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Surgical Incisions

Wifanto Saditya Jeo


Departemen Ilmu Bedah
FKUI- RSCM
Jakarta
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
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
 The direction of wound naturally heal is from side-to-side, not end-
to-end
 The arrangement of tissue fibers in the area to be dissected will
vary with tissue type
 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)
 Is the skin lines oriented perpendicular
to the direction of the underlying
muscle fibers
 Determined by examination of patient’s
natural skin creases at rest
 Orientation of the final scar parallel to
or within a natural skin crease gives a
superior cosmetic result.
Principles of Wound Incision
• Dissection technique
 Clean incision should be made with one
stroke or evenly applied pressure on the
scalpel
 Preserve integrity of as many of
underlying structures as possible

• Fusiform excision
 Performed with longitudinal axis running
parallel to RSTL
 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
 Areas of redundant skin and subcutaneous tissue
resulting from a wound margin being longer on one
side than the other
 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
 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
 Minimum tissue trauma promotes faster healing
 Surgeon must handle all tissues very gently - and as little as
possible
 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
• Monofilament vs. multifilament
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 (e.g. vicryl, monocryl,
nilon)
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
15
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 medium for
microbial growth  infection
• Drain insertion or pressure dressing application 18
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


 To prevent suture disruption
 e.g. abdominal fascia will be placed under excessive tension
after surgery if patient strains to cough, vomit, void, defecate

• Immobilization of wound
 Adequate immobilization of the approximated wound, but not
mandatory for the entire anatomic part
 For efficient healing and minimal scar formation
Principles of Wound Closure
• Factors influencing surgical wound closure
 Local factors
 Skill and techniques
 Sutures Materials
 Tight suturing : Tension
 Vascularity  necrosis and wound breakdown
 Infection/contamination
 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 middle of


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

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

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


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

• Now has been abandoned The incision is made mostly on


because of damage to the nerves the lower abdomen over the
lateral part of the rectus
entering the sheath laterally
muscle

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 supply in the
mons pubis)
The incision is made horizontally
• Disadvantages: Limited just above the pubis. The anterior
exposure to upper abdomen, rectus sheaths and linea alba are
aortic and lymph nodes (should transected and reflected upward
never be used in oncologic 8-10 cm
surgery)
Mcminn. Last’s Anatomy Regional and Applied. Abdomen pg. 311
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


• Nowdays, the incision is made appendicetomies and can be used
transverse and placed in a skin in the left lower quadrant in left
crease (Lanz incision) more sided colonic pathology
aesthetically pleasing & the scar
is hidden in the bikini line
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 of the rectus sheath
• Widely used for open 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