Surgical Incisions

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 Introduction

• Pre-operative planning - important!

• Optimal cosmetic and functional result
• Healing process  wound contraction
and scarring - may compromise
function and appearance

• Goals
• To re-establish functional soft tissue
structural support
• To give the most natural aesthetic
appearance with minimal distortion
Incision: a cut produced
surgically by a sharp
instrument that creates an
opening into an organ or
space in the body
J Pel Surg 2002; 6:295
SYARAT INSISI
Insisi harus memenuhi minimal 3 syarat:

1. Akses mudah dicapai

2. Mudah diperlebar
3. Aman
 Principles of Wound
Incision
• First priority - maintain a sterile and aseptic
technique to prevent infection.

THE LENGTH AND DIRECTION OF INCISION –

To afford sufficient operating space and
optimum exposure
ü The direction of wound naturally heal is from side-
to-side, not end-to-end
ü The arrangement of tissue fibers in the area to be
dissected will vary with tissue type
ü The best results  when incision made to the
direction of tissue fibers
 A well-planned incision has 4
essential elements:
1.Accessibility: give adequate access
2.Extensibility: possible to be enlarged
3.Safety: preservation of function
4.Security: it should heal with
adequate strength

Mizell JS. Principles of abdominal wall incisions.

Principles of Wound
Incision
• Relaxed Skin Tension Lines
(Langer’s line)
ü Is the skin lines oriented
perpendicular to the direction
of the underlying muscle fibers
ü Determined by examination of
patient’s natural skin creases
at rest
ü Orientation of the final scar
parallel to or within a natural
skin crease gives a superior
cosmetic result.
 Principles of Wound
Incision
• Dissection technique
ü Clean incision should be made
with one stroke or evenly
applied pressure on the scalpel
ü Preserve integrity of as many
of underlying structures as
possible

• Fusiform excision
ü Performed with longitudinal
axis running parallel to RSTL
ü The length should be 4 times
with the width of the defect to
produce an accurate coaptation
of skin edges without dog ear
formation.
 Principles of Wound
Incision

• Dog ears
ü Areas of redundant skin and
subcutaneous tissue resulting from a
wound margin being longer on one side
than the other
ü Dealt with either by
§ Incremental oblique placement of sutures to
redistribute the tension across the wound
§ Fusiform excision of the dog ear with
lengthens the scar considerably
 Principles of Wound
Incision
ü Removal of a ‘dog ear’
• Skin defect is sutured
until the “dog ear”
becomes apparent
• The “dog ear” is defined
with a skin hook and is
incised round the base
• Excess skin is removed
and the skin is sutured
 Principles of Wound
Incision
• Tissue handling
ü Minimum tissue trauma promotes faster
healing
ü Surgeon must handle all tissues very gently -
and as little as possible
ü Retractors should be placed with care to
avoid excessive pressure, since tension can
cause serious complications
 Principles of Wound
Incision
HAEMOSTASIS - allows surgeon to work
in as clear a field as possible with greater
accuracy. Without adequate control,
bleeding may interfere with the surgeon’s
view of underlying structures.
• Also to prevent formation of postoperative
hematomas
• Collection of blood (hematomas) or fluid
(seromas) can prevent direct apposition of
tissue
• These collections provide an ideal culture
medium for microbial growth  serious
infection
 Principles of Wound
Closure
Goal: “approximate, not strangulate”

CHOICE OF CLOSURE MATERIALS - proper

closure material will allow surgeon to
approximate tissue with a little trauma as
possible, and with enough precision to eliminate
dead space
• Suture Materials - categorized by three
characteristics:
• Absorbable vs. non-absorbable
• Natural vs. synthetic
 Principles of Wound
Closure
1. Absorbable suture - degraded and
eventually eliminated (e.g. cat gut, vicryl,
monocryl)
2. Non-absorbable suture - not degraded,
permanent (e.g. prolene, nylon, stainless
steel)
3. Natural suture - biological origin; may
cause intense inflammatory reaction (e.g.
cat gut, chromic, silk)
4. Synthetic suture - synthetic polymers; do
not cause intense inflammatory reaction
 Principles of Wound
Closure
1. Monofilament suture - grossly appears
as single strand of suture material; all
fibers run parallel
• Ties smoothly (e.g. monocryl, prolene, nylon)

2. Multifilament suture - fibers are

twisted or braided together
• greater resistance in tissue e.g. vicryl
(braided), chromic (twisted), silk (braided)
 Principles of Wound
Closure
• Cellular response to foreign materials
• Whenever foreign materials such as sutures
are implanted in tissue, the tissue reacts -
depending on type of material implanted
• more marked if complicated by infection,
allergy, trauma
• Tissue will deflect passage of needle and
suture  edema of the skin and subcutaneous
tissue  discomfort during recovery, as well
as scarring secondary to ischaemic necrosis
 Principles of Wound
Closure
Some of the Suturing Techniques

1. Simple interrupted stitch - single

stitches, individually knotted
• Used for uncomplicated laceration repair
and wound closure
2. Continuous stitch - allows more
rapid wound closure
• Carries the risk of complete wound
opening
if the suture breaks 18
 Principles of Wound
Closure

3. Horizontal mattress stitch

Provides added strength in fascial closure
Also used in calloused skin (e.g. palms and
soles)

4. Vertical mattress stitch

Affords precise approximation of skin
edges
with eversion
 Principles of Wound
Closure
5. Subcuticular stitch - intradermal
horizontal bites
• allow suture to remain for a longer
period of time without development of
crosshatch scarring
• better cosmetic result
 Principles of Wound
Closure dead space in wound
Elimination of dead space in the
wound
• Critical to healing!!
• Results from separation of wound edges
which have not been closely
approximated, or from air trapped
between layers of tissue
• If the needle is not placed perpendicular
to the skin, it can create dead-space,
while unequal bites will create poor
apposition
• Collection of blood or serum  ideal
21

medium for microbial growth 

 Principles of Wound
Closure
• Closing with sufficient tension - to prevent
exaggerated patient’s discomfort, ischaemia,
tissue necrosis during healing
• Sutures must be placed tight enough to seal the
wounds, but loose enough as to not strangulate the
wounds edges and create tissue necrosis and
increased scarring
• The deep layer is used to minimize tension on the
superficial layer
 Principles of Wound
Closure
• Stress placed upon the wound after surgery
ü To prevent suture disruption
ü e.g. abdominal fascia will be placed under
excessive tension after surgery if patient strains
to cough, vomit, void, defecate

• Immobilization of wound
ü Adequate immobilization of the approximated
wound, but not mandatory for the entire
anatomic part
ü For efficient healing and minimal scar
formation
 Principles of Wound
Closure
• Factors influencing surgical wound closure
ü Local factors
§ Skill and techniques
§ Sutures Materials
§ Tight suturing : Tension
§ Vascularity  necrosis and wound breakdown
§ Infection/contamination
ü Systemic factors
§ Nutrition
§ Comorbid diseases : Diabetes, rheumatoid arthritis
 impaired microcirculation, imunodeficiency HIV
§ Shock/Oxygenization impairment
Incision: a cut produced
surgically by a sharp
instrument that creates an
opening into an organ or
space in the body
J Pel Surg 2002; 6:295
 Types of Incisions
1. Vertical incisions: midline incision,
paramedian incision, pararectal
(Battle’s) incision
2. Transverse incisions: transverse
epigastric incision, transverse
supropubic (Pfanestiel) incision,
Lanz’s incision
3. Oblique incisions: Kocher’s subcostal
incision, Mc Burney’s incision
Scandinavian Journal of Surgery 91: 315–321, 2002
 Vertical
INCISIONS
Abdominal Rectus sheath

Plate 399 from Gray's Anatomy

 Vertical Incisions
A. Incision through the
linea alba (midline)

B. Incision through the

rectus muscle
(paramedian) splitting
the muscle

C. Incision lateral to the

rectus sheath
(pararectus)
1. Skin, 2. Three flat muscles and their aponeuroses, 3.
Transversalis fascia, 4. Peritoneum, 5. Rectus abdominis muscle,
6. Linea alba
Anatomical Complications in General Surgery McGraw-Hill 1983
 1. Midline Incision
Advantages:
1. Adequate exposure
2. Minimal blood loss
3. Minimal nerve and
muscle injury
4. Can be quickly made,
suitable for emergency
& exploratory surgery

Incision down the

Disadvantages: middle of abdomen
1. Midline scar along and through skin,
subcutaneous fat, linea
alba & peritoneum
Scandinavian Journal of Surgery 91: 315–321, 2002
 2. Paramedian Incision

Advantages: Disadvantages:
1. Provides access to 1. Longer time to make
lateral structures and close
2. Superior extension may
2. Rectus muscle is not be limited by costal
divided
margin
3. Can be extended by a 3. May strip muscles from
curvilinear incision their lateral blood and
towards the xyphoid nerve supply: atrophy
process ifCarol
required of muscle
E. H. Operative Anatomy: Chapter 41 Exploratory Anatomy. medial to the
Paramedian Incision

Incision through the

rectus sheath without
muscle splitting
A. Lateral retraction of
the rectus muscle
following incision of
the anterior layer of
the sheath

B. Release traction
allows intact muscle
to bridge the incision
through the sheath
Anatomical Complications in General Surgery McGraw-Hill 1983
 3. Battle’s Pararectus
Incision
• This incision is similar to
the paramedian but near
the lateral border of
rectal sheath

• Previously used for

appendectomy and for
unilateral gynaecological
operations
The incision is made
mostly on the lower
abdomen over the
• Now has been lateral part of the
abandoned because of rectus muscle
damage to the nerves
Mcminn. Last’s Anatomy Regional and Applied. Abdomen pg. 311
Transverse
INCISIONS
 1. Transverse Epigastric
Incision

• The incision is done mid way between umbilicus

and xiphoid by muscle cutting
• Advantages: Good exposure to upper abdomen,
healing is supported by muscle contraction
which pull transeversely, nerve supply of recti is
not affected (segmental)
• Disadvantages: Time consuming, more bleeding
(epigastric and muscular vessels)
Carol E. H. Operative Anatomy: Chapter 41 Exploratory Anatomy.
 2. Pfannestiel (Supropubic)
Incision
• Commonly used for
approach for the pelvic
organs (widely used by
gynecologists)

• Advantages: rarely
associated with
incisional hernia, can
heal without significant
scarring (good blood The incision is made
supply in the mons horizontally just above the
pubis. The anterior rectus
pubis) sheaths and linea alba are
• Disadvantages: Limited transected and reflected
upward 8-10 cm
exposure to upper
abdomen, Mcminn.
aortic andRegional and Applied. Abdomen pg. 311
Last’s Anatomy
Pfannestiel (Suprapubic)
Incision
 3. McBurney’s & Lanz’s
Incision
• McBurney point (1884)
is 2/3 from the
umbilicus and 1/3 from
the right superior iliac
spine

• The incision is oblique

beginning laterally from
above and ending
medially This is the incision of
most appendicetomies
and can be used in the
• Nowdays, the incision is left lower quadrant in left
made transverse and sided colonic pathology
placed in a skin crease
(Lanz incision) more
Carol E. H. Operative Anatomy: Chapter 41 Exploratory Anatomy.
Oblique INCISIONS
 1. Kocher’s Subcostal
Incision
• The incision is done on the right
subcostal region

• 3 cm parallel to and below the

right costal margin, from the
midline to beyond the lateral
border
• Widely used for open of the rectus sheath
cholecystectomy,
splenectomy and partosystemic shunts

• Advantages: Hernia is less likely to occur

• Disadvantages: Limited exposure

Mcminn. Last’s Anatomy Regional and Applied. Abdomen pg. 311
2. McBurney Incision

Charles McBurney

Surgical Recall 6th ed.

 Other Incisions

Mercedes-Benz Incision (Vertical and

Transverse incisions)
The incision features an upper midline incision that branches
out into a Kocher incision, giving access to organs in the upper
abdomen.

Carol E. H. Operative Anatomy: Chapter 41 Exploratory Anatomy.

Laparoscopy Incisions
 Complications for
Abdominal Incisions
1. Haematoma
2. Infection: Stitch infection, Deep
abscesses, Cellulitis or Meleney's ulcer
3. Burst Abdomen
4. Incisional hernia
In Conclusion…
Thank You