1) The document discusses different types of surgical incisions including vertical, transverse, oblique, and flank incisions. It notes key details about each incision like preferred procedures, layers cut, advantages, and disadvantages. 2) Complications from surgical incisions are categorized as immediate, early, or late. Immediate issues include bleeding, organ injury, and anesthesia problems. Early complications involve infections, fluid buildup, and wound separation. Late complications comprise hernia, bowel obstructions, pain, and abnormal healing. 3) Selection of an incision depends on factors like the surgery, patient characteristics, and surgeon preference. Considerations include visibility, extension ability, and minimizing trauma to structures like nerves and blood

1. Surgical Incisions
Under observation:
Dr. Hameed ahmed
Submitted By:
Amr kamal
Muhammadyosif
Heleen ayoub
Zikra Hussein
SinahiShawkat
Dunya jameel

2.  General principles
 Classification of incisions
 Advantage and disadvantage of each type
 General complications
Learning Objectives

3. 3
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.

4. In doing so, three essentials should be achieved:
Accessibility Extensibility Security
4

5. 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
5

6. Choice of incision
Type of surgery
[elective/emergency]
6
Target organ
Previous surgery
Grade of patient
Obesity
Surgeons own experience &
preference

7. 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.
7
Lines Of Cleavage
Or
Langer’s Line

8. 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.
8

9. 9

10. Common Abdominal & Pelvic incisions
Vertical Incisions
Transverse incisions
Oblique Incisions
10
• Midline
• Paramedian
• Transverse Muscle Dividing
• Pfannenstiel Incision
• Maylard Incision
• Kocher Subcostal Incision
• Mc Burney Incisions
• Oblique Muscle cutting
• Inguinal incision

11. Common Abdominal & Pelvic incisions
11

12. Vertical Incisions
MedlineIncision
vertical incision which follows the linea alba.
It may be:
▪ Upper Midline Incision
▪ Lower Midline Incision
▪ Single Incision
12

13. 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
MedlineIncision
13

14. 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
14

15. Advantage
• 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
Disadvantage
• Care needs to be taken just above the umbilicus where the
falciform ligament is.
• Midline scar
• Bladder injury
• Incisional hernia
• Adhesions in lower incisions
15

16. ModifiedMakuuchiIncision
1
A. The modified incision is used for liver and
right-sided abdominal surgery. This
incision begins cephalad to the xiphoid,
extends to 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.
16

17. 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
ParamedianIncision
17

18. Advantage
• 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
Disadvantage
• 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
18

19. Mayo-Robson incision
19
• 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.

20. 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
20

21. 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
21

22. Advantage
• 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.
Disadvantage
• 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
22

23. PfannenstielIncision
• 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.
23

24. 24

25. Maylard Transverse (Muscle Cutting Incision)
25
• Gives Excellent Exposure To
Pelvic Organ
• Skin Incision Is Placed Above But
Parallel To Traditional Placement
Of Pfannenstiel Incision

26. • 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
26
Joel-Cohen incision

27. 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
27

28. Kocher (Subcostal) Incision
28
• 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

29. Chevron (rooftop) modification
29
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

30. 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
30

31. 31

32. 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.
32

33. • 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.
33
Thoraco-abdominal Incisions (left / Right)

34. 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.
34

35. 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.
35

36. 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
36

37. Originally placed the incision obliquely
from above laterally to below medially.
Also used in left lower quadrantto deal
with certain lesion of sigmoid colon suchas
drainageof diverticular abscess.
37
Grid iron (muscle splitting) incision

38. 38

39. Lanz incision
• It is a variation of McBurneys
incision that is made the same point
but in transverse plane.
• It gives cosmetically good scar
39

40. Rutherford-Morrison Incision
40
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.

41. Inguinal incision
Done for
❑ Inguinal hernia
❑ Testicular cancer
❑ Cryptorchidism
❑ Hydrocele
❑ Varicocele
❑ UDT
❑ Orchiectomy
41

42. 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.
42
Gibson Incision

43. Complications of abdominal surgical incisions
Immediate Complications (Intraoperative)
Early Complications (Within the First Few Days Postoperatively)
Late Complications (After the First Week Postoperatively)

44. Immediate Complications (Intraoperative)
A) Bleeding : Excessive bleeding from blood vessels or tissue during the surgery can
lead to hemodynamic instability.
C) Organ Injury : Accidental injury to nearby organs, such as the bowel, bladder, or
major blood vessels.
E) Anesthesia-Related Issues : such as allergic reactions, airway obstruction,
respiratory depression, Nausea and vomiting.
G) Blood clots : Formation of blood clots in veins or arteries .
I) Hypothermia: A drop in body temperature during surgery.
K) Nerve injury: Damage to nerves, which may result in loss of sensation or function.

45. Early Complications (Within the First Few Days Postoperatively)
A) Surgical site infection : Infection of the surgical wound can lead to redness,
swelling, warmth, pain, and discharge.
C) Seroma : the accumulation of clear fluid under the skin, may require drainage if it
becomes symptomatic.
E) Hematoma : Accumulation of blood within the surgical site can cause swelling
and discomfort. Drainage or evacuation may be necessary.
F) Dehiscence : Partial or complete separation of the surgical incision can occur due
to poor wound healing, infection, or excessive tension on the incision. Re-suturing
or surgical repair may be needed.

46. Surgical site infection

47. Seroma Hematoma

48. Dehiscence

49. Late Complications (After the First Week Postoperatively)
A) Incisional Hernia : Weakened or poorly healed incisions can lead to the protrusion of
abdominal contents through the abdominal wall. Surgical repair is usually necessary
C) Adhesive Bowel Obstruction : Formation of scar tissue (adhesions) within the abdomen
may cause bowel loops to become entangled, leading to bowel obstruction.
E) Chronic Pain : Some patients may experience long-lasting abdominal pain at the incision
site due to nerve damage or surgical trauma.
G) Surgical Site Pain and Hypersensitivity : Increased sensitivity or discomfort at the
incision site can persist for an extended period.
I) Abnormal Wound healing : Hypertrophic or keloid scarring, cosmetic issues, or itching
can develop over time.

50. 12-cm incisional hernia following a gastric pull-up procedure and open abdominal wounds.

51. Adhesive Bowel Obstruction