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Fig. 17-27: Relations of the submandibular salivary gland.

Fig. 17-28: Submandibular and sublingual salivary glands and their muscular relations.

commissure of the eye to end as angular artery. Its tortuosity in neck and face allows movements of pharynx, mandible, cheek and lips. In the neck it lies on middle and superior constrictors of pharynx. In the face it is deep to platysma, risorius, and zygomaticus major but super cial to buccinator and levator labii superioris. Anterior facial vein is posterolateral to the facial artery in the face; but anterior to facial artery in neck. It communicates with dorsal nasal artery of internal carotid artery.

Branches of facial artery are – in the neck: ascending palatine artery, tonsillarartery,submentalartery,glandularbranches;in theface:inferior and superiorlabialarteries,lateralnasalbranch(tonasalis)andterminal angular artery. Most of the facial muscles are supplied by facial artery.

One has to remember that transverse facial artery is a branch of super cial temporal artery (not from facial artery) while in the parotid gland. It runs horizontally in the parotid gland substance, between parotid duct and lower border of zygomatic arch resting on the masseter to supply parotid gland and duct and anastomose with facial, masseteric, buccinator and infraorbital arteries.

Excision of the Submandibular Salivary Gland

It is done under general anaesthesia. Neck should be extended with chin towards opposite side. Incision is made 2-4 cm below and parallel to margin of the mandible of 6-8 cm in length (Fig. 17-29).

Fig. 17-29: Incision for submandibular salivary gland excision.

Marginal mandibular nerve is in subplatysmal plane in neck; incision should be deepened across deep fascia without raising subplatysmal plane to avoid injury to this nerve. Anterior facial vein

(facial vein anterior tributary of common facial vein) crossing the super cial part of the gland is ligated using silk or vicryl. Super cial lobe of the gland is exposed fully in digastric triangle between two bellies of digastric and stylohyoid muscles below and margin of the mandible above with gland overlapping over mylohyoid muscle medially. Deep fascia of neck covering the gland is visible. Common facial veinwith its anterior (facial vein) and posterior (anterior division of retromandibular vein) tributaries are visible deep to deep fascia in close relation to sternocleidomastoid muscle. Few lymph nodes may be present outer to deep fascia also. Dissection begins at the lower end of the gland by incising the fascia just above the digastric muscle. Super cial lobe of the gland is mobilised upwards. Facial artery lies in the groove on the deeper aspect of the gland, often either embedding in the gland or runs around the gland with a variable course and so artery has to be ligated twice above anteriorly and below posteriorly. Posterior part of the artery is ligated rst using silk or vicryl ligatures. While re ecting the gland upwards from posterior surface hyoglossus

with hypoglossal nerve is seen and nerve is safeguarded. Hypoglossal nerve at lower part very close to the digastric tendon which is accompanied with lingual vein (lingual vein should be ligated) and lingual nerve at upper part is identi ed and safeguarded. Mylohyoid muscle is retracted soas to remove the deep portion of the gland which is in front of the hyoglossus and mylohyoid. Submandibular ganglion is often seen just above the gland which can be sacri ced. Wharton’s duct identi cation and ligation is done. Dissection is done using ne scissor and monopolar cautery. Closer to nerves it is better to use bipolar cautery instead of monopolar especially whenever there is lot of adhesions due to chronic in ammation. Chronic in ammation with

brosis makes dissection di cult risking the injury of hypoglossal and lingual nerves. Structures in view after elevation of the submandibular salivary gland are – lingual nerve, chorda tympani, submandibular ganglion and Wharton’s duct above; hypoglossal nerve, digastric and stylohyoid muscles below (Fig. 17-30).

Complications of Submandibular Salivary

Gland Excision

Complications of submandibular salivary gland excision include—

Haemorrhage; infection; injury to marginal mandibular nerve (drooping of saliva with deviation of the angle of the mouth), lingual

Fig. 17-30: Submandibular salivary gland stone on X-ray and gross specimen after excision. Here excision of the gland through external approach is the treatment.

nerve and hypoglossal nerve (deviation of tongue towards same side); injuryto mylohyoid nervecausing anaesthesia overthe submental skin.

Radical Excision of Submandibular Salivary

Gland

Radical excision is done in malignant tumours of the submandibular salivary gland. Here gland with soft tissuesaound is removed. However nerves are sacri ced only if they are in ltrated. It is di cult to retain marginal mandibular nerve in these patients as oncological clearance is priority. Radical neck lymph node dissection is also usually added along with that. Incision is same but much lengthier; it is often extended below posteriorly on the anterior margin of the trapezius or in the centre of the incision if neck dissection is additional added procedure.

Extraction of Stone from the Submandibular Salivary Duct (Wharton’s)

Stone in the Wharton’s duct is removed per orally under local anaesthesia. Intraoral X-ray or orthopantomogram is done prior to that. Stay suture using 4 zero vicryl is placed on the duct proximal to the stone. A ne dilator or probe is inserted into the duct opening. Longitudinal incision is placed on the duct over the stone. Stone is extracted using ne haemostat. Saline wash is used to clean the duct and clear any debris. Duct is not sutured instead left open into the oral cavity. Patient is sent with antibiotic coverage (Figs 17-31 and 17-32).

MINOR SALIVARY GLANDS

ere are around 450 minor salivary glands which are distributed in lips, cheeks, palate and oor of the mouth. Glands also may be present in oropharynx, larynx, trachea and paranasal sinuses. ey contribute to 10% of total salivary volume. Sublingual salivary glands are minor salivary glands (almond shaped, weighs 4 gram) one on each side; located in the anterior aspect of the oor of the mouth in relation to mucosa, mylohyoid muscle, body of the mandible near mental symphysis, lateral to genioglossus muscle. Gland drains directly into mucosa through around small ducts or through a duct which drains into submandibular duct. is duct is called as Bartholin duct. Mikulicz‘s disease is common in sublingual salivary gland. Minor salivary glands are not present in gingivae and anterior portion of the hard palate.

Incision biopsy of minor salivary gland tumour is done under general anaesthesia if it is posterior. Wide excision of minor salivary gland tumour is done under general anaesthesia with nasal intubation. Wide mouth gag is placed to oral cavity for retraction of jaws. Lesion is excised with 1 cm clearance up to the mucoperiosteum when lesion is in the palate. Raw area is allowed to granulate and heal. If palate is involved by disease, palate is excised. Later proper reconstruction is done with the help of reconstructive surgeon (Fig. 17-33).

ECTOPIC SALIVARY GLAND

Ectopic salivary gland also called as aberrant salivary gland/migrant salivary gland is nothing but ectopic lobe of the juxtaposed salivary gland. It is commonly seen in relation to submandibular salivary gland. Commonest ectopic salivary tissue is Stafne bone cyst. It is

invagination of the juxtaposed submandibular salivary gland into the mandible bone on its lingual aspect. X-ray shows radiolucent area due to the cyst below the angle of the mandible, lower to inferior dental

vessels and nerve. Jaws, eyelids, middle ear, paranasal sinus, nose, rarely skin of face and neck are other sites wherein ectopic salivary tissue can be demonstrated.

GENERAL PRINCIPLES IN LAPAROTOMY

Laparotomy is opening the abdomen for surgical intervention. Laparotomy can be –

1. Elective laparotomy

Elective laparotomy wherein proper preoperative diagnosis has been established with various imaging and biochemical analysis. Even though it is done with proper preoperative diagnosis, being a magic box, in spite of all newer diagnostic aids, nding and diagnosis on opening may be entirely di erent from what was thought during evaluation.Atthatstagesurgeonshouldbereadytoalterthe treatment strategy depending on the need.

2. Emergency laparotomy

It is done in trauma and acute abdomen like peritonitis. Even here basic investigations like USG/CT abdomen and haematological assessment are done to proceed with laparotomy at the earliest. Midline vertical incision centered on the umbilicus with curve at umbilicus towards left side is done. is incision is called as incision of indecision/registrar’s incision. It can be extended above or below easily depending on the need. It also can be extended horizontally if needed (Figs 18-1 and 18-2).

Fig. 18-1: Incision of indecision/registrar’s incision.

Proper Bowel Preparation

Properbowelpreparationisessentialdependingonthetypeofsurgery and condition to which surgery is done. In gastrectomy, pancreatic and biliary surgeries stomach wash, correction of electrolytes is needed; in colorectalsurgeries bowel preparation using polyethylene glycol or sodium phosphate is needed. For simple perineal surgeries enema is su cient. Hydration, bowel antiseptics, keeping ready necessary amount of blood for surgery, antibiotics perioperatively is needed.

Proper Planning

Properplanningshouldbe donein alllaparotomycases.Patientshould take proper scrubbathonthemorningofthesurgery.Skinpreparation even though is done on previous night or early morning of the day of surgery, evidence suggests that it should be done on table.

Anaesthesia:Generalanaesthesiaisrequired.Epiduralsupplement may be used. Spinal or epidural anaesthesia is su cient for lower abdominal surgeries.

Position of the Patient

Position of the patient in laparotomy is very important. It may be – supine;supine with onesidetilt; lateralposition(for kidney/adrenal); lithotomy position(for APR/LAR/AR/perinealsurgeries/cystoscopic procedures, etc); position for thoracoabdominal approach (in Ivor Lewis operation/diaphragmatic surgery/liver surgeries, etc). Head down position is needed in colorectal surgeries to keep small bowel away from surgical dissection eld. For upper abdominal surgeries like cholecystectomy head up position is needed often with right up tilt. Strapping of the pelvis and chest wall to the table is needed in patients who need steep head down position.

Other Needs and Principles

Nasogastric tube,urinarycatheterisation,centralvenouslineandoften arterial line (radial) is needed in major procedures. Often two or three venous lines are needed in major surgery and trauma patients. Stockings to both legs from foot to proximal thigh are essential to reduce the incidence of DVT.

Right selection of the procedure; right way executing it with right principles at right time is important. Selection; execution; timing; implementing; skill are the essential features of successive surgery with best outcome.

Selection of incision; adequacy of incision; good retraction; exposureofthesurgical eld;properdissection;notouchorminimum touchtechnique;haemostasis;ontabledecisioninrelationtosurgical principles – are the basic need.

Anticipation of problems; perfection in surgical anatomy; tissue touch are important. Live anatomy di ers from cadaveric or clinical anatomy (Live anatomy bleeds and gets injured; cadaveric anatomy does not bleed).

In present era speedy surgery is not important; perfect proper surgery is more crucial. But then undue slowness should not be there, as it causes unnecessary increase in the anaesthesia and eld exposure time. Accuracy is more important than speed in surgery.

Proper light; proper position; adequate height of the table; good assistants; avoiding repetitive movements; clean bloodless surgical eld; knowing the next step – are needed.

Holding the instrument - Fingertip pressure (finger grip) is better to hold instruments thanvise grip

Incision is made using scalpel belly while keeping two fingers of the other hand apart

Depthofthe incision is assessed by feel and by vision.

During dissection traction by surgeon’s other hand and counter traction by assistant’s hand helps rapid separation/creation of the tissue planes. Dissection can be done using scalpel, scissor, and cautery. It is done using cutting cautery. But cutting cautery may not be haemostatic. Haemostasis is achieved using coagulation cautery. Dissection using coagulation cautery willbehaemostatic butcausesboilingoffatmoretissuetraumaleadinginto woundinfection.Overcoagulationoftissuesduringcauterydissectionideally should be avoided.

Tissuesareheldusingforcepsbygentlemaneuver.Skinandtoughstructures are held using toothed forceps; soft, smooth, delicate structures should be held using non-toothedforceps.

Needle holder should be held between thumb and ring fingers to achieve rotation movement using wrist (not pushing movement). Index and middle fingers are used to steady the handle. Needle is laced at the junction of proximal 2/3rd and distal 1/3rd ofthe distal jaws (Figs 18-3and18-4).

Fig. 18-3: Finger grip holding is better to hold the instrument than vise grip.

Cleaning and Draping

Cleaning is done using povidone iodine. Solution is collected in a sterile small bowl, sterile folded/rolled gauze or sponge with Rampley’s sponge holding forceps is used to clean the abdomen. In perineal surgery cleaning with proper scrubbing should be done after lithotomy position by OT technician prior to formal cleaning by surgeon. Draping is done using sterile green towel. Often sterile plastic sheet (ioban sheet/plastic surgical adhesive drape/plastic incisive drape) is used on the abdomen over the green cloth drape and incision is made through it. Many studies show that plastic adhesive drape reduces the bacterial contamination of the wound and deeper part compared to cloth drape. ere is controversy about pricking the towel clip into the skin of that particular corner point or placing interrupted skin sutures over the drape margins to x it. It may break the barrier into the deeper plane away from the surgical site incision and it is not much con rmed that such xation will reduce/prevent the bacterial contamination across (Fig. 18-5).

Fig. 18-4: Vise grip to hold the instrument. It is used when extra power is needed while using the instrument.

Fig. 18-5: Draping the surgical site using sterile towels.

Incision

Type of incision; possible need for extension of incision, direction of extension – all to be thought of prior to starting the incision.

Principles in abdominal surgery

•Adequate incision - Incision shouldbe long enoughfor agood exposure

•Splitting the muscle is better than cutting, except rectus muscle

•Avoid cutting nerves and vessels in the abdominal wall

•Adequate retraction -Retract muscle, abdominal organs towards the neurovascular supply

•Adequate exposure of surgical site andsurrounding field

•Adequate meticulous dissection

•Adequate haemostasis

•Adequate proper closure; if requiredwith a drain (tube). Insert a drainage tube through a separate incision.

•Transverse incisions are betterthan vertical incisions.

Requirements

•Accessibility

•Extensibility

•Security.

Surgical Anatomy of Abdominal Wall

Anterior Abdominal Wall

e anterior abdominal wall is a musculofascial dynamic structure which maintains intra-abdominal pressure for various physiological functions. It has got three paired at muscles, two recti abdominis muscles and linea alba in midline. These are anteriorly related to skin, subcutaneous tissue and superficial fascia; posteriorly related to transversalis fascia and peritoneum. External oblique fascia (external layer of the fascia of external oblique muscle is also

Fig. 18-6: Layers of the abdominal wall – as seen in paramedian incision.

called as innominate fascia of Gallaudet) is thin fascial covering of external oblique muscle and fascia which forms intercrural bres of the super cial inguinal ring; and it extends below into the scrotum as external spermatic fascia. Anterior abdominal wall has got anterolateralpartwhichconsistsofexternalandinternalobliqueand transversusabdominismuscles;andamidlinepartcontainingrectus abdominis and pyramidalis muscles (Fig. 18-6).

External Oblique Muscle

It arises from middle of body of lower eight ribs running below/ downwards, front/forwards and medially inserting into xiphoid process, linea alba, pubic symphysis, pubic crest, pectineal line of pubis and anterior 2/3rd of outer lip of the iliac crest. It is supplied by lower 6 thoracic nerves. Lower free border of the external oblique aponeurosis forms inguinal ligament. Triangular opening in its aponeurosis above the pubic crest is called as super cial inguinal ring (Fig. 18-7).

Fig. 18-7: External oblique muscle.

Internal Oblique Muscle

It arises from lateral 2/3rd of inguinal ligament, anterior 2/3rd of intermediate part of iliac crest, thoracolumbar fascia; runs upwards, forwardsandmediallytoinsertintolower4ribsandcartilages,xiphoid process, pubic crest, pectineal line of pubis. It is supplied by lower 6 thoracic nerves, 1st lumbar nerve. Aponeurosis below the level of umbilicusremains as asinglelayer formingthe anterior rectussheath and lineal alba. Above aponeurosis splits into anterior lamina which passes medially in front of rectus abdominis and posterior lamina which passes behind rectus abdominis which ends below midway between umbilicus and pubic symphysis as linea semicircularis of Douglas(arcuateline).SemilunarlineofSpieghellies inlateral border oftherectussheathfrompubictubercletothetipofthe costalcartilage of 9th rib (Fig. 18-8).

Transverse Abdominis Muscle

It originates from lateral 1/3rd of inguinal ligament, anterior 2/3rd of inner lip of iliac crest, thoracolumbar fascia, lower 6 cartilages with bres running horizontally forwards inserting into an aponeurosis extending from xiphoid process, linea alba, pubic crest, pectineal line of pubis. Lowest bres fuse with lowest bres of internal oblique to form conjoined/conjoint tendon. It is supplied by lower 6 thoracic and rstlumbarnerves.Neurovascularplaneofabdomenliesbetween internal oblique and transverse abdominis muscles (Fig. 18-9).

Rectus Abdominis Muscle

It arises from lateral part of pubic crest (lateral head) and anterior pubic ligament (medial head) runs vertically upwards to insert into xiphoid process and 7th, 6th and 5th costal cartilages. It is supplied by lower 6 thoracic nerves. ere are three tendinous intersections one at xiphoid, one at umbilicus level and another one between two which are adherent to anterior half of muscle and anterior wall of rectussheath. eyareduetoembryologicsegmentaloriginofmuscle which adds to the power of muscle. Tendinous intersections do not extend into the posterior rectus sheath (Fig. 18-10).

Rectus sheath is an aponeurotic sheath which covers the rectus abdominis muscle infront and behind.Rectus sheathcontainsrectus abdominismuscleandpyramidalisinitslowerpart.Pyramidalisliesin front of the lower part of the rectus muscle. Superior epigastric artery enters the sheath by passing between the costal and xiphoid origins of the diaphragm crossing upper margin of transversus abdominis muscle behind the 7th costal cartilage running behind the rectus muscle in front of the posterior rectus sheath to anastomose with the inferior epigastric artery. Inferior epigastric artery enters the sheathbehind themusclebypassingacrossthearcuateline. Superior and inferior epigastric veins also accompany the arteries. Terminal branches of the lower 5 intercostal nerves and subcostal nerve enter the sheath after piercing the posterior rectus sheath at its lateral part running in front of the epigastric vessels to pierce the rectus muscle.

Anterior rectus sheath is complete covering rectus entirely from origin to insertion. Its upper ¾ is formed by external oblique

Fig. 18-10: Rectus abdominis muscle.

aponeurosis and anterior lamina of internal oblique. Its lower ¼ is formedbyallthreeaponeurosis.Inthispartaponeurosis oftransversus and internal oblique muscles are fused; aponeurosis of external oblique remains separate.

Posterior rectus sheath is de cient above the costal margin and below the arcuate line. Between the costal margin and arcuate line it is formed by posterior lamina of internal oblique aponeurosis and transversus abdominis aponeurosis. Midway between the umbilicus and pubic symphysis posterior rectus sheath ends as arcuate line/ linea semicircularis /fold of Douglas which is concave downwards.

Inupper¾oftheabdominalwall–rightandleft rectiareseparated; both anterior and posterior rectus sheaths are present; anterior rectus sheath is formed by external obliqueaponeurosis and anterior lamina of internal oblique; posterior rectus sheath is formed by posterior lamina of internal oblique aponeurosis and transversus abdominisaponeurosis;lineaalba iswelldeveloped;external oblique aponeurosis and fascia is weak.

In the lower ¼ of the anterior abdominal wall - right and left recti are very close to each other; anterior rectus sheath only is present which is formed by all 3 muscular aponeurosis; posterior rectus sheath is absent; external oblique fascia is stronger; lineal alba is not well developed.

Muscles of the Posterior Abdominal Wall

ey are psoas major, psoas minor, quadrates lumborum and iliacus. Psoasmajorarisesfrombodyand transverseprocessesofalllumbar vertebrae toinsert into the tip and medialpart of the lesser trochanter of thefemurafterpassingbehindthe inguinal ligament along withthe iliacus tendon (lateral part of the lesser trochanter). It is supplied by

L2, L3, L4 spinal nerves.

Psoas minor is small muscle in front of the psoas major arises from bodies of T12 and L1 vertebrae to insert into the pectin pubis and iliopubic eminence.It is suppliedbyL1.Iliacusarisesfromupper2/3rd of inner aspect of fossa of ilium, upper lateral part of the sacrum to insert intolateralpart of the lessertrochanteralong with psoas major. It is supplied by femoral nerve.

Quadratus lumborumarises from transverse process of L5 vertebra and inner lip of iliac crest to insert into medial part of the anterior surface of 12th rib and transverse processes of upper 4 lumbar vertebrae. It is supplied by spinal nerves T12 to L4.

Fascia Transversalis (Cooper’s Fascia)

It is the fasciathat lines the innersurface of the transversus abdominis muscle separatedfromthe peritoneum byextraperitoneal connective tissue. In front it isadherent tolinea alba above the umbilicus; behind merges with anterior layer of thoracolumbar fascia and renal fascia; above with diaphragmatic fascia; below it is attached to inner lip of iliac crest, inguinal ligament; medially it is attached topubictubercle, pubic crest and pectineal line which prolongs down as anterior layer of femoral sheath. It also forms internal spermatic fascia around the cord. Deep inguinal ring is U/lambda/oval shaped opening 1.25 cm above the midinguinal point (between pubic symphysis and anterior superior iliac spine) which is lateral to inferior epigastric artery, transmits spermatic cord in males and round ligament in females. In the inguinalareatransversalisfascia isbilaminarenclosingtheinferior epigastric vessels. Space of Bogros is extension of the retropubic space of Retzius which is located beneath the posterior lamina of transversalis fascia andinfront ofthe peritoneum. Inlaypreperitoneal mesh repair is done by placing mesh in this space. ickening of the transversalis fascia at medial side of the internal ring and in front of the inferior epigastric vessels is called as interfoveolar Hesselbach’s ligament.

Endoabdominal Fascia

Endoabdominal fascia is connective tissue that lines inner aspect of the entire abdominal musculature. Part in relation to transversus abdominisiscalledas fascia transversalis.Itforms iliac,diaphragmatic and renal fascia.

Deep Nerves of the Abdominal Wall

Lower 5 intercostal and subcostal (Lower 6 thoracic primary rami) nervesand iliohypogastric and ilioinguinalnerves supply theanterior abdominal wall. Lower 5 intercostal nerves pass through the slips of origin of transversus abdominis muscles; run between transversus abdominis and internal oblique; pierce the posterior lamina of internaloblique aponeurosistoreachrectussheath; thenpass behind the rectus sheath in front of the epigastric vessels, pierce the rectus muscle to continue as anterior cutaneous nerve. Before piercing it supplies the anterior rectus sheath, transversus abdominis, internal oblique, external oblique and rectus abdominis. During its course it also gives lateral cutaneous nerve of the abdominal wall through at abdominal muscles. Battle’s incision which is pararectal incision will injure these nerves causing weakening of the rectus muscle and so is avoided.

Subcostalnerve,anteriorprimaryramusof12ththoracicnerve after traveling behind the diaphragmatic lateral arcuate ligament, passes in front of the quadrates lumborum and then pierces the transversus abdominis to runlikeother intercostalnerves. It supplies pyramidalis muscle and gluteal region as lateral cutaneous branch.

Note: ere are 11 intercostal nerves and one subcostal nerve.

Blood Supply of Abdominal Wall

It is divided into super cial and deep vessels.

Super cial vessels are super cial epigastric, super cial circum ex iliac and super cial external pudendal arteries – are branches of femoral artery. ey travel towards umbilicus in subcutaneous plane. Super cial epigastric artery communicates with opposite super cial epigastric artery and all three communicate with deep arteries.

Deep arteries are posterior intercostal arteries (10, 11), anterior branches of 4 lumbar and subcostal arteries and deep circum ex iliac artery. Deep arteries travel between transversus abdominis and internal oblique muscles. Rectus sheath is supplied by superior and inferior epigastric arteries. Superior epigastric artery is one of the two terminal branches of the internal thoracic/mammary artery. It originates at 6th intercostal space enters the abdomen between costal and xiphoid origin of the diaphragm, enters the rectus sheath from above behind the 7thcostal cartilage. It descends downwards communicating with inferior epigastric artery behind the rectus muscle. Branches are muscular, cutaneous, hepatic along the falciform ligament and anastomotic to opposite side artery.

Inferior epigastric artery (IEA) originates from external iliac artery just above the inguinal ligament runs upwards and medially in the extraperitoneal connective tissue between peritoneum and posterior lamina of transversalis fascia initially medial to internal ring; pierces the transversalis fascia at the lateral border of the rectus muscle; runs in front of the arcuate line supplying the rectus and ends by anastomosing with superior epigastric artery. Branches are – muscular, cremasteric, pubic,and cutaneous. Cremasteric branchafter travelling laterally towards deep ring supplies cremaster and runs along the spermatic cord. Pubic branch runs medially along the pubic bone to communicate with pubic branch of anterior division of obturator artery. Often obturator artery may be replaced by this pubic branch of inferior epigastric artery as abnormal/aberrant obturator artery.

is pubic branch crosses over femoral ring and Cooper’s ligament. is may be injured during xation of mesh in TEP repair or femoral herniarepaircausingtorrentialbleeding frombothcutends.Asmedial cut end retracts deep into the obturator fat and fascia it is di cult to control bleeding. is area is often called as circle of death. Inferior

epigastric vein is medial to IEA.

ABDOMINAL INCISIONS

Principles in Abdominal Incision

•Incision should give adequate proper access to the surgical site in the abdomen – well planned; with adequate exposure of adequate length. Patient should lie symmetrical the operation theatre table.

•It should be amenable for extension as needed. Muscle should be split as much as possible, not cut in vertical and oblique incisions.

•Incision should be chosen with plan so as to have proper accessibility, extensibility, safeguard of function, cosmetically acceptable and with possible least complications like dehiscence and incisional hernia.

•Care should be taken while opening the peritoneum. Abdominal contents should not be injured especially bowel. is is more

important aspect in previous laparotomy patients. Peritoneum should be incised using ne scissor or scalpel after feeling the site of incision using ngers for any adherent bowel or omentum. One should not use cautery to incise peritoneum.

•If there is previous incision scar (re-laparotomy), care should be taken not to injure bowelwhile opening the peritoneum; it is better to open the peritoneum at a new site.

•Layer by layer incision should be done.

•Extension across umbilicus is done from left side of the umbilicus.

•Further cutting of the peritoneum after incising should be done under vision with two fingers underneath the peritoneum to prevent injury to bowel.

•Wound dehiscence is less in transverse incision than vertical incision.

•Drain should be kept through a separate incision; not through the

main wound. If drain is passed through the main wound it will prejudice the strength of the nal scar.

•Proper anaesthetic relaxation is essential before closure of the abdomen otherwise closure will be troublesome.

Exploratory Laparotomy

All opened abdomen should be explored by putting hand inside (right hand usually) – It is done through a proper method called as laparotomy circuit.

Complications of Abdominal Incision

•Wound infection.

•Surgical site infection (SSI).

•Fascial dehiscence – (Burst abdomen): Dehiscence is due to infection, severe cough and vomiting and sudden raise in intraabdominal pressure. Initially sudden severe pain occurs; feeling of givingwaywithserosanguineousdischargeis common.Abdominal viscera (bowel) will be visible through the given away wound. Occasionally evisceration occurs with intestine coming out of the abdominal wound. Patient is shifted to operation theatre. Under general anaesthesia, bowel contents are placed inside the abdominal cavity. All layer through and through mono lament interrupted sutures are placed after a through wash. Previously retention (tension) sutures are practiced. Usually patient recovers well unless there is bowel injury. L. E Hughes double near and far suture or modi ed Smead-Jones single layer sutures are better in such situation.

•Incisional hernia – It is due to wound sepsis, peritoneal cavity infection, malnutrition and deficiencies, nerve injuries, weak rectus, obesity, precipitating causes like cough, straining, urinary problem and constipation.