Mamiek Dwi Putro

Departemen / SMF Ilmu Bedah

FK Unair / RSU Dr Soetomo
Surabaya
 Accessibility : provide direct
exposure to the diseased or injured
anatomy and sufficient space for the
procedure to be well performed.

Flexibility : amenable to extension if

the complexity of the procedure
demand greater exposure than
originally anticipated

Security : closure of the wound must be

strong and reliable
 Vertical : medline,
medial paramedian,
lateral paramedian.

Transverse and Oblique

Abdomino thoracic

Retroperitoneal and extraperitoneal

 The organ of interest and anticipated
procedure
Thebody habitus of patients and degree of

obesity
The urgency of procedure
The presence of previous abdominal

incisions
The preference and experience of the

surgeon
a.Midline Incisions
Fastest approach toward the peritoneal
cavity
Adequate exposure to the abdominal cavity
and retroperitoneum
Nearly bloodless
Not require division of muscle fibres
The upper midline / epigastric midline
incision
The lower midline / infraumbilical
 The Upper Midline :
- incision from the xiphoid process to 1 cm
above umbilicus
- the incision is carried down to the linea alba,
extra peritoneal fat and peritoneum
- with small incision is enlarged to admit 2
fingers to protect the underlying viscera

The Infra Umbilical Midline : incision from 1

cm sub umbilical to symp pubic in the same
manner

The Full Length Incision : Midline laparotomy

 Medial Paramedian Incisions

An Upper PI : begun at the costal margin 2,5 cm

from midline on either the right or left side of the
abdomen, to 2 cm below umbilicus .
An Lower PI : begun 1 cm below umbilicus to 8cm
below
umbilicus

The anterior rectus sheath is incisied, then diseccted

off the rectus muscle to its medial edge

The inferior and superior epigastric vessels will be

dissected ( divided and tied)
 B. Paramedian incision in transverse section.
A. Paramedian incision: dissection of the
rectus muscle from the anterior rectus
sheath.
 Lateral Paramedian Incisions

- Modification of standard PI ( Guillou Incision)

- Incision is placed at the junction of the

middle and outer thirds of rectus sheath

- The rectus muscle is retracted laterally,

posterior sheath , peritoneum are divided
as the same plane as the anterior sheath
 Vertical Muscle Splitting Incision :

- The same way as the traditional paramedian

incision except the rectus muscle is split
longitudinally in its median one third to one
sixth

- The posterior rectus sheath and peritoneum

are incised in the same line
Lower paramedian Retraction of the rectus abdominis muscle
incision. A. Surface
markings
B. Incision of the rectus sheath
D. Location of the branches of
the inferior epigastric vessels F. The peritoneum is
that run across the lower incised for the full
portion of the incision. length of the wound.

E. Peritoneum opened
 B. Lateral paramedian and conventional paramedian incisions
compared in transverse section

C. Closure of the lateral paramedian incision; it is

sufficient to suture the anterior rectus sheath,
A. Lateral paramedian incision compared leaving the posterior sheath open.
with conventional paramedian incision.
Note that the upper or lower extension
may be angled medially (darker lines) for
greater access.
 There are several variaton, can be strictly
horizonal or may curve to varying degree.

The wound may be limited to lateral oblique

muscle abd. wall, divide portion of one rectus
or complete width of both rectus

Generally folow Langers line

On Infra umbilical transverse incision , exposure

is limited when pathology is located in both the
upper and lower abdomen
 Kocher Subcostal Incisions :

- There are right subcostal incision and left

subcostal incision or may be carried across
the midline as bilateral sub costal incision.

- The standard subcostal incision commences

in the midline about 2.55 cm below the
xiphoid process
(approximately onethird of the way between
the xiphoid and the umbilicus
- It is extended laterally and inferiorly about
2.5 cm below the costal margin for
approximately 12 cm, although the length
will vary with the build of the patient

-The incision should leave sufficient room

from the costal margin that if a hernia
develops, adequate superior abdominal wall
tissues are available for repair.

-The incision can be continued on to the lateral

abdominal muscles
Kocher incision.
A. Surface markings

B. Division of the rectus and medial portions of the

lateral abdominal muscles.
- Originally described by Charles McBurney in 1894, 17
the muscle-splitting right iliac fossa incision is well
suited for appendectomy.

- The classic McBurney incision is made in an

oblique direction.

- Most surgeons today use the Rockey-Davis incision.

It is a modification of the time-honored McBurney
incision that employs a cosmetically superior
transverse incision in the line of the skin crease

-Tranverse incision on Mc Burney so called Lanz

Incision ( Otto Lanz from Amsterdam )
- Incision is used frequently for gynecologic operations and for
access to the retropubic space in the male for extraperitoneal
retropubic prostatectomy.

- The skin incision is placed in the curving interspinous crease

that lies approximately 5 cm superior to the symphysis pubis
and 12 cm in length.

- Both anterior rectus sheaths are exposed and divided transversely

for
the entire length of the wound, that are widely separated from the
underlying rectus muscles superiorly to the umbilicus and inferiorly
to
the pubic symphysis. The recti are retracted laterally and the
peritoneum is opened vertically in the midline.

-Care must be taken to protect the bladder at the lower end of the
wound
 B. Horizontal division of the anterior
rectus sheath and developing fascial
flap
Pfannenstiel incision.
A. Skin incision

C. Dividing in the midline and entering the peritoneal cavity

Opening midline

Inferior retractors placed for exposure.

Closure midline and inferior rectus.

Lateral retractors are placed for exposure

- The thoracoabdominal incision provides
excellent exposure by converting the peritoneal
and pleural spaces into one common cavity

- Two variations : Left and Right

Abdominothoracic Incision

- The patient is placed in the "corkscrew" position

on the operating room table for maximal access
into both the abdominal and thoracic cavities.

- The abdomen is tilted approximately 45 degrees from

the horizontal by using sandbags, and the thorax is
twisted into the full lateral position
- The abdominal part of the incision may
consist of a midline or upper paramedian
incision,which allows preliminary exploration
of the abdomen.

- An obliquely placed limb of the abdominal

incision is then added to continue along the
line of the eighth inter space, identified
easily where it is immediately caudal to the
inferior pole of the scapula
A. The "corkscrew" position, with the thorax in
the lateral position and the abdomen at 45
degrees from the horizontal. Very careful
positioning on the operating table is essential
to prevent injury to the brachial plexus or
pressure on peripheral nerves and should be
closely supervised by the surgeon.
B. The abdominal incision is ordinarily made first, to
determine operability and be certain that the thoracic
extension is needed. This is usually done with a vertical
midline incision that is extended into the chest through
the eighth intercostal space. The abdomen has been
opened and the pleural space is being entered.
C. The diaphragm is usually opened in a radial
fashion with an incision directed toward the
esophageal or aortic hiatus.
D. The diaphragm can be opened with a
hemielliptical incision 23 cm from the lateral
chest wall; this incision is longer than a straight
phrenicotomy but preserves phrenic nerve
function, of importance in patients with chronic
pulmonary disease or less than optimal pulmonary
function.
 Retroperitoneal approach to the lumbar area

Posterior Approach to the adrenal glands

Retropritoneal Approach to the iliac fossa

Perineal

Kraske

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SELAMAT

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