The skin is composed of two main layers, the epidermis and dermis. Various types of incisions can be made through the skin for surgical procedures, with considerations including accessibility, extensibility, security, and following natural lines of tissue tension. Different suturing methods can be used to close wounds, including everting, inverting, interrupted, running, and locking stitches.

2.  The skin is the largest and heaviest organ of the
body. The two main layers that compose the
integument are ….
 Epidermis
 Dermis
 The combined thickness of the epidermis and
dermis ranges from 4 mm and 1.5 mm .

3.  The epidermis is the outermost layer.
 It contains no organs, glands, nerve endings, or
blood vessels. It renews itself every 15 to 30
days.
 Epidermal layers are..
 Stratum corneum
 Stratum lucidum
 Stratum granulosum
 Stratum spinosum
 Stratum basale

4.  The dermis is
composed of papillary
and reticular layers of
flexible connective
tissue.
 The dermis contains
pain
and touch receptors,
glands, blood vessels,
and lym-phatics . It is the
key layer in wound repair
and tissue healing.

5. Surgical Incision….
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. Security

6.  Natural line of tension correspond to the natural orientation
of collagen fibers in the dermis .
 Generally parallel to the orientation of the underlying muscle
fibers.
 Austrian anatomist, Karl Langer (1819-1887) described how
incisions could be more cosmetic if natural cleavage lines were
followed when planning the surgical incision.
 The angle of the incision should be no more than 30 degrees at
each margin .

8.  A correct incision
provides..
◦ a large area to easily
permit dissection
◦ Repair of lesions
◦ Heal Rapidly
◦ Without scars limiting
mobility
◦ Preserve sensation
◦ Avoid painful scars

9.  They are
responsible for
◦ An Insufficient
access
◦ Necrosis
◦ Contractures
◦ Painful scars

12.  Before the procedure begins, the surgeon
chooses the most suitable incision for the
procedure being performed. Certain things
of consideration are ….
• Condition of the patient.
• Knowledge of previous surgery.
• Natural lines of tissue tension (Langer’s
lines) .
• Maximum exposure of surgical site and
adjacent structures .
• Ability to extend the incision if necessary .
• Minimum trauma and scar formation.

14.  Layer of Anterior Abdominal Wall..
 Skin
 Subcutaneous tissue
 Superficial Fascia
 Deep Fascia(Gallaudet’s Fascia)
 Musculoaponeurotic Layer
-External Oblique Muscle
-Internal Oblique Muscle
-Transverse Abdominal Muscle
-Rectus Abdominis-Pyramidalis Muscle
 Fascia Transversalis
 Preperitoneal Fatty Tissue
 Peritoneum.

16. 1) Midline Incision
 Almost all operations in the
abdomen and retroperitoneum
 Advantages :
- 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 lenght of
abdomen curving around
umblical scar.

17. 2) Paramedian Incisions
 Has 2 theoretical
advantages:
-it offsets vertical Incision
to right or left, providing
access to lateral str. such as
spleen or kidney-closure is
theoretically more secure
because rectus muscle can
act as a buttress between
reapproximated posterior
and anterior fascial planes.
is placed 2 to 5 cm lateral to
midline

18. 2) Paramedian Incision
Disadvantages:
1. It tends to weaken and strip off the muscles from its lateral
vascular and nerve supply resulting in atrophy of the muscle
medial to the incision.
2. The incision is laborius and difficult to extend superiorly as
is limited by costal margins.
3. It doesn’t give good access to contralateral structures.

19. 1)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 downwards ,
outwards and paralel to and
about 2.5 cm below costal
margin
 Especially used in
cholecystectomy.

20. 2) Transverse Muscle dividing
 In newborn and infants , this incision is preferred bcs
more abdominal exposure is gained per lenght of
incision than with vertical exposure
 Because infants’ abdomen longer transverse than
vertical girth.
 Also true of short, obese adult

21. 3) McBurney Incision (muscle split )
 İncision of choice most
appendicectomies
 The level and lenght of incision
will vary according to thickness of
abd. wall and suspected position of
apendix.
 is made at the junction of middle
third and outer third of a line
running from umblicus to anterior
superior iliac spine,McBurney
point.
 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.

23. 4) 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..

25. 5) Pfannenstiel Incision
 Used frequently by gynecologist and urologist for
access to pelvic organ, bladder, prostate and for c-
section.
 is usually 12 cm long and is made in skin fold
approximately 5 cm above symphysis pubis.

26. 6) Maylard Transverse Muscle Cutting Incision
 gives excellent exposure to pelvic organ
 Skin incision is placed above but parallel to traditional
placement of Pfannenstiel incision ..

28.  Either right or left
 Converts pleural and peritoneal cavities into one
common cavity
 Thereby gives excellent exposure
 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.
 Incision is extended along line of 8th intercostal
space,the space immediately distal to inferior pole of
scapula.

29. Methods of wound closure include sutures, staples, clips, tapes, and glues.
Everting sutures: These interrupted (individual stitches) or continuous
(running stitch) sutures are used to evert skin edges.
a. Simple continuous (running): This suture can be used to
close multiple layers with one suture. The suture is
not cut until the full length is incorporated into the
tissue (see Fig. 28-8, A).
b. Continuous running/locking (blanket stitch):
A single suture is passed in and out of the tissue layers and looped
through the free end before the needle is passed through the tissue for
another stitch.
Each new stitch locks the previous stitch in place.
Methods of suturing….

30. c. Simple interrupted:
Each individual stitch is placed, tied, and cut in succession
from one suture (see Fig. 28-8, C).
d. Horizontal mattress:
Stitches are placed parallel to wound edges. Each
single bite takes the place of two
interrupted stitches (see Fig. 28-8, D).
e. Vertical mattress:
This suture uses deep and superficial bites, with each
stitch crossing the wound at right angles. It works
well for deep wounds. Edges approximate well (see
Fig. 28-8, E).

31. 2. Inverting sutures:
These sutures are commonly used for two-layer anastomosis
of hollow internal organs, such as the bowel and stomach.
Placing two layers prevents passing suture through the lumen
of the organ and creating a path for infection. A single layer
is placed for other structures, such as the trachea, bronchus,
and ureter. The edges are turned in toward the lumen to
prevent serosal and mucosal adhesions. The number of layers
is proportional to the quality of the blood supply. Stitches can
be interrupted or continuous.

34.  Endoscopic sutures are available as
 ligatures and preknotted loops or with curved or
straight, permanently swaged needles for use through
an endoscope.
 The ligatures are fashioned into loosely knotted loops
before being passed through the endoscope to tie off
vessels and tissue pedicles. After the loop is placed
around the target site, the knot is slid into position
and tightened. The ends are cut with endoscopic
scissors and removed through the endoscope.