post graduate presentation

1. Abdominal Access
Dr. Pashi V
Prof: Munkonge
THE UNIVERSITY TEACHING
HOSPITAL.

2. Relevant anatomy of the abdomen
Region of the trunk between the thorax and the
pelvis
Generally abdomen includes false pelvis
Abdomen proper excludes the false pelvis
Functions of the abdomen:
◦ Houses and protects major viscera
◦ Assists in breathing
◦ Accounts for change in intra-abdominal pressure

3. SURFACE ANATOMY

5. ANTERIOR ABDOMINAL WALL

6. ABDOMINAL MUSCLES

7. RECTUS SHEATH
Above arcuate line of Douglas
Below arcuate line of DouglasAbove arcuate line of Douglas

8. The umbilicus and the skin
• In the fetus, the umbilicus transmits the
vitelline and umbilical vessels and yolk stalk.
• It is surrounded by the paraumbilical veins
that establish connections with both the
portal vein and the inferior vena cava
(portacaval anastomosis) through a series of
venous channels

9. • It is also the site of attachment of the
umbilical ligaments that consist of the median
umbilical (remnant of the urachus),medial
umbilical (obliterated umbilical arteries) and
lateral umbilical (inferior epigastric vessels)
ligaments/folds
• The umbilicus may also receive the
embryological remnant of the vitelline duct
known as Meckel’s diverticulum

10. • The umbilicus also receives the round
ligament of the liver, a remnant of the
umbilical vein.
• The umbilical vein remains patent for some
time during early infancy and allows blood
transfusion or general venous access

11. • An incision made perpendicular to the
direction of Langer’s lines is most likely to
gape and result in prominent scarring.
• Since the course of the nerves and vessels that
supply the anterolateral abdomen parallels
the cleavage lines of the skin, transverse
incisions of the abdomen are surgically more
favourable,
• They are less likely to gape or cause damage
to nerves or vasculature and heal faster
without visible scarring

12. Abdominal incisions
• Deciding the right type of surgical incision is
extremely important.
• The ideal incision allows:
1. ease of access to the desired structures
2. can be extended if needed
3. ideally muscles should be split rather than cut
4. heals quickly with minimal scarring
5. aesthetically pleasing
6. The incision must traverse muscle rather than
fascia since the scar left in the peritoneum is
best protected by muscles

13. 7. rectus abdominis muscle maybe cut transversely
without weakening the abdominal wall. The cut
passes between two adjacent nerves without
injuring the nerves.
8. The incision must not divide no nerve
9. Drainage tubes should be inserted through separate
incision like wise colostomy or ileostomy should be
made through a separate incision
10. The openings made by the incision through different
layers of the abdominal wall must not be
superimposed

15. Different ways of classifying abdominal
incisions
1. Approach to the abdominal cavity
a. Incisions through anterior abdominal wall
b. Incisions through the Posterior Abdominal wall
2. Orientation of incision to the body axis
a. Transverse incisions
b. Vertical incisions
c. Oblique incisions

16. 3. Based on approach to musculature of the
abdominal wall
a. Dividing no muscles
b. Diving muscles (Transrectal)
c. Splitting muscles

17. Abdominal incision

18. SURGICAL INCISIONS
 1. Kocher’s incision
 2. midline incision
 3.Gridion muscle splitting
 4. Battle incision
 5. Lanz incision
 6. paramedian
 7. transverse
 8. Rutherfold Morrison incision
 9. Pfannestiel

19. Vertical incision 1: Midline incision
Use:
• Virtually all abdominal procedures may be performed
through this incision.
Location:
• in the midline of the abdomen, and can extend from
the xiphoid process to just above the umbilicus.
• It can be continued to below the umbilicus by curving
the incision around the umbilicus.
Layers of the abdominal wall:
• skin, fascia (camper's and scarpa's), linea alba,
transversalis fascia, extraperitoneal fat and
peritoneum

20. Midline incision

22. Advantages
• Adequate exposure of most if not all of the
abdominal viscera
• Minimal blood loss as the incision is through the
linea alba
• Minimal nerve injury
• Minimal muscle injury
• Can be quickly made, such as in an emergency
and quickly closed with a mass closure technique
Disadvantages
• Care needs to be taken just above the umbilicus
where the falciform ligament is
• Midline scar

23. Vertical incision 2: Paramedian incision
Use:
• provides laterality to the midline incision,
allowing lateral structures such as the kidney,
adrenals and spleen to be accessed.
Location:
• about 2- 5cm to the left or right of the midline
incision.
• Incision is over the medial aspect of the
transverse convexity of the rectus.

24. Paramedian incision

25. Layers of the abdominal wall:
• skin, fascia (camper's and scarpa's) and the
anterior rectus sheath are incised.
• The anterior rectus muscle is freed from the
anterior sheath and retracted laterally.
• The posterior rectus sheath (if above the
arcuate line) or transversalis fascia (if below
the arcuate line)
• extraperitoneal fat and peritoneum are then
excised allowing entry to the abdominal
cavity.

29. Advantages
• Provides access to lateral structures
• Rectus muscle is not divided
• Incisions in anterior and posterior sheath is
separated by muscle which acts as a buttress,
therefore closure is more secure
• Can be extended by a curvilinear incision
towards the xiphoid process if required

30. Disadvantages
• Takes longer to make and close
• Incision needs to be closed in layers
• Difficult extension superiorly as limited by the
costal margin
• Tends to strip the muscles of their lateral
blood and nerve supply resulting in atrophy of
the muscle medial to the incision

31. Vertical incision 3: Mayo-Robson incision
• This is really a paramedian incision that has
been curved towards the xiphoid process.
• It allows a bigger and wider opening.
• Dissection continues in the same fasical planes
as the paramedian incision.

32. Mayo-Robson incision

33. Transverse incision 1: Transverse incision
Use:
• right or left colon, duodenum, pancreas,
subhepatic space.
Location:
• This incision is made just above the umbilicus,
dividing one or both of the rectus muscles.

34. Layers of the abdomen:
• skin, fascia, anterior rectus sheath, rectus
muscle (+/- internal oblique, depending on the
length of the incision), transversus
abdominus, transversalis fascia,
extraperitoneal fat and peritoneum.
• The medial aspect of this incision will be
through the layers just like as in the midline
incision

35. Transverse incision

36. Advantages
• Less pain than a midline incision
• Good access to midline upper GI structures
• Transverse incisions cause the least amount of
damage
• As the recti have a segmental nerve supply, it
can be cut transversely without weakening a
denervated segment
• Muscular segments can be rejoined

37. • Commonly used in children as greater
abdominal exposure is gained in comparison
with the vertical midline.
• This is due to the longer transverse length of
the abdomen in children
Disadvantages
• Limited lateral access in comparison with
midline incisions that can then be extended
• More wound infections compared to midline
thought to be due to greater difficulty in
controlling bleeding and haematoma
formation.

38. Transverse incision 2: Subcostal incision
Use:
• gallbladder and biliary tract, spleen.
• It is also known as the Kocher subcostal
incision, after the person who discovered it.
• With the roof top or Chevron modification,
access to oesophagus, stomach, kidney and
adrenals and liver is also possible.
• Another modification is the Mercedes

39. Location:
• starts in the midline, 2-5 cm below the xiphoid,
extending in parallel with the costal margin at
about 2.5 cm below the costal margin.
• A rooftop of Chevron incision is a double Kocher
incision.
• The mercedes incision involves a vertical incision
from the rooftop incision, like a mercedes sign.
• Layers of the abdominal wall: Skin, rectus sheath,
rectus muscle, internal oblique, trasnversus
abdominus, transversalis fascia, extraperitoneal fat
and peritoneum

40. Subcostal incision and modifications

41. Advantages
• Greater lateral exposure
• Less painful to midline incision
• Less post-operative complications such as PE
to a midline incision
• Heals well
Disadvantages
• Longer operation time as the incision is closed
in 2-3 layers

42. Transverse incision 3: McBurney's
incision and the Lanz incision
Use:
• This is the incision of most appendicetomies and
can be used in the left lower quadrant in left sided
colonic pathology.
• Location:
• McBurney's point, as described by Charles
McBurney in 1884, is two thirds from the
umbilicus and a third from the right anterior
superior iliac spine.
• The incision is oblique beginning laterally from
above and ending medially.

43. • If palpation reveals a mass, perhaps an
appendiceal abcess, then the incision is made
directly over the mass.
• Nowadays, the incision is made transverse and
placed in a skin crease, the so called transverse
Lanz incision as this is more aesthetically pleasing
and the scar is hidden in the bikini line.
• If it is anticipated that the incision will need to be
extended, the oblique incision is used with lateral
extension and as a muscle splitting (gridiron)
surgical technique.

44. • Muscle splitting involves spitting the muscles
fibres in a direction that is parallel to the
direction of the muscle fibres.
• Layers of the abdominal wall: skin, fascia,
internal oblique medially and external oblique
laterally, transversus abdominus, transversalis
fascia, extraperitoneal fat and peritoneum.

45. McBurney's incision and the Lanz
incision

46. Advantages
• Aesthetically pleasing incisions as they both
follow Langer's skin lines
• A wide range of pathologies in the right and
left lower quadrants can be dealt with, with
room for extension if required
• Minimal damage to muscles as muscle
splitting techniques can be utilised
• Avoids damage to local nerves

47. Disadvantages
• The ilioinguinal and iliohypogastric nerves
cross the appendicectomy incision and there
is a risk of injury.
• This can then predipose to inguinal hernia
formation post-operatively.
• This is more evident with the Lanz incision.

48. Transverse incision 4: Pfannenstiel incision
Use:
• Allows exploration of the lower GI and UT, as well
as the pelvic reproductive organs.
Location:
• A convex 5cm to 12cm incision, located a the
suprapubic skin crease about 2cm to 5cm above
the pubic symphysis.
• Once the peritoneum is reached, it is incised
vertically, taking care to avoid the bladder.

49. • Layers of the abdominal wall: skin, fascia,
anterior rectus sheath, rectus muscle,
transversalis fascia, extraperitoneal fat,
perineum.
• NOTE: this incision is below the arcuate line
and this there is no posterior rectus sheath.

50. EXTRA: MAYLARD INCISION

51. • This incision is placed a couple of cm's above
the pfannenstiel and also provides good
exposure of the pelvic organs.
• It cuts through the rectus fascia and muscle
as well as external and internal obliques.
• Once transverse abdominus and transversalis
fascia are reached, a muscle splitting
technique is employed.

52. Advantages
• A convex incision is made instead of a
transverse as this parallels the course of the
segmental nerves that are cut and so
minimising muscle parasthesia and paralysis
post-operatively. It also follows the cleavage
lines in the skin resulting in less scarring
• Location of incision means it is hidden in the
pubic hair line

53. Disadvantages
• Limited exposure of the abdominal organs.
• Use of incision is therefore restricted to the pelvic
organs
• High risk of injury to the bladder especially because
the fascia thins towards the lower abdomen,
leaving the bladder relatively exposed, and if the
bladder is not catheterised during surgery
• Extension of the incision is difficult laterally
• Exploration of the deep pelvic organs is difficult
making dissection in the obese difficult

54. Oblique incision: Thoraco-abdominal incisions
• Thoracoabdominal incisions may be located in
the RUQ or LUQ.
• They convert the pleural and peritoneal
cavities into one.
• They allow good access to the lungs, liver
and spleen.
• The left incision can also provide good
exposure to the oesophagus and the stomach.

55. Thoraco-abdominal incisions

56. INCISIONS THROUGH THE POSTERIOR
ABDOMINAL WALL
These usually used to exposure of
• Kidney
• Ureter
• Suprarenal gland

57. KIDNEY INCISIONS
1.Oblique incisions
• This is the favourite
• This extends from kidney angle in oblique
direction down wards and outwards toward
the anterior superior spine.
• The kidney angle is formed by the outer
border of sacrospinalis muscles at the
junction with the 12th rib.
• The incision runs in the direction of the fibres
of external oblique muscle.

58. Kidney incisions

59. It divides
1.Skin and superficial fascia
2.Latissimus dorsi and serratus posterior inferior
3.External oblique split in direction of its fibres
4.Internal oblique and transverses
5.Fascial transversalis
6.Extraperitoneal and perirenal fat

60. • Lateral cutaneous branch of 12th thoracic nerve
will be cut and this results in an area of
anaesthesia the size of palm over the gluteal
region.
• The incision may also cut ilio-hypogastric nerves.
The outer border of quadrutus muscles is
exposed at the upper part of the incision. Care
should be taken not to open peritoneum.
• This incision gives good exposure to kidney and
ureter. The advantage of the incision is that it
can be extended forward to expose the lower
half of the ureter and the base of the bladder.

61. VERTICAL INCISION
• This extends perpendicularly along the outer
border of sacrospinalis muscle from the 12th
rib to the iliac crest. This incision divides the
following
• Skin and fascia
• Latissimus dorsi and serratus posterior inferior
• The three layers of lumbodorsal fascia
• Fascia transversalis and extraperitoneal fat
• This incision does not interfere with the
muscles in this region. It has the biggest
disadvantage in that it does not give exposure
to ureter and can not be extended.

62. Kidney incisions

63. Layers of posterior kidney incisions

64. HORIZONTAL URETERIC INCISION
• A transverse incision a little above the level of
iliac crest extending outwards from the lateral
border of the sacrospinalis muscle.
• The ureter is identified so that the divided
proximal end is implanted into the skin.

65. Laporoscopic incisions
• These incisions are small cuts in the skin made in
the abdominal wall to allow the instruments of
laparoscopy access to the contents of the
abdominal cavity.
• Their location will depend on the organ being
operated on.
• Generally there will be 3-4.
• One is always at the umbilicus to allow a port for
the camera.
• The other incisions will be located in one of the 4
quadrants for tools such as the griper, cutting and
dissecting scissors and so on.

66. Laporoscopic incisions

67. summary
• Pediatric surgeons utilize several types of
abdominal incision to approach different
surgical problems in newborns, infants and
children.
• In most children and during the first five years
of life transverse incisions are preferred.
• It has been demonstrated that the younger
the child, the relatively larger the abdominal
cavity and wall.

68. • In babies a supraumbilical transverse incision
is ideal to explore all four quadrants and solve
almost every surgical congenital abdominal
condition.
• Another advantage of transverse incision over
longitudinal incision is the low incidence of
fascial dehiscence, hernia formation, and
evisceration of transverse incisions.

69. References
• Askew, A.R. (1975) : The Fowler-Weir
approach to appendicectomy. British Journal
of Surgery, 62(4): 303-4.
• Brennan, T.G., Jones, N.A., Guillou, P.J. (1987):
Lateral paramedian incision. British Journal of
Surgery, 74(8): 736-7.
• Burnand, K.G., Young, A.E.: The New Aird’s
Companion in Surgical Studies. Churchil
Livingstone Edinburgh (1992).

70. References
• J. Anat. Soc. India 50(2) 170-178 (2001)
• Gauderer MW: A rationale for routine use of
transverse abdominal incisions in infants and
children. J Pediatr Surg 16(4 Suppl 1):583-6,
1981
• Grantcharov TP, Rosenberg J: Vertical
compared with transverse incisions in
abdominal surgery. Eur J Surg 167(4):260-7,
2001