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duodenum, pancreas, and hepatobiliary system. If extended, it allows major hepatic resection, adrenalectomy, and splenectomy. Midline incisions are the most versatile incisions because easy extension superiorly or inferiorly allows access to all parts of the abdominal and retroperitoneal space without difficulty. Upper midline incisions are very painful and restrict pulmonary function, particularly vital capacity, by about 50 percent. Pulmonary problems, especially in patients with a history of lung disease, prior pneumonia, emphysema, etc. are common after an upper midline incision, so the subcostal incision is preferred by many surgeons. Subcostal (Kocher) The subcostal, or Kocher incision is used for open biliary surgery,such as cholecystectomy. The Kocher incision is not to be confused with the Kocher Maneuver, which describes the mobilization of the second and third portion of the duodenum and the pancreatic head. The subcostal incision is also used for access to the liver for wedge resections; for the adrenal gland on either side; and the spleen if on the left side. When extended laterally on the right with the patient in a rotated position, the incision is used for portacaval shunts. The incision may be extended medially as an alternative to the upper midline incision. Bilateral subcostal incisions are used to access to liver for transplant and liver resections. The exposure is often helped with a vertical extension to the xyphoid. Specialized retractors such as the Olivier and some blades for the upper hand have been developed for this incision. Procedure: The standard subcostal incision is made 1 to 2 finger breadths below the costal margin, to facilitate closure so that the incision line is not on or over the costal margin. The exposure requirements will determine the incision length. The incision should be sized at the smallest length possible while safely permitting an adequate procedure. The incision is closed in two or three layers; usually the inner two layers are closed with a running absorbable suture, and the outer layer (external oblique and anterior rectus fascia) with either running or absorbable suture. The major advantage of the subcostal incision over the upper midline incision is greater lateral exposure and less pain. Upper midline incisions are very painful and restrict pulmonary function, particularly vital capacity, by about 50 percent. Pulmonary problems, especially in patients with a history of lung disease, prior pneumonia, emphysema, etc. are common after an upper midline incision, thus the subcostal incision is preferred by many surgeons. The disadvantage of the subcostal incision is that the operation takes longer, because there are more layers to close. Generally, the subcostal incision heals well. Transverse The transverse incision is made just above the umbilicus and divides one or both sides of the rectus muscle as necessary. Transverse incisions are most commonly used for access to the right colon (when placed on the right), duodenum, and access to the pancreas where the incision is carried across the midline. They provide excellent exposure to the subhepatic space and upper gastrointestinal tract, reportedly with less pain than a midline incision. However, in the current era, many surgeons have entirely replaced transverse incisions with midline incisions extended as necessary to gain lateral access to the abdominal and retroperitoneal viscera. Lower Midline Lower midline incisions are used for complex appendicitis, sigmoid colonic, rectal, urological, and
gynecological procedures. The muscles at the midline often overlap obscuring the linea alba and making division of the muscle necessary in lower midline incisions. In general, these incisions are well tolerated by patients but are often painful. The weight of the abdominal contents and an obese abdominal wall may put additional strain on such incisions, increasing the risk of hernia formation. For very obese patients, stretching of the abdominal wall can occur. Access to the pelvis is best achieved through an upper abdominal or periumbilical incision in these cases. The principle advantage of the lower midline incision is that the incision can be extended superiorly for processes or operations that involve the upper abdominal viscera or require extra exposure. Similarly, the best exposure of the pelvis is gained by a lower midline incision to the pubis. McBurney When the diagnosis of appendicitis is clear, the McBurney incision is one of two incisions used for appendectomy. The McBurney's Point is located one third of the distance from the anterior superior iliac crest to the umbilicus. This is the classic location of the appendix. Since the appendix is a mobile part of the body, it may be found in various places in the right lower quadrant. For best exposure, incision should be adapted after physical examination at the maximum point of tenderness. This incision is usually made parallel with the course of the fibers of the external oblique fascia, one or two inches cephalad to the anterior superior spine of the ilium. The Rocky-Davis incision provides another option. Unlike the McBurney incision, it is a straight transverse at the skin and splits the muscle. Again, either incision is made as long as necessary to achieve adequate exposure. Thin people require a smaller incision than obese patients. Those patients with an anterior appendix are usually easier to manage through a small incision, as opposed to retrocecal appendices which require an extended incision. Extending the right lower quadrant incision for greater exposure usually requires either medial extension opening the rectus fascia and displacing the rectus muscle medially, or a second midline incision. The second midline incision may be considered in patients with pathology that extends beyond the right lower quadrant. Paramedian Paramedian incisions are rarely used. This incision provides little additional exposure beyond a midline incision. The blood and nerve supply to the abdominal wall enters from either side and may cross the midline poorly. For this reason paramedian incisions have an increased risk of rendering part of the abdominal wall anesthetic and ischemic. The result is poor wound healing and increased risk of hernias. Groin incision Groin incisions may be oblique or within the skin lines and nearly transverse. Generally, they end medially at the level of the external ring, usually 1 to 2 finger breadths above the external ring. Laterally, these incisions usually extend for 10-12 cm, depending on the size of the patient, the size of the hernia, and prior surgery. Staying out of the inguinal crease reduces the risk of infection. Such incisions are closed in layers.The oblique inguinal incision may be on the right or left side and is used for hernia repair. The superficial epigastric vein is usually encountered in the subcutaneous tissue. It is ligated and divided. Pfannenstiel, or "bikini incision" Pfannenstiel incisions are horizontal at the skin but divide the fascia and muscle of the abdominal wall vertically in the midline. They are principally used for urological and gynecological procedures because they minimize scarring. However, large skin flaps are developed under such incisions and with contamination, they may be more prone to infectious complications. Since the size of the incision is necessarily restricted by the lateral extent of the skin incision, exposure to deep pelvic structures may be less than optimal. These incisions should be avoided in patients who are obese, those requiring extensive deep pelvic dissection, and those with prior lower abdominal midline incisions where the scar is already present.
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