Professional Documents
Culture Documents
Angeles City
College Of Nursing
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N- 310
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For a midline abdominal incision, the skin and subcutaneous fat are incised to the
level of the fascia. The scalpel or electrocautery can be used to incise this tissue. Some
surgeons believe the infection rate is higher with the use of electrocautery. Studies from
the 1980s suggested a 2-fold increased risk of wound infection with electrocautery
compared with a scalpel. However, more recent prospective studies indicate no increased
wound complications with electrocautery compared with a scalpel in midline abdominal
incisions.
Using either instrument, the principle is to make long smooth strokes through the
subcutaneous fat to the fascia. The subcutaneous fat should not be dissected from the
fascia because this creates unnecessary dead space. Next, the fascia is incised, and the
rectus muscles are separated vertically in the midline. The midline may not be evident in
patients with previous abdominal surgery. Identifying where the rectus muscles diverge
around the umbilicus or locating the pyramidalis muscles assists in identifying the
midline. Once the rectus muscles are divided, the peritoneum is grasped between 2
hemostats, opened with a scalpel, and extended the length of the incision.
If the operative findings necessitate extending the incision above the umbilicus,
avoid cutting through the umbilicus. Postoperative wound infections may be increased
due to bacterial colonization of the umbilicus. Extension of the incision should pass to the
left of the umbilicus to avoid cutting through the ligamentum teres.
Closure of the midline incision has evolved over the last 2 decades. Layered
closure using interrupted sutures was previously the choice of many surgeons. Today,
most surgeons prefer to close the abdominal wall with a continuous running suture using
delayed absorbable sutures. The use of a continuous suture to close the fascia is faster,
with dehiscence rates comparable to those of interrupted closures. Two basic techniques
are used to close the abdomen with continuous suture, the single-layer mass closure and
the internal mass closure. The single-layer mass closure involves using a heavy
monofilament delayed-absorbable or permanent suture. Fascial closure involves
penetrating the fascia 1.5 cm from the edge with the suture. The suture should also
include the underlying muscle and peritoneum.
Some surgeons close the wound using the internal mass closure technique
advocated by Smead-Jones. This is a far-far, near-near suturing technique. The anterior
fascia is included in the near-near bite. The initial stitch is similar to the single-layer mass
closure. The second bite only includes the anterior rectus fascia, approximately 0.5 cm
from the fascial edge. Either technique requires starting from each end of the incision.
Securing the suture with 5 knots at each end is sufficient. In patients who are slender,
burying the knot is helpful.
Transverse incision
Pfannenstiel incision
The Pfannenstiel incision results in good exposure to the central pelvis but limits
exposure to the lateral pelvis and upper abdomen. These factors limit the usefulness of
this incision for gynecologic cancer surgery. If the patient is thin and has a gynecoid or
platypelloid pelvis, this incision can be used for a radical hysterectomy and pelvic lymph
node dissection.
The incision is usually made 1-2 fingerbreadths above the pubic crest. Use of a
marking pen is helpful to keep the incision symmetric. An incision length of 10-14 cm is
sufficient. Increasing the length of the skin incision usually does not improve exposure
due to the rectus muscles. The incision is made through the subcutaneous fat to the fascia.
The superficial epigastric vessels are often near the lateral edges of the incision.
The anterior fascia is incised in the midline with a scalpel or electrocautery. Using
curved scissors or electrocautery, the fascia is incised in a curvilinear fashion 1-2 cm
lateral to the rectus muscle. The upper edge of the fascia is grasped with 2 Kocher clamps
on either side of the midline. Using electrocautery, the rectus muscle is dissected free
from the fascia. Electrocautery allows coagulation of multiple small vessels that perforate
the rectus muscle to the fascia. The rectus muscles are mobilized off the fascia to the
level of the umbilicus. Next, the lower fascial edge is grasped with Kocher clamps.
Electrocautery is used again to dissect the rectus muscles and the pyramidalis muscle
from the fascia. The rectus muscles are separated. The peritoneum is opened and incised
vertically to complete a Pfannenstiel incision.
Maylard incision
To facilitate closure of a Maylard incision, flex the operating table. Close the
peritoneum with an absorbable suture. Next, inspect the ties placed on each inferior
epigastric vessel, and irrigate with water. Examine the cut edges of the rectus muscles for
any bleeding areas. The fascia and underlying rectus muscle can be closed with a
monofilament absorbable suture.
Cherney incision
Closing a Cherney incision begins with closure of the peritoneum. Attach the cut
ends of the rectus muscle to the distal end of the anterior rectus sheath with interrupted
nonabsorbable sutures. Fixing the rectus muscle to the pubis symphysis can result in
osteomyelitis. Next, the fascia is closed with 2, running, continuous, delayed-absorbable
sutures.
Cesarean Section
> removal of the infant from the uterus through an incision made in the
abdominal wall and in the uterus.
Indications:
• Cephalopelvic disproportion
• Placenta previa
• Severe toxemia of pregnancy
• Previous classic- elective CS
1. Low Segment CS
• Method of choice
• Incision made transversely in the lower segment of the uterus which is the
thinnest and the most passive part during active labor
• also referred to as Pfannenstiel Incision or a bikini incision
• advantages:
less likely to rupture in subsequent labor – VBACS
minimal blood loss
incision is easy to repair
decrease postpartal uterine infections
• disadvantage:
Longer to perform
2. Classic CS
• Incision is made vertically through both the abdominal skin and the uterus.
• Made high on the uterus so that it can be used with a placenta previa
• Disadvantages:
o Wide skin scar
o This type of scar could rupture during labor – if this type is used
the woman cannot have a subsequent vaginal births