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Abdominal WallIncision

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Vertical Incision

1.Midline Incision

2.Paramedian Incision

3.Vertical Muscle-Splitting Incision

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1.Midline Incision

Fastest approach

Adequate exposure

No muscle fibers divided

No nerves injured

Can extend upward & downward

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1.Midline Incision

Skin

Subcutaneous fat

Linea alba

Properitoneal fat

Peritoneum

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1.Midline Incision

Upper Midline Incision

Esophageal hiatus, abdominal esophagus

stomach, duodenum, GB, pancreas, spleen

Lower Midline Incision

Lower abdominal and pelvic organs

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2.Paramedian Incision

2.5 4.0 cm from midline Can extend from the pubis to xiphoid

Satisfactorily for any intraabdominal surgery

Diminish risk of dehiscence & incisional hernia

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2.Paramedian Incision

Skin

Subcutaneous fat

Anterior rectus sheath

Rectus muscle

Posterior rectus sheath - above the arcuate line

Transversalis fascia

Properitoneum fat Peritoneum

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3.Vertical Muscle-Splitting Incision

Same way as paramedian incision

Rectus is split longitudinal in medial 1/3

Satisfactory when limited incision needed

Tenckhoff catheter insertion

Avoid extensive incision

More injury to nerve & muscle More bleeding

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TransverseOblique Incision

1.Kochers Subcostal Incision

2.Rockey-Davis Incision

3.Pfannenstiels Incision

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1.Kochers Subcostal Incision

Midline 2.5-4.0 cm below xiphoid

2.5 cm below costal margin

Control branch of superior epigastric a.

Cut only one intercostal nerve

No weakening of abdominal musculature

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2.Rockey-Davis Incision

Oblique direction at McBurneys point

Open apppendectomy or cecostomy

Similar incision on the Left

sigmoid colostomy

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3.Pfannenstiels Incision

Gynecological procedures

Extraperitoneal retropubic prostectomy

Interspinous crease

5 cm above symphysis pubis

Rectus & peritoneum open vertically

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Retroperitoneal

&Extraperitoneal

1.Retroperitoneal Approach to the Lumbar Area

2.Retroperitoneal Approach to the Adrenal gland

3.Retroperitoneal Approach to the Iliac Fossa

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1.Retroperitoneal Approach to the Lumbar

Frequency used for

Nephrectomy, aortic surgery, lumbar

sympathectomy, ureterolithotomy

Operation at Rt. Side supine position

Rt. side elevated 30o-45o

Rt. Knee & hip flexed

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1.Retroperitoneal Approach to the Lumbar

Incision

Lateral margin of rectus sheath at umbilical level

Extend to flank toward the 12th rib

12-20 cm Open external, internal oblique m. & TA

blunt dissection Peritoneum & retroperitoneal fat

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2.Retroperitoneal Approach to the Adrenal

Prone jack-knife position

Curvilinear from 10th rib toward iliac crest

Retracted medially the erector spinae m.

Resected 12th rib

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2.Retroperitoneal Approach to the Adrenal

Divided diaphragmatic attachment at 12th rib

Incised middle layer of lumbodorsal fascia alonglateral margin of quadratus lumborum m.

Gently pushed out diaphragm & pleura

Avoided pneumothorax

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3.Retroperitoneal Approach to the Iliac Fossa

Distal ureter, bladder

Common iliac, external iliac vessels

Used for kidney transplantation

2 cm above ASIS to lateral to symphysis Can extend as far as the costal margin

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3.Retroperitoneal Approach to the Iliac Fossa

EO, IO & TA & TF are divided

Retroperitoneal fat & peritoneum

blunt dissected upward & medially

If peritoneum opened should be closed immediately

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ThoracoabdominalIncision

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Thoracoabdominal Incision

Excellent exposure

Lower esophagus or cardia

Some portocaval shunt

Large adherent spleen high morbidity

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Thoracoabdominal Incision

Corkscrew position

Midline incision

Obliquely into Rt. or Lt. 8th ICS

Not necessary to resection a rib Inferior angle of scapular posteriorly

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Thoracoabdominal Incision

After operation

chest tubes to drain pleural cavity

Repair diaphragm with 2 layer nonabsorbtable

interrupted mattress suture

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Thank You