or as an extra peritoneal approach
to the distal ureter with low morbidity.
It is started 3 cm above and parallel to the inguinal
ligament and extended vertically 3 cm medial to the
anterior superior iliac spine up to the umbilicus
The Gibson incision cannot be extended easily in
case of unexpected intraoperative situations.
Gibson Incision

Incisions on posterior abdominal wall

Complications of
abdominal incision
Hematoma, Stitch abscess, Wound infection
Wound dehiscence
Burst abdomen
Fistula formation
Wound pain
Incisional hernia
Adhesion and its complications
Thanks for your
attention

William Golden
British Novelist –Playwright and Poet
1911 - 1993
I think women are foolish to pretend they are equal to men.
They are far superior and always have been.
Whatever you give a woman, she will make greater.
If you give her sperm, she will give you a baby.
If you give her a house, she will give you a home.
If you give her groceries, she will give you a meal.
If you give her a smile she will give you her heart.
She multiplies and enlarges what is given to her.
So, if you give her any crap, be ready to receive a ton of shit!”

Surgical incisions

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