Anatomy

1
General Surgery

• Anatomy Incisions

2
Incisions

• A variety of incisions are used
• The type chosen is dependent on a number of
  factors
• Access desired
• Procedure
• Surgeon
• Extensibility (can we make it bigger?)
• Wound security

3
Layer by layer

• Abdominal wall layers
• Skin
• Subcutaneous
• Fascia
• Muscles
• Preperitoneal fat
• Peritoneum

4
(No Transcript)
5
(No Transcript)
6

• Tissue Layers of the Abdominal Wall

(Redrawn from Ethicon Wound closure manual,
Somerville, NJ, 2002, Ethicon, Inc.)
7
(No Transcript)
8
Organs by Quadrants
9
(No Transcript)
10
Incisions, continued
Abdominal incisions
(Modified from Rothrock JC Alexander's care of
the patient in surgery, ed 12, St Louis, 2003,
Mosby.)
11
The good, the bad and the scar tissue

• Each incision type has advantages and
  disadvantages
• Adequacy of exposure
• Closure time
• Disruption of blood and nerve supplies
• Muscle damage
• Wound hernia
• Effect pulmonary function

12
Other Factors

• Other things may influence choice
• Patient condition
• Need for speed
• Previous surgery
• Minimize bleeding and trauma
• Postop discomfort
• Room to roam

13
And yet more pain

• Cosmetics
• Changes in the blood supplies to the anterior
  wall
• Limit choices for future surgeries and
  reconstruction

14
Vertical Midline Incision

• Simple to perform
• Good exposure to all of the abdominal cavity
• Can be extended from the sternal notch to the
  symphysis pubis

15
Paramedian

• Vertical incision that is placed 2 off of the
  midline
• Same indications as the vertical with the
  exception of trauma
• Longer to create and close
• Bleed more readily
• Prone to herniation

16
Oblique Incisions

• Allow access to specific structures
• Strong
• However,
• Splits muscles
• Bleeding
• Nerve damage

17
Muscle-Splitting Incisions
Surgical options for muscle
(Redrawn from Ethicon Wound closure manual,
Somerville, NJ, 2002, Ethicon, Inc.)
18
McBurney

• Used most commonly for open appendectomy
• Quick and easy to close
• Firm closure
• Poor exposure

19
Oblique Inguinal

• From the pubic tubercle to the iliac crest above
  the inguinal crease
• Used for Inguinal Herniorraphy repair
• May also be used for urologic, transplant or
  vascular procedures in this region

20
Subcostal

• Usually made on the right side (kocher)
• Used for open gall bladder procedures
• Left sub costal used for spleenectomy
• Strong but painful
• Limited exposure
• Good cosmetic closure

21
Transverse Incisions

• Used to expose either the upper or lower regions
  of the abdomen
• Same issues as the oblique incision

22
Pfannenstiel

• Used for pelvic surgery
• Approximately ½ above the symphysis pubis
• Most commonly used for OB/GYN
• Excellent exposure
• Cosmetic

23
Midabdominal

• Used for retroperitoneal approaches
• Colectomy or colostomy

24
Thoracoabdominal

• Used for proximal stomach, distal esophagus, and
  anterior spine
• Patient is in a lateral position
• Begins at midpoint between xiphoid and umbilicus
  and extends to midscapular line into the chest