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Fig. 18-31: Pfannenstiel incision closure.

Turner-Warwick’s Incision

Incision is placed 2 cm above the symphysis pubis and within the lateral borders of the rectus muscles. The sheath overlying the rectus muscles at the symphysis pubis is released for about 4 cm transversely, and the incision angled up to the lateral borders of the rectus muscles. e lateral edges of the incision remain medial to the

the retropubic space. Pelvis and abdomen is not exposed adequately in this incision.

OBLIQUE INCISIONS

Kocher’s Subcostal Incision (Emil Theodor

Kocher)

Right subcostal incision is used for open cholecystectomy and to approach biliary system and liver. Incision extends from anterior axillary line towards xiphisternum up to midline 2–2.5 cm below the costal margin. Skin, subcutaneous tissue, super cial fascia, anterior rectus sheath, rectus muscle, external and internal oblique muscles and transverse abdominis muscle are cut using monopolar cautery. Anterior rectus sheath once cut in front of the rectus muscle, long haemostat (artery forceps) is passed behind the rectus muscle and lifted forward to cut the muscle horizontally using cautery. Superior epigastric vessels deep to rectus muscle are ligated securely. 8th thoracic nerve which is smaller is cut. It is ideal to identify larger 9th thoracic nerve and preserve it to prevent weakening of abdominal muscles. Peritoneum is incised in the line of incision. Large bowel will be very close to this incision and so care should be taken not to injure it inadvertently while opening the peritoneum.

Incision is often modi ed by not cutting the rectus muscle but retracting it after incising the anterior rectus sheath (Figs 18-32 and 18-33).

Smaller subcostalincision<10cminlengthisusedbymanysurgeon asminilapcholecystectomywithoutincisingtherectussheath.Itcauses less postoperative pain, early recovery and good cosmesis. But Calot’s dissection isdi cult and oftenis doneblindly. Adventof laparoscopic cholecystectomy as standard approach made this a surgical legacy.

Fig. 18-32: Right and left subcostal incision.

Closure of Kocher’s incision is done by closing posterior and rectus sheaths separately and rectus muscle with vicryl sutures. Rectus has got segmental nerve supply and due to its upper tendinous intersections it will notretractand brous scar itself causes additional support to the muscle.

Advantages:It gives very good exposure to Calot’s and biliary system. It can be extended towards opposite side if needed.

Disadvantages: Injury to 9th thoracic nerve causes muscle weakness and loss of sensation below the scar. Hernia if develops in Kocher’s incision is di cult to manage (Fig. 18-34).

Left Subcostal Incision

Leftsubcostalincisionis used for splenectomy,distalpancreatectomy.

Chevron Incision (Rooftop Incision)

In this incision a cut is made on the abdomen below the rib cage. It is actually bilateral subcostal incision. e cut starts from the midaxillary line below the ribs on the right side of the abdomen and continuesallthewayacrossthe abdomentothe oppositemid-axillary line leading into cutting of entire width of the abdomen providing accesstotheliverforliverresection/transplantation,oesophagogastric junctionforoesophagectomy,surgeryforrenovascularhypertension, pancreatic surgeries, bilateral adrenalectomy. e average length of the incision is about 60-80 cm (Fig. 18-35).

Mercedes Benz Incision

It is bilateral lower Kocher’s incision (about 3-5 cm below the costal margin) withamiddleverticalupperlimbpassestowardsandthrough the xiphisternum. It gives very good exposure to liver, oesophageal hiatus (Fig. 18-36).

Fig. 18-36: Mercedez Benz incision.

Oblique Iliac Incision (Abbernethy’s/Modi ed Gibson’s)

It is used for extraperitoneal approach for ureteric stone, urinary bladder and lumbar sympathectomy. It is muscle cutting incision. It can be used as transperitoneal also (Figs 18-37 and 18-38).

Position is partial or complete lateral, depends on the side surgery is needed. Incision is placed from mid-axillary line at the level of the umbilicus directing downwards and forwards towards

Fig. 18-37: Oblique iliac incision.

pubic symphysis up to the lateral margin of the rectus muscle. Skin, subcutaneous fat, super cial fascia, external oblique muscle and aponeurosis below are incised layer by layer in the line of incision. Internal oblique and transverse abdomen muscles are also cut in the line of incision. Under transversalis fascia extraperitoneal fat and peritoneum is visualised. In extraperitoneal approach, peritoneum is swept forward from behind by blunt nger dissection. Psoas major muscle, genitofemoral nerve and inferior vena cava are identi ed. Ureterwithitstypicallookandperistalsisisalsoidenti ed.Depending on the type of surgery further procedure is undertaken. Muscle is retracted using self retaining retractor. Peritoneum if inadvertently opened, it can be sutured using 2 zero vicryl.

LOIN INCISIONS

It is mainly used to approach kidney, adrenal and retroperitoneum. Patient is placed in loin position. Full lateral position with kidney bridge raise with exion of the knee of the leg which is on the theatre tableisdone.Flatwidepillowshouldbe keptbetweenlegs. Arm facing upwards is positioned towards head end with a support. Patient is strapped rmly to prevent tilting or changing the position during surgery. Back support is often needed. Mayo’s table is placed on the leg side after draping which facilitates to keep instruments safely. After cleaning and draping, incision begins posteriorly behind the posterior axillary line in posterior subcostal line extending forward towards the outer margin of the rectus muscle. Rectus is usually not cut.Skin,subcutaneoustissueandsuper cialfasciaarecut.Posteriorly latissimusdorsi, serratus posteriorinferior and quadratuslumborum are cut; anteriorly external and internal oblique muscles are cut. Usually 12th or 11th is cut. Rib is identi ed. Incision is made over its periosteum. Periosteum is re ected using periosteal elevator. Care should be taken to avoid injury to vessels underneath which often need proper ligation. Rib after mobilization, is cut using bone cutter. Cutend isoftensmoothenedusing bone le.Pleuraisverycloseto the rib which should not be opened. If opened pneumothorax develops; which is usually managed by placing vicryl sutures to pleura while anaesthetist is ventilating the lung with adequate expansion. Usually intercostal tube is not necessary. Postoperative check chest X-ray needed for the evidence of pneumothorax. Transverse abdominis muscle is usually split from posterior to anterior. Peritoneum is adherent to the abdominal wall in front. So care should be taken not

Fig. 18-38: Oblique iliac incision and closed wound also.

to tear on the anterior aspect. Peritoneum is swept forward to reach the Gerota’s fascia (Fig. 18-39).

Closure of the Loin Wound Approach

It is done in two layers. Transversus abdominis and internal oblique muscles are closed using continuous vicryl suture as inner layer. Externalobliqueis closedusingnonabsorbableordelayed absorbable

Fig.18-39:Lateralkidneypositiontoapproachkidneyforvarioussurgeries like nephrectomy, pyeloplasty.

continuous suture as outer layer. Covering fascia should be included in the bite which is stronger than muscle itself. Drain when needed should be kept below the lower margin of the wound and on the anterior aspect in front of the level of the anterior superior iliac spine; through a separate stab incision.

Incision can be extended into the thorax or into the peritoneal cavity as needed.

High 11th rib excision approach is called as Nagamatsu approach which is used in approaching upper pole renal cell carcinoma (RCC).

Lumbotomy Incision (Gil-Vernet)

It is vertical posterior incision from 12 rib level to iliac crest. Incision is along the lateral border of the sacrospinalis. It is deepened through latissimus dorsi, serratus posterior inferior, lumbosacral fascia, quadratus lumborum. It is done in prone position. Both sides’ two separate incisions can be placed in bilateral approach. It is used bilateral partial nephrectomies and bilateral adrenalectomies.

PRINCIPLES IN CLOSURE OF THE

ABDOMINAL INCISION WOUND

Layer by layer closure is good old standard. But it is now proved that peritoneum closure is not necessary.

In Layer by Layer Closures

(interrupted sutures may be better if there is sepsis); subcutaneous tissue is closed using 3 zero rapid vicryl (ideal) or plain catgut; skin closedusinginterrupted mattress sutures. Skin stapler can be used as it is quicker and easy to remove; but it is not haemostatic, skin edge bleeding may occur.

Single Layer

Mass closure is also used. It is also equally good; rapid. Usually continuous suture isplaced; but interrupted suturesalso can beused. Skin is apposed separately.

Retentionsutures,used earlierafteranemergencysurgery,ismore often replaced by modi ed Smead Jones sutures. Retention suture is still practiced in many centers of world.

Modi ed Smead–Jones Sutures

It is interruptedspecialised sutures usedin theclosure of abdomen as single layer excluding the skin. Linea alba is held with Allis’ forceps. Number one polyethylene or PDS suture material is used. First bite on one side taken 3 cm away (width) from the margin from outside to inside; it is then passed through the corresponding opposite edge with 3 cm width from inside to outside; later again one small loop of 5 mm width from the edges of each side of the wound from rst bite site to second bite site is taken; suture is knotted on the free edge of the rst bite side. Full thickness bite holds the suture and maintains the tension inthewound.Smallerloopkeepsthelineaalba inapposed place. Large curved Ferguson needle is better to place these sutures. Each suture isplaced at2 cm interval. is is the type of suturing used at present in acute abdominal conditions instead of the retention sutures. Here also it is better to place all sutures under proper vision and knotting is done at the end. At least four knots should be placed. Excessivetension should be avoided. In upper abdomen peritoneum need not be included in the bite; but in lower abdomen as linea alba is indistinct, peritoneum is included in this (Fig. 18-40).

L. E. Hughes Double Near and Far Suture

It is similar with same indications as Smead-Jones, with double near and far sutures placed to have a strong loop with knot on one side

(Fig. 18-41).

While taking bite from the peritoneum, care should be taken not to take bites from bowel; if inadvertently taken leads into dangerous

Peritoneum is closed using vicryl or polypropylene; rectus sheath is closedwithcontinuouslockingmono lamentnonabsorbablesutures;

Fig. 18-40: Modifi ed Smead-Jones sutures. These sutures are better than placing retention sutures.

Fig. 18-41: L E Hughes double near and far suture.

ideal to place index nger under the sutured peritoneum to con rm that suture line is perfect and without any bowel entangling.

Drain if needed to place, it should be placed away from the min incision; usually along the anterior axillary line; side and site (upper or lower) is decided depending on the type and area of surgery. Often double drains are placed on the same or both sides.

Retention Sutures

In this suturing the all abdominal layers are held together without tension; the sutures take the tension o the wound edges.

Uses

Itisusedforpatientswhoaredebilitated(malnutrition,oldage,immune de ciency or advanced cancer); patients su ering from conditions associated with raised intra-abdominal pressure like obesity, asthma or chronic cough; those with impaired healing; burst abdomen.

Material used

Monofilament nonabsorbable suture material no. 1 (nylon/ polyethylene/polypropylene) is used (Fig. 18-42).

Technique

Retention sutures are inserted through the entire thickness of the abdominal wall leaving them untied in the beginning. All sutures are

passed rst. Sutures are through and through all layers from skin, rectussheath,rectusmuscleandperitoneumononesideandback on theoppositeedgewithasu cientgapof1.5-2cmfromtheedgesofthe wound.Suturesmaybesimpleormattress.Laterperitoneumisclosed with continuous vicryl sutures and then continuous or interrupted anterior rectus sheath, subcutaneous tissue and skin (interrupted).

After completion of skin suture, each untied retention suture is threadedwith(sleeve)1-2cmlengthofplasticorrubbertubes/sleeves. Plasticsleevescanbeplacedearlier itself; oftenit is practicedto place twotubes/sleevesoneithersidesofthewoundtocompletethevertical mattress sutures. Now sutures are apposed and tied but without any tension. Undue tension may compromise the blood supply of the tissues at wound edges. Horizontal mattress retention sutures are also used by many.

Retention sutures are left in place for 14 days.

Many surgeons advocate closure only by placing retention sutures with skin sutures without placing the apposition sutures on peritoneum and rectus sheath (Fig. 18-43).

Controversy

Presently use of retention sutures is controversial. Hughes far and near sutures or Smead-Jones sutures are said to be better. However retention sutures are used wide worldwide even now (Fig. 18-44).

Note

Continuoussuturesarestartedfromfarpointofthewoundtowardssurgeon. Forehand suturing is better during closure which makes shoulder, arm and wrist less straining allowing surgeon to do more precise firm strong suturesatspecifiedsites.Hereforearmmovesfrompronatedtosupinated position.

In backhand suturing, supinated hand rotates to pronated position; here needleshouldbedirectedtowardssurgeon’srightfoot(righthandsurgeon). Scalpelincision and dissectionneeds backhand movement.

Proper foot positioning is important in various levels of suturing to make suturing easier and perfect.

During scissor dissection, scissor tip should be directed towards surgeon’s left foot.

Bychangingthebodyandfootpositioninperpendiculardirection(parallelto table) forehandmovementcan be used inall forehand suturing.

Left foot of the surgeon should be more close to the operating table; right foot should be more lateral.

All instruments should be held in fingertip position.

Instrumentsshouldbeheldwithfingergripratherthantightvisegrip.Relaxed wrist movements are essential to avoid wristtremors.

When suturing comes towards the end of the abdominal wound; last few sutures should not be tied if they are interrupted or last few bites and their loopsiskeptlooseuntil lastbiteistakentoavoidinjurytodeeperstructures (bowel).

Suturebiteandstitchshouldnotbetakenblindlywithoutseeingthetip(point) ofthe needle atall the time.

Optimum tension only used; excessive tension should be avoided.

ABDOMINAL RETRACTORS

Retractors are essential for all abdominal surgeries. Simple Langenbeck to complex self retaining chain retractors are used in various procedures. Retraction facilitates the surgery in the deeper plane.

Self-retaining or Manual Retractors

Manualretractorisheldbyassistantconstantly.Itfatiguestheassistant in lengthy procedures and retraction varies depends on the assistant whoholdstheretractor.Butretractorcan betemporarilyrelaxedwhen not needed so that tissues underneath (muscle) can be allowed to relax in between to reduce crushing e ects on the muscle mass. Its position is adjustable in time to time.

Self-retainingretractorsare either xedthrough itsownbeamsor bars or through a specialised devices strong chain or handle to the side

assistant’s hands to be free for other works like suctioning, passing ligatures, cauterising, etc. But self-retaining retractors may cause more damage to the muscle as retraction is persistent and constant for long period. Upper hand retractoris often used with a steelbridge which is attached to both sides of the operating table crossing across the sternum at 5 – 10cm height. Retractor blades are placedand xed on to this steel bridge to facilitate the retraction at the operating site

(Figs 18-45 to 18-47).

Precautions

While using the retractor care should be taken to avoid entangling of the vital structures bowel, soft tissues, organs, etc.

Fig. 18-45: Balfour’s self-retaining retractor.

Undue retraction may injure the woundedgesleading into wound infection, dehiscence, etc.

Deeperends oftheretractors maynotbevisibleand oftenassistant won’t be having proper control on it allowing ends of theretractorsto injure organs like liver or spleen.

It is often better to place a mop underneath the deep retractor to avoid injury to organs underneath.

DRAINS IN LAPAROTOMY

Even though advantages are under debate and controversial, drain is used to prevent the collection in dead space; to allow the escape of uidor air from the cavities;to prevent infection; to promote healing.

When there is an abscess or pus inside peritoneal cavity, drain is a must. Here it is therapeutic. Drains commonly advocated are tube drainswhichareconnectedoutsidetoasterilebagorcontainer.Drains placed in other situations are rather prophylactic.

Drain is placed to allow escape of bile, pancreatic and intestinal juices, lymph, serum, blood and pus from peritoneal cavity. Drain

Fig. 18-46: Finochietto retractor.

creates a track and walls o the leaking/infected site from peritoneal cavity and so prevents the spread of infection. is is said to promote the healing of the area, preventing the sepsis by uid collection. It is no doubt that it is useful in sepsis, peritonitis, and in abscess. Prophylactic peritoneal drainage is controversial even though it is done in anticipation of possible disruption of the anastomotic site and so that to reduce its dangerous consequences. Drain creates a controlled stula so that peritoneal cavity is safeguarded from sepsis or contamination. But concept of drain preventing wound infection and promoting faster wound healingisquestioned/disproved? Drain as a foreign body action, can be a focus for infection from outside. Drain may erode vessels, bowel or organs.

Drainsmaybepassiveoractive.PassivedrainlikePenroseorcorrugate function depending on the pressure di erence between inside and outside abdominal cavity and high pressure inside forces the fluid outside. Active drains use low or high negative pressure (suction) to remove accumulated uid from a wound. Active drains require some special device and maintenance. e collection reservoir of an active drain expands as uid is collected by exchanging negative pressure for uid; if the vacuum is lost, the drain will lose its e ectiveness. e uid collection reservoir is either a manually activated, or through bulb evacuatororaspring-loadeddevicethathasvariablepresetsuctionlevels.

Fig. 18-48: Corrugated drain is a passive drain which drains by gravity and capillary action. It is rather an overfl ow.