114 SYNOPSIS OF SURGICAL ANATOMY uscles may be cut transversely without s, ha cut passes between 1, ake ‘odominal wall, as suc io can injuring them, The rectus has a segmental nerye pe there i norsk ofa transverse inision cutting off the yap iretee from its nerve supply, a8 would be the situation jy mPt of Tepended on a single nerve were o be divided (Fig. 104) cal 4, The rectus mi serious) A 8 Fig. 104, Demonstrating that division of a muscle (A), with a single nerve supply causes paralysis distal to the section, whercas division of a muscle (B). such as the rectus, with a segmental supply produces no paralysis. as the nerves arc uninjured Above the umbilicus, the tendinous intersections prevent retraction of the rectus muscle after it has been divided. 5. Drainage tubes should be inserted through separate small incisions, as their presence in the main wound may seriously prejudice the strength of the ultimate scar. For the same reason, a colostomy should be made through a separate incision and not through the main wound 6. Closure of abdominal incisions has been more readily understood since it hhas been realized that they heal by forming a block of fibrous tissue, and that disruption is @ mechanical problem, often due to ischaemia. Tous wound closure without tension is necessary for a secure closure. GENERAL LAPAROTOMY INCISIONS. Specific incisions for particular purposes have béen included in the consideration of individual organs. More flexible incisions may be required where wider or multipurpose exposure is desired Midline incisions Midline incisions (Fig. 105) traverse the abdominal wall ina vertical diTHE ANATOMY OF ABDOMINAL, INCISIONS 115 — — Be | Fig. 105. Midline incision. shove or below the umbilicus. They are extensively wed. The incision divides: (a) skin: (b) linea alba; (c) fascia transversalis; (d) extraperitoneal fat: (e) peritoneum. The linea alba above the umbilicus is a dense, strong structure | em wide, formed by the interlacing fibres of the rectus sheaths. It holds sutures well and its relatively avascular. The incision may be extended downwards by cutting around the side of the umbilicus. The side chosen is determined by the faleiform whieh travels from the umbilicus upwards and to the right A midline incision may be extended upwards by cutting or excising the xiphoid process of the sternum and, if necessary, splitting the sternum. In exposing the bladder, the incision may stop short of the peritoneum so that the bladder is dealt with through its anterior surface which is devoid of | peritoneum in the region of the space of Retzius (prevesical) ‘The midline lower abdominal incision is occasionally followed by an | incisional hernia, particularly at the lower end just above the pubis. A major reason for this is that, at the time of closure of the incision, the surgeon sutures the external oblique fascia (Gallaudet’s fascia) instead of the linea alba. The external oblique fascia lies on the outside of the external oblique aponeurosis, to which it is adherent. It is given off over the cord as the exterral spermatic fascia at the external ring, and extends over the pubis, into the perineum. It is not as strong as the linea alba and, unless the linea alba is sutured, a hernia will develop immediately above the pubis. Where a supra-umbilical midline incision gives insufficient access, it may be combined with a second incision carried laterally at right-angles to the first (Fig. 106). Whes more exposure is necessary, an oblique upward extension can be used Thie will cut the rectus and the muscles of the lateral abdominal wall in the line of the intercostal nerves, which will therefore be preserved, and it will be possible to extend the wound further into an intercostal space (Fig. 107). Paramedian incisions Th paramedian incision (Fig. 108A) is made vertical, parallel to the midline, nari 2-5 cm away from it to one oF other side. It may be made of any|ATOMY YNOPSIS OF SURGICAL AN. 6 S ision by a Fight-angle extension supra-umbila incision by a i es Fe cee endete ine tyows Rutherford Morison's acs fori ll ugh the rectus. B, aie! _»Intercostal nerves length, and, even if extended from costal ‘margin to pubis, the scar does not Breatly weaken the abdominal wall, The i i incision traverses: (a) skin; (6) anterior rectus sheath: (c) rectus (see below): (d) posterior rectus sheath above the arcuate line: (e) fascia Mransversalis; (f) extraperitoneal fat, he incision may be extended yPwards to the xiphoid process of the ecm, (Mayo-Robson incision)” in haemorrh, this manoeuvre. troublesome ior epigastric artery ig frequently encounteredFig. 109. Mayo-Robson incision: a paramedian incision, the upper end of which may be extended. if necessary, to the xiphisternum In this incision there are different ways of dealing with the rectus: 1. The muscle may be displaced outwards intact without any further interference with it. When the wound is closed the muscle returns to its bed and forms the most efficient protection possible to the line of the incision, which it directly covers (Fig. 108B). This is a sound incision extensively used on the right or left of the midline. When used to deal with the terminal part of the pelvic colon or for excision of the rectum, the incision extends low down so that the rectus may be mobilized down ii n to the pubis. 2. The muscle may be divided in the line of the incision (Fig. 110), The nerves to the rectus enter it from the side or back about its middle. ‘Should the incision through the rectus be made too far laterally, the nerves will be divided and the muscle paralysed. . >|ATOMY yNoPsIS OF SURGICAL AN. 1g. SY Skin Sheath of rectus, f Fascia transversalis Rectus *Peritoneum Sheath of rectus 110, Structures divided by the paramedian muscle-splitting incision Fig. Security in closure is based on the same principles cy closure oh mi incision, but at this site the fibres of the anterior an. Posterior she; transverse and may not hold sutures well. Special care is therefore necessary in suturing. In addition, since the blood supply enters with the nerve, an extensive split, combined with a tight closure, may result in ischaemia to the medial part of the muscle enclosed within the incision However, ifthe muscle is split well medially, only the small medial segment of muscle will be affected and this has been shown by experience to have nol effects, Splitting the muscle in the direction ofits fibres is quicker, and closure ‘Sas effective as the muscle displacing Procedure. idling ath are ted tumours, such as ded at Muscles are cut across and no mses renee ry the rectus sheath may be opened and the "ttoperitoneal sqm erinecle May be cut acroee In the case of medially, and the dissection ind te ehOt entered, but ie displaced Ie pe: "iPhery of the peritoneum