Abdominal Incisions and sutures

16. Mar 2019

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Abdominal Incisions and sutures

  1. • 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
  2. •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
  3. • 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
  4. 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
  5. . Midline (median) easily extended. Para Median . Good extensibility, especially on the side of the pelvis
  6. • 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
  7. Oblique incisions
  8. 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
  9. Rockey–Davis (or Elliot) incisions. • transverse incision
  10. Closure techniques and wound closure materials • tissues need approximation, not strangulation. • Sutures, staples and adhesive tapes are the traditional methods of wound closure.
  11. 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.
  12. Others
  13. 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.
  14. 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.
  15. 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.
  16. Steri-Strip STM Surgical Skin Closure
  17. 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.
  18. 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).
  19. Principles of suturing skin incisions

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  1. Kutsner sometimes incorrectly referred to as modified Pfannenstiel incision, 3 cm below the level of the ASIS :joel kohen Joel cohen ::less blood loss ,less pain cuz strtching nerves not cutting them ,, fast Begins below the level of the ASIS ,Extends below pubic hairline.
  2. In a patient with clinical evidence of impaired circulation in the lower extremity, a midline incision should be preferred to the Maylard incision, in view of the risk of lower extremity ischaemia secondary to inferior epigastric artery ligation. Cherney : Can provide access to retziu space for urinary incontinence procedures
  3. aEarlier studies reported that increased incidence of eviscerations with vertical incisions might be associated with inappropriate closures. Recent studies have shown no difference in fascial dehiscence between transverse and vertical incisions.5 division of multiple layers of fascia and muscle and nerves, may result in potential spaces with haematoma or seroma
  4. Traditionally, vertical incisions were used for CS For very obese women a transverse incision above the umbilicus has been suggested, but not shown, to decrease morbidity
  5. There is no difference in wound infection, dehiscence or respiratory problems with midline and paramedian incisions.
  6. used for a transperitoneal or extraperitoneal approach to abdominal surgery,
  7. a downward and inward from the McBurney point. The peritoneum may then be reflected away from the abdominal wall inferiorly. This The incision is carried through the skin and subcutaneous fat to the abdominal wall muscles, which is split along the direction of the fibres.
  8. These staples contain an absorbable copolymer of predominantly polylactide and a lesser component of polyglycolide.24 Prior to stapling, it is useful to grasp the wound edges with forceps to evert the tissue so as to prevent inverted skin edges. have a low tissue reactivity. Additionally, contaminated wounds closed with staples have a lower incidence of infection compared with those closed with sutures. Disadvantages of staples include the potential for staple track formation, bacterial migration into the wound bed, and discomfort during staple removal.
  9. Laser welding
  10. Evidence shows no difference in continuous versus interrupted closure, with a similar incidence of wound breakdown and hernia formation. Other sutures include buried, purse string and subcuticular sutures