The high combined incidence of surgical site infection, wound dehiscence, and hernia formation suggests a dominant contribution of wound complications to surgical morbidity. Moreover, the quality of exposure provided by an incision influences outcome in ways that defy easy quantification. An incision must provide access to the site of abdominal pathology and allow ready extension if greater exposure is required. Indeed, the adequacy of an incision is determined above all else by the safety with which an operation can be undertaken. Nothing should compromise this, and a larger incision or even, on occasion, a second incision, should be created without hesitation if exposure is inadequate. Notwithstanding this, the incision should be executed in a fashion that anticipates a secure wound closure and interferes as little as possible with the function and cosmesis of the abdominal wall.
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The high combined incidence of surgical site infection, wound dehiscence, and hernia formation suggests a dominant contribution of wound complications to surgical morbidity. Moreover, the quality of exposure provided by an incision influences outcome in ways that defy easy quantification. An incision must provide access to the site of abdominal pathology and allow ready extension if greater exposure is required.
Indeed, the adequacy of an incision is determined above all else by the safety with which an operation can be undertaken. Nothing should compromise this, and a larger incision or even, on occasion, a second incision, should be created without hesitation if exposure is inadequate. Notwithstanding this, the incision should be executed in a fashion that anticipates a secure wound closure and interferes as little as possible with the function and cosmesis of the abdominal wall.
While the vertical midline incision remains most popular and is, perhaps, the most versatile, a variety of other incisions may have distinct advantages in specific settings. Abdominal incisions can be vertically, transversely, or obliquely oriented. The avascular linea alba affords the vertical midline its superior flexibility.
Indeed, when optimal exposure of the entire abdominal cavity is necessary eg, exploration for abdominal trauma , the vertical midline incision is preferred and can be extended superiorly to the xiphoid process and inferiorly to the symphysis pubis.
Resection of the xiphoid may afford even better superior exposure when needed. Alternatively, vertical incisions may be placed in a paramedian position, an approach that was previously more popular than it is today but continues to have its proponents. Transverse and oblique incisions can be placed in any of the 4 quadrants of the abdomen depending on the site of pathology.
Common examples include the Kocher subcostal incision for biliary surgery, the Pfannenstiel infraumbilical incision for gynecologic surgery, and the McBurney and Rocky-Davis incisions for appendectomy.
A bilateral subcostal incision affords excellent exposure of the upper abdomen. Alternatively, when superior exposure of upper abdominal organs eg, the esophagogastric junction is required, thoracoabdominal incisions may be used. Retroperitoneal and extraperitoneal structures eg, the kidney, adrenal gland, and aorta may be readily exposed through abdominal wall incisions; often obliquely oriented or curvilinear flank incisions are used.
Recently, J- or L-shaped incisions have gained popularity for exposure of the upper quadrants of the abdomen and for hepatic resection in particular. The relative merits and disadvantages of vertical versus transverse incisions remain subjects of active debate. Proponents of transverse incisions argue that they anticipate a more secure closure than with vertical incisions—a hypothesis supported by anatomic and surgical principle.
The fascial fibers of the anterior abdominal wall are oriented transversely or obliquely. Transverse incisions, therefore, parallel this orientation and allow for ready reapproximation with sutures placed perpendicular to the fibers.
In contrast, vertical incisions disrupt fascial fibers and must be reapproximated with sutures placed between fibers. Despite these concerns, little evidence supports a substantial benefit of transverse incisions, and proponents of vertical incisions argue that larger transverse incisions obligate division of muscle fibers with greater functional consequences and leave fewer options for remediation when hernias do develop.
A number of retrospective clinical studies and a meta-analysis do suggest that transverse incisions are superior to vertical incisions with regard to long-term and short-term outcomes eg, postoperative pain, pulmonary complications, and frequencies of incisional hernia and dehiscence.
One randomized controlled trial compared vertical and transverse incisions with regard to the frequency of evisceration; no significant difference in outcome was observed with either technique.
More wound infections were seen with transverse incisions. Controversy also persists regarding the relative advantages of midline versus paramedian incisions. The theoretical advantage of a paramedian over a midline incision is a diminished risk of wound dehiscence and incisional hernia owing to the presence of rectus muscle interposed between layers of divided fascia. In practice, when these incisions are reopened, the medial edge of the rectus muscle is frequently adherent to the anterior or posterior sheath incision and does not effectively buttress the wound.
The potential advantages of the paramedian incision have also been investigated in prospective randomized trials, which have failed to demonstrate an advantage with regard to wound failure rates. In the patient who has had prior abdominal surgery, the cosmetic advantages of reentering the abdomen through a preexisting scar must be balanced against the challenges associated with dissection in a reoperative field.
Close proximity of a new incision to an old one should be avoided in order to minimize the risk of ischemic necrosis of intervening skin and fascial bridges.
Prior to incision, the surgical field is prepared with antiseptic solution and draped in order to reduce skin bacterial counts and the likelihood of subsequent wound infection.
Shaving prior to operation has been associated with an increased rate of surgical site infection and should, therefore, be avoided. If hair at the surgical site will interfere with accurate wound closure or precludes easy application of the sterile preparation, the use of clippers is preferred to a razor.
The efficacy of povidone-iodine depends on the release of the active iodine from a carrier molecule. The solution should, therefore, be applied several minutes prior to incision to maximize its efficacy. The use of chlorhexidine gluconate has been associated with greater reductions in skin bacterial counts and lower rates of surgical site infection when compared to povidone-iodine in a number of studies and is emerging as the preferred skin antiseptic.
The midline incision allows rapid access to and adequate exposure of almost every region of the abdominal cavity and retroperitoneum. It is typically associated with little blood loss and does not require transection of muscle fibers or nerves.
The upper midline incision ie, above the umbilicus may be used to expose the esophageal hiatus, abdominal esophagus and vagus nerves, stomach, duodenum, gallbladder, pancreas, and spleen Fig. The lower midline incision ie, below the umbilicus provides exposure of lower abdominal and pelvic organs.
When broad exposure is required, as in an exploration for trauma, the midline incision can be extended to the xiphoid process superiorly and to the pubic symphysis inferiorly. In creating a midline incision, the operating surgeon and assistant apply opposing traction to the skin on both sides of the abdomen.
The skin is then incised with a scalpel. Gauze pads are applied to the skin edges to tamponade bleeding cutaneous vessels, and gentle lateral traction is placed on the subcutaneous fat on both sides of the incision. The incision is then carried down to the linea alba using either electrocautery or a scalpel; the decussation of fascial fibers in the upper abdomen serves as an important landmark for the midline.
The linea alba, extraperitoneal fat, and peritoneum are then divided sequentially. If exposure of both the upper and lower peritoneal cavities is required, the incision is carried around the umbilicus in a curvilinear fashion.
The peritoneum itself is best divided with scissors or scalpel to avoid coagulation injury to underlying intra-abdominal organs. In addition, safe entry may be facilitated by picking up a fold of peritoneum, palpating it to ensure that no bowel has been drawn up, and sharply incising the raised fold. The falciform ligament is best avoided by entering the peritoneum to the left of the midline in the upper abdomen.
To avoid injuries to the bladder, the peritoneum is entered in the upper portion of the incision. After a small opening is created in the midline, it is enlarged to accommodate 2 fingers that are then used to protect the underlying viscera as the peritoneum is further divided along the length of the wound Fig. Paramedian incisions are vertical incisions placed either to the right or left of the midline on the abdominal wall.
Like midline incisions, paramedian incisions obviate division of nerves and the rectus muscle and may be made in the upper or lower abdomen. Superiorly, additional access can be obtained by directing the upper portion of the incision along the costal margin toward the xiphoid process Fig.
The anterior border of the rectus sheath is exposed and incised across the entire length of the wound. The medial aspect of the anterior rectus sheath is then dissected away from the rectus muscle to its medial edge Fig. Particular care must be taken during this dissection in the upper abdomen where tendinous inscriptions that attach the rectus muscle to the anterior fascia are associated with segmental vessels.
These vessels should be ligated when encountered. Once free, the rectus muscle is retracted laterally. The posterior sheath above the arcuate line and peritoneum are then incised to gain entry into the abdomen.
During creation of a paramedian incision in the lower abdomen, the inferior epigastric vessels may be encountered and must be ligated prior to division Fig. Upper paramedian incision: surface markings. Additional exposure can be obtained by sloping the upper portion of the incision upward toward the xiphoid process.
Paramedian incision: dissection of the rectus muscle from the anterior rectus sheath. Paramedian incision in transverse section. Lower paramedian incision. Surface markings. Incision of the rectus sheath.
Retraction of the rectus abdominis muscle. Location of the branches of the inferior epigastric vessels that run across the lower portion of the incision. Peritoneum opened. The peritoneum is incised for the full length of the wound. The vertical muscle-splitting incision is made in much the same way as the traditional paramedian incision except that the rectus muscle is split, rather than retracted laterally. This wound can be opened and closed quickly and is of particular value in reopening a previous paramedian incision where dissection of the rectus muscle away from the rectus sheath can be difficult.
Longer incisions should be avoided, however, because they result in significantly more bleeding and sacrifice of nerves that may lead to muscle atrophy and weakening of the corresponding area of the abdominal wall. Importantly, the rectus muscle has a segmental innervation derived from intercostal nerves that enter the rectus sheath laterally. Transverse or slightly oblique incisions through the rectus largely spare these nerves.
Provided that the anterior and posterior fascia is closed, the rectus muscle can be divided transversely without significantly compromising the integrity of abdominal wall. Although properly placed transverse incisions can provide exposure of specific organs, they may be limiting when pathology is located in both the upper and lower abdomen. A right subcostal incision is used commonly for operations in which exposure of the gallbladder and biliary tree is necessary.
The left-sided subcostal incision is used less often, mainly for splenectomy or left upper quadrant masses. A bilateral subcostal incision provides excellent exposure of the upper abdomen and can be employed for hepatic resections, liver transplantation, total gastrectomy, and anterior access to both adrenal glands.
The standard subcostal incision begins at the midline, 2 fingerbreadths below the xiphoid process, and is extended laterally and inferiorly, parallel to the costal margin Fig.
The incision should not be placed too far superiorly because sufficient fascia must be preserved to allow a secure abdominal closure. Following incision of the rectus sheath along the plane of the skin incision, the rectus muscle is divided using electrocautery or ligatures to control branches of the superior epigastric artery.
The peritoneum is then divided in the plane of the skin incision. The incision can be extended beyond the lateral aspect of the rectus muscle if necessary to facilitate exposure. Kocher incision. Division of the rectus and medial portions of the lateral abdominal muscles. Originally described by Charles McBurney in , 12 the muscle-splitting right iliac fossa incision known as the McBurney incision is well suited for appendectomy.
This incision is oriented obliquely. The McBurney incision has largely been supplanted by the Rockey-Davis incision, which is oriented transversely as opposed to obliquely, allowing for better cosmesis Fig. Surface markings of the right iliac fossa appendectomy incisions. The classic McBurney incision is obliquely placed. The Rockey-Davis incision is transversely placed in a skin crease.
NCBI Bookshelf. Leandra A. Jelinek ; Mark W. Authors Leandra A.
Incisions, Closures, and Management of the Abdominal Wound
In surgery , a surgical incision is a cut made through the skin and soft tissue to facilitate an operation or procedure. Often, multiple incisions are possible for an operation. In general, a surgical incision is made as small and unobtrusive as possible to facilitate safe and timely operating conditions. Surgical incisions are planned based on the expected extent of exposure needed for the specific operation planned. Within each region of the body, several incisions are common.