Surgical Incisions—Their Anatomical Basis

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J Anat. Soc. India 50(2) 170-178 (2001)

Surgical Incisions—Their Anatomical Basis Part IV-Abdomen
*Patnaik, V.V.G.; **Singla, Rajan K.; ***Bansal V.K.. Department of Anatomy, Government Medical College, *Patiala, **Amritsar, ***Department of Surgery, Govt. Medical College & Hospital, Chandigarh, INDIA. Abstract. The present paper is a continuation of the previous ones by Patnaik et al2000 a, b & 2001. Here the anatomical basis of the various incisions used in anterior abdominal wall their advantages & disadvantages are discussed. An attempt has been made to add the latest modifications in a concised manner. Key words : Surgical Incisions, Abdomen, Midline, Paramedian, McBurney, Gridison, Kocher.

Introduction : It is probably no exaggeration to state that, in abdominalsurgery, wisely chosen incisions and correct methods of making and closing such wounds are factors of great importance (Nygaard and Squatrito, 1996). Any mistake, such as a badly placed incision, inept methods of suturing, or illjudged selection of suture material, may result in serious complications such as haematoma formation, an ugly scar, an incisional hernia, or, worst of all, complete disruption ofthe wound (Pollock, 1981; Carlson et al, 1995). Before the advent of minimally invasive techniques, optimal access could only be achieved at the expense of large high morbidity incisions. Endoscopic and laparoscopic technology has, however revolutionized these concepts facilitating patient friendly access to even the most remote of abdominal organs (Maclntyre, 1994). It should be the aim of thesurgeon to employ the type of incision considered to be the most suitable for that particular operation to be performed. In doing so, three essentials should be achieved (Zinner et al, 1997): 1. 2. 3. Accessibility Extensibility Security

be extensible in a direction that will allow for any probable enlargement of the scope of the operation, but it should interfere as little as possible with thefunctions of the abdominal wall. The surgical incision and the resultant wound represent a major part of the morbidity of the abdominal surgery. Planning of an abdominal incision : In the planning of an abdominal incision, Nyhus & Baker (1992) stressed that the following factors must be taken into consideration (a) preoperative diagnosis (b) the speed with which the operation needs to beperformed, as in trauma or major haemorrhage, (c) the habitus of the patient, (d) previous abdominal operation, (e) potential placements of stomas (Funt, 1981; Telfer et al, 1993). Ideally, the incision should be made in the direction of the lines of cleavage in the skin so that a hairline scar is produced. The incision must be tailored to the patients need but is strongly influenced by the surgeon’spreference. In general, re-entry into the abdominal cavity is best done through the previous laparotomy incision. This minimizes further loss of tensile strength of the abdominal wall by avoiding the creation of additional fascial defects (Fry & Osler, 1991). Care must be taken to avoid ‘tramline’ or ‘acute angle’ incisions (Figure 1), which could lead to devascularisation of tissues. It is alsohelpful if incisions are kept as far as possible from established or proposed stoma sites and these
J. Anat. Soc. India 50(2) 170-178 (2001)

The incision must not only give ready and direct access to the anatomy to be investigated but also provide sufficient room for the operation to be performed (Velanovich, 1989). The incision should

Patnaik, V.V.G., et al

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Classification of incisions: The incisions used for exploring the abdominal cavity can be classified as : (A) Vertical incision : These may be (i) (ii)
(a) (b)

Midline incision Paramedian incisions Kocher's subcostal Incision (a) Chevron Modification) (Roof top

(B)

Transverse and oblique incisions : (i)

Fig. 1. (a) Tramline Incision. (b) Acute angle incision.

stomas should be marked preoperatively with...