• curved
• 10–15 cm long
• 2 cm above PS
• skin and rectus sheath are
opened transversely using
sharp dissection.
• RM are not cut and the fascia
is dissected along RM
Pfannenstiel
• slightly curved
• Extends below pubic hairline.
• The superficial branches of
IEA , IEV may be encountered
in the fat.
• time-consuming
• Limited extensibility
Kustner Joel-Cohen
•straight
•higher than Pfannenstiel incision;
•Skin is incised by sharp dissection
•Subsequent layers are separated
bluntly

•muscle-cutting incision,
•3–8 cm above PS, depending on
the pt’s habitus and indication for
surgery.
•Used to extend exposure
•Not to be done for pts with
clinical evidence of lower limb
ischemia
Maylard
• runs at the upper limit of
the pubic hair and is thus
lower than the Maylard
incision
• The muscles are divided
above the openings of the
inguinal canals.
Mouchel Cherney
• Transections of the rectus
muscle at their insertion on
the PS and retraction
cephalad to improve
exposure
• gain exposure to the pelvic
side-wall for hypogastric
artery ligation

• Advantages:
o best cosmetic results
o less painful
o less interference with postoperative respirations
o greater strength
• Disadvantages:
o time-consuming
o haemorrhagic
o compromised ability to explore upper abdominal
cavity
o may result in potential spaces with haematoma or
seroma

Incisions for caesarean section
• Joel-Cohen VS Pfannenstiel incision
– Joel-Cohen is superior
• less postoperative febrile morbidity,
• less analgesia requirements,
• shorter operating time,
• less intraoperative blood loss
• Less adhesion formation,
• reduction in hospital stay
• Less wound infection.
• For very obese women a transverse incision
above the umbilicus

. Midline
(median) easily extended.
Para
Median .
Good extensibility, especially on the side
of the pelvis

• Advantages:
o excellent exposure
o easily extendable
o minimum nerve damage
o Median Incision  rapid entry into abdomen and
pelvis , least hemorrhgic
• Disadvantages:
o wound dehiscence and hernia may be more
frequent
o poorer cosmetic results
o paramedian incision  higher infection rates,
haemorrhage and operative time

Oblique incisions

Gridiron (muscle-
splitting) incision of
McBurney
• allows extraperitoneal
drainage of abscess
• can be performed on the left
lower quadrant to drain
abscess
• can be varied for
appendicectomy in pregnant
women

Rockey–Davis (or
Elliot) incisions.
• transverse
incision

Closure techniques and wound
closure materials
• tissues need approximation, not strangulation.
• Sutures, staples and adhesive tapes are the
traditional methods of wound closure.

Sutures
• Consider
– age of the patient, location of the wound, presence/
absence of infection, and surgeon’s experience in
handling a suture material.
• Three main types of suture include the non-
absorbable, slowly absorbable, and the rapidly
absorbable. These can be further divided into
monofilament or braided sutures.
– The incidence of wound infection is low with
monofilament sutures.
– prolonged wound pain and suture sinus  increases
in non-absorbable suture.

Others

Staples
The non-absorbable staple
– is made of stainless steel
– highest tensile strength of any wound
closure material.
The absorbable staple
– device which deploys U-shaped
absorbable staples into the dermal layer of
tissue.
– maintain 40% of their strength at 14 days
and are completely absorbed over a period
of months (tissue half-life of 10 weeks). T
– lower infection rate.

Glue
• 2-octylcyanoacrylate is the only US Food and Drug
Administration-approved surgical adhesive.
• The cyanoacrylates polymerise upon contact with blood,
forming a solid film that bridges the wounds and holds
the apposed wound edges together.
• The established indication in gynaecology is for closure of
port wounds, while emerging indications include control
o active bleeding during laparoscopic surgery.

Adhesive strips
• used to approximate wound edges after
buried sutures are placed.
– relieve tension at the wound edges,
– improve the aesthetics of the wound
– reduce wound care.
• One disadvantage
– tape may not adhere to moist areas or to mobile
areas under tension.

Steri-Strip STM Surgical Skin Closure

Primary suture line :
A continuous suture
leaves less foreign
body mass in the
wound.
It derives its strength
from tension
distributed evenly
along the full length
of suture strand.
Interrupted sutures
may be used in the
presence of
infection: if one
suture breaks the
remaining sutures
will hold the wound
edges in
approximation.
Buried sutures are
placed so that the
knot protrudes to
the inside, under the
layer to be closed
Subcuticular sutures
are continuous or
interrupted sutures
placed in the dermis,
beneath the
epithelial layer.

Secondary suture line
• AKA retention sutures,
• done to
– reinforce the primary suture line,
– eliminate dead space and prevent fluid accumulation
• Retention sutures are placed about 2 inches
from each edge of the wound.
• if used in cases of non-healing, they should be
placed in the opposite fashion from the
primary sutures
– (i.e. interrupted if the primary sutures were
continuous, continuous if primary sutures were
interrupted).

Principles of suturing skin incisions

REFERANCE