Abdominal incisions A simple guide for nurses Prepared by: Mr. Varghese. Y M.Sc.

, (N), II year Shanmuga College of Nursing Salem 1

Abdomen walls:(i) (ii) (iii) (iv) (v) Skin Subcutaneous fat Rectus sheath Extern al peritoneal fat Peritoneum Anterior Rectus Abdominis Posterior Abdominal Incisions:Incisions for various laparotomy procedure Types:I) Vertical Incisions:II) Horizontal Incisions:III) Transverse Incisions:Para Median Side M idline 2

(i) Vertical Incision (ii) Horizontal Incision 3

(i) Transverse Incision 4

Vertical Incisions: (1) Supra Umblic Midline Incision (SUMI):Definition:Making incision above the Umbl icus in midline of adomen. Layers to Open:Skin Subcutaneous fat Anterior Rectus abdominis Rectus sheath Pos terior Rectus Umblicus External Peritoneum Peritoneum 5

Procedure:Emergency Vagotomy / Gasterior : Jejunostomy Gatrectomy total (or) par tial Pancreaolomy Dueodenectomy] Advantages:Easy to open because minimum midline layers. Less bleeding because of Avascular layers Fast to open Disadvantages: W eak layer because of incision hernia is common. Extensive is difficult, is not p ossible for removal of stemum. (2) Infra Umblical Midline Incision (IUMI):Definition:Making incision below the um bilicus the middle of abdomen. 6

Layers to open:Skin Subcutaneous fat Anterior Rectus abdominis Rectus sheath Pos terior Rectus Umblicus External Peritoneum Peritoneum Procedure:(i) (ii) (iii) ( iv) (v) Total Abdominal Hystrectomy LSCS (Lower Segment Cesarian Section) Sulphi ngo Oophrectomy Cystostomy Cystecotomy Advantages:Easy to open because of avascular line Less bleeding Fast to open Dis advantages: Weak layer because of incision hernia is common. Extension is diffic ult because of umbilicus. (3) Right Para Median Incision (RPMI):Definition:Making incision on the Rt. Side o f midline of abdomen. Layer to Open:Skin Subcutaneous fat (Anterior Rectus betwe en rectus sheath) External oblique apponeurosis 7

External oblique muscle Internal oblique apponeurosis Transverse abdominis Exter nal Peritoneum Peritoneoum Procedure:Cholecystectomy. Choledochastomy (open a ---------------) Perforature Pyloroplasty closure (Perforature) i.e., Duodenal ulcer perforature closes 8

Advantages:Strong layers to no chances for incisional hernia. Entenstabilty is e asy Disadvantages:Bleeding will be more Post-operative pain is sever, because of transverse nerve. (4) Left Para Median Incision (LPMI):Definition:Making incision on the Lt. side of the Abdomen. Layers to open:Skin Subcutaneous fat Anti Rectus 9

Rectus sheath Posterior Rectus Exterior rectus External Peritoneum Peritoneoum P rocedure:Spleenectomy Distal Pancreadectomy (removal body and tail of pancreas) Gastreotomy Fundaapplication Advantages:Strong layers to no chances for incision al hernia Extansibilty easy Disadvantages:Bleeding will be more Post operative p ain is severe, because of transverse nerve 10

Horizontal Incision (1) Right Subcostal Incision (RSI) or Kochers Incision:Definition:Making incision j ust bleow the lower rib on right side of abdomen is called Rt. Subcoastal incisi on (or) Kochers Incision. Layers to Open:Skin Subcutaneous fat External Oblique ap poneurosis External Oblique muscle Internal oblique muscle Transverse addominis External Peritoneum Peritoneoum 11

Procedures: Cholecystostomy Liver Surgery Bilary Externic anastomosis Advantages :Easy accessibility Easily extensibility Restriction of Diaphragm movement becau se to basal peritonitis. Tumor excessive Partial Heptectomy 12

(2) Left Subcoastal Incision (LSI):Definition:Making incision just below the last rib on the left side of abdomen. Layers to open: Skin Subcutaneous fat External Oblique muscle Internal oblique m uscle Transverse addominis External Peritoneum Peritoneoum 13

Procedures:Spleenectomy Bilrth Surgery (Pastial Gastrectomy) Helle Myotomy ie. I t is a condtion dilation of oesophagus called Achalasia Cardia Advantages:Easy a ccessibility Easy entenstabilty Disadvantages:Bleeding will be more. Post-operat ive pain will be more Restriction of Diaphragm movement. E.g: Basal Peritonitus (3) "Roof Top Incision:Definition:Making incision just below the rib on both side of abdomen. Layers to open:Skin Subcutaneous fat Linea alba External Peritoneum Peritoneoum In Laterally:Skin Subcutaneous fat External Oblique muscle Internal oblique muscle Transverse addominis 14

External Peritoneum Peritoneoum Procedure:Liver Transplant Pancreatic Transplant Whipples Procedure (Radial Pancr ea toduodenectomy for Carcinoma of hed of pancreas) Abdominal Aortic Surgery Mercedes Benz Incision:Defintion:A combination of vertical and transverse making i ncision just below the lower rib on both side of abdomen with extension vertical ly in midline. 15

After layers and procedures are some as Roof Top Incision. Procedures:Liver transp lant Pancreatic Transplant Whipples Procedures Abdominal Aortic Surgery Advantage s:Easy accessibility Good Visualization Wide working space Disadvantages:Bleedin g will be more 16

Severe post operative pain Restricted Diaphragm Long time consisting more. (4) Right Inguinal Incision (or) Rt. Iliac Incision:Definition:Making incision jus t below the inguinal cannal (or) iliac hole on the Rt. Side of abdomen. Layers to Open:Skin Subcotaneous Fat External Oblique Muscle 17

Internal Oblique Muscle External Opponeurosis Inguinal cannel. Procedures:Rt. In guinal Hernia Surgery a) Hermotomy (Child) b) Hermorraphy (Adult) c) Hernioplast s (Old Age) Rt. Femoral Hernia Surgery Rt. Spermatic Cord Surgery a) Vas differe nt b) Vesticular Artery c) Vesticular Vein Rt. Vericocelotomy Advantages:Easy ac cessibility No need to open peritoneal cavity Disadvantages:Nerve injury is very common. i.e. Common nerve get injury ilio hypagastric nerve, iliac ingunnal ner ve Injury to spermatic cord for testis (5) Left Inguinal (or) Iliac Incision:Definition:Making incision just below the i liac cannal (or) inguinal cannal on the Lt. side of abdomen. Layers to open same as Rt. Iliac incision. Procedure:Lt. Inguinal Surgery Lt. Femoral Hernia Surger y 18

Lt. Spermatic Cord Surgery Lt. Vericocelectomy. (6) Pfannenstiel Incision:Definition:Making incision just above iliac bone (or) In guinal cannal on both side of abdomen. Layers to Open:External Oblique Muscle Internal Oblique Muscle Transverse Abdmom inis External Peritoneum Peritoneum Mid Line:Anti-Rectus Abdominas 19

Rectus Sheath Post-Rectus Abdominis External peritoneum Peritoneum Procedure:Low er Segment cesarian Segment (LSCS) Cystecotomy Total Abdominal hysterectomy Bila teral salphingo oophrectomy Cystostomy Advantages:Cosmatic Incision Pain will be more. 20

Oblique Incision (1) Right Oblique Incision:Definition:Making incision on abdomen obliquely from anterior abdominal wall to lateral abdominal wall at right side. Layers to open:Skin Subcotaneous tissue External Oblique apponeurosis External O blique Muscle Internal Oblique Muscle Peritoneum 21

Procedure:Nephrectomy Urethrolithotomy (Removal of a calcius from Uterus i.e ope n and remove stone Advantages:More specific incision No need to open pesitoneum Disadvantages:Sever bleeding] Injury to pleura is common because it is near or c aused pneumothorax. Less accessibility (2) Left Oblique Incision:Definition:Making incision on abdomen obliquely from an terior abdominal wall to lateral wall to lateral abdominal wall at left side. La yers to Open:Skin Subcotaneous tissue External Oblique apponeurosis External Obl ique Muscle Internal Oblique Muscle Peritoneum Advantages:More specific incision No need to open pesitoneum 22

Disadvantages:Sever bleeding] Injury to pleura is common because it is near or c aused pneumothorax. Less accessibility (3) Mc. Burneys Incision:Definition:Making incision on Mc. Burneys Point (Mc. Burneys poiont is cutting the layer. Lateral and medally 2/3 i.e from umbilical and far lateral is anterior supra iliac spine. The spino umbilical line). Layers to ope n: Skin Subcotaneous tissue External Oblique apponeurosis External Oblique Muscl e 23

Internal Oblique Muscle Transverse abdominis Peritoneum-again cut Procedures:Appendectomy Drainage of appendicular abscers Caecostomy (open of cae cum) Ilio Cacal Lymh biopsy Advantages:More specific incision Less bleeding beca use of cutting muscle Disadvantages:Less accessibility Ilio inguinal nerve will get injury then causes 24

(4) Transverse Incision:Definition:Making small transverse incision any where in a nterior abdominal wall. Layers to open:It is depend upon the region like medical (or) lateral. Same as Ro of Top Incision. Procedure:Emergency Colostomy (open of colon) Ileostomy Supra Pu blic Cystostomy Advantages:Good accessibility or more specific incision. Disadva ntages:Small incision injury to near by organ (or) structure. 25