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• Injury to bowel during laparotomy.

• Fistula formation. Gastrointestinal stula may be biliary, faecal or pancreatic. It may be end or lateral; high or low output.

•Nerveinjury-Woundpain. Nerveinjurycanoccurinmusclecutting incisions, lateral incisions, laparoscopic dissection. Ilioinguinal nerve may get injured after appendicectomy causing right sided direct inguinal hernia. Open inguinal hernioplasty may cause inguinodynia postoperatively. Intercostal nerves may get injured in Kocher’s subcostal incision or thoracoabdominal incision. Pfannensteil incision may injure hypogastric nerve.

•Adhesion and its complications.

•Paralyticileus– itiscommon after12-24hours; but depends on the typeandconditionforwhichsurgeryisdone.Causeslikeelectrolyte imbalance,sepsis should beruledout. Oftennasogastricaspiration

and atus tube insertion may be required.

Factors a ecting the strength of the scar

•Type ofsurgery (acute abdomen, surgery for malignancy, major surgery)

•Obesity

•Pregnancy

•Straining

•Cough

•Ascites

•Nutrition

•Diabetes

•Immunosuppression

•Type ofincision

Abdominal Incisions may be –

•Vertical or transverse. Vertical may be midline or paramedian. Horizontal incisions are better.

•Incision may be with extension or without extension.

•Incision may be upper or lower. Upper incisions are better.

•Muscleretractionormusclesplittingormusclecutting(Fig.18-11).

Di erent Abdominal Incisions (Figs 18-12 to 18-14)

•Upper midline.

•Upper right paramedian.

•Upper left paramedian.

•Kocher’s incision (right subcostal).

•Left subcostal.

•Bucket handle.

•Upper horizontal.

•oracoabdominal.

•Umbilical crease incision.

•Subumbilical.

•Incision for lumbar sympathectomy.

•Lower midline.

•Lower right or left paramedian.

•Incisions forappendicectomy—McBurney’s,Rutherford Morison’s, Lanz, laparoscopic.

•Pfannenstiel incision.

•Lower horizontal .

Classi cation of abdominal incisions

Vertical incision

•Midline incision – upper, loweror entire length from xiphoid to pubis

•Paramedian incisions – right, left, upper, middle, lower. Muscle retracting/muscle splitting/pararectal (Battle’s)

Transverse incisions

•Upper abdominal transverse – one or both sides

•Lower abdominal transverse

͵Transverse muscle dividing lower abdominal incision

͵Maylards incision

͵Joel Cohen’s incision

͵Pfannenstiel incision

͵Cherney’s incision

͵Kustner’s incision

Contd...

Contd...

͵Turner Warwick’s incision

͵Subumbilical incision

Oblique incisions

•Kocher’s subcostalIncision

͵Classical rectus muscle cutting

͵Modified rectus muscle retracting

͵Mini lap Kocher’s incision

•Chevron(Roof top modification) incision

•Mercedes Benz modification

•Appendicectomy incisions

͵McBurney’s /Mac Arthur’s Grid ironmuscle splitting incision

͵Rutherford Morrison’s muscle cutting (laterally upwards)incision

͵Rocky Davis or Elliot’s muscle cutting (medially and downwards) incision

͵Lanz crease (interspinous crease) line incision

͵Oblique iliac incision(Abbernethy’s), muscle cutting incision

Abdominothoracic incisions

Fig. 18-12: Incision for liver resection.

MIDLINE INCISION

It is commonly advocated incision. It can be upper midline/lower midline or both upper and lower lengthy midline incision. Midline

incisioniseasiertoreachacrosslineaalbawithrapidaccess,minimum blood loss, and also quicker and easier to close. Extension above or below will be easier and faster. In emergency surgeries and common elective surgeries midline incision is better. Midline incision gives excellent adequate exposure of the abdomen. It can be extended below,above,horizontallyorobliquelyorasthoracoabdominalwhen needed. Gastrectomy, pancreaticojejunostomy, hiatus hernia repair, pseudocyst surgery, exposure of aorta, colectomy and biliary tract surgeries can be done with midline incision (Figs 18-15 to 18-18).

Upper Midline Incision

Skin is incised vertically in midline from xiphoid to umbilicus. Super cialfascia,external oblique fasciaisincised. Whitishcrisscross tough linea alba is visible. It is incised using monopolar cautery or 22 no. blade. Once incised in full depth linea alba separates away to visualise the extraperitoneal pad of fat and peritoneum. Extraperitoneal pad of fat is separated of the peritoneum gently. Peritoneum appears like a shiny whitish thin structure. It is carefully held using a haemostat during expiration phase. One should be sure not to hold the deeper contents. Another haemostat is applied 5-10mmawayontheperitoneumhorizontallysothatperitoneumfold is lifted properly. Lifted fold of peritoneum is gently moved to make any content if at all to get dislodged and fold is pinched between the thumb and ngers to con rm that no content is felt. Peritoneum is incised using blade obliquely or using scissor towards just left of the midline which is avascular. Once peritoneum is opened air enters insidetodistendperitoneumandcontenttofalldeep.Bothhaemostats arereappliedtocutedgesoftheperitoneum.Usingscissorperitoneum is cut above and below under vision or by placing ngers under the peritoneum to guard the contents with forward lift of the abdominal wall. One should be careful about the adhesions in the peritoneum in the line of cut. Extension down is done by curving the incision left side oftheumbilicus.Right sideofumbilicusisvascular and falciform ligament is attached towards right side hence incision is made on the left side of the umbilicus. Few advocate incision vertically through the umbilical midline. Only abdominoperineal resection (APR) for carcinoma rectum incision is extended above from right side of the umbilicusaspermanentcolostomyisplacedonthe left side inleftiliac fossa. Occasionally when approach to the OG junction is inadequate

Fig. 18-14: Horizontal incision at umbilical level.

Fig. 18-16: Different types of midline incisions.

Fig. 18-15: Layers which will come across while making the midline incision.

proximal extension is done by cutting the xiphoid process. Care must be taken not to injure terminal branches of internal mammary artery which can cause bleeding (Fig. 18-19).

Lower Midline Incision

Inthelower midline incision posteriorrectus sheath is de cient,makingincisiondownwards needscareasurinarybladdermaygetinjured. Prevesicalfat shouldnot beincised. isfatcannotbeseparatedof the deeper bladder. Bladder should beemptied before givinganaesthesia or an indwelling urinary catheter may be needed.

Midline Incision Closure

It is done using nonabsorbable mono lament suture material number zero or1. Polyethylene/polypropylene/nylon/PDS (polydioxanone) is used. Silk and catgut are not used. Many advocate delayed absorbable suture material like no. 0 or 1 vicryl; but it is not as ideal as nonabsorbable mono lament suture material. Continuous mass closure is sufcient. Often locking sutures are placed. Peritoneum bite is not always necessary/compulsory as it will appose naturally when anterior layers are sutured. During continuous suturing in between supporting knots are placed at few points to prevent loosening and giving way of the suture line. Minimum distance to be kept between each bite is 1 cm;

each bite should be taken 1 cm away from the cut margin. Linea alba/ anterior rectussheath may retractafterincision;andoftenbite is taken onlyfromexternalobliquefasciaof Gallaudet’sinsteadofrectussheath especially in the lower abdomen. is fascia is not strong and so will eventually dehisce to cause incisional hernia. One should maintain adequate uniform tension on the suture material. Over pulling may cause tissue strangulation. Length of the suture material required is 3 times the length of the abdominalwound. One should becarefulwhile closing incision close to pubis due to close proximity of bladder. Inadvertentbite of the urinarybladder should be avoided.Similarly closing incision adjacent to umbilicus should be perfect otherwise defect may be left leading to incisional hernia at that site (Figs 18-20 to 18-22).

Ending of the continuous suture is done using needle holder by knotting to the previous bite loop. It is better and stronger. At least 4-5 knotsshould beplacedto make it stronger. Knotof thenonabsorbable suture material will persists and may project towards skin causing pain on the skin later and so knot should always be buried under the rectus sheath. Many use Aberdeen knot at the end in continuous suture. Interrupted single layer mass closure using nonabsorbable suture material is also used with each suture 1 cm apart. Again often peritoneum is closed rst by continuous suturing using 2 zero vicryl and rectus sheath is closed by continuous or interrupted (layer by layer) suturing. But now it is proved that there is no additional advantage by layer by layer closure.

Fig. 18-21: Different methods to close the midline.

Fig. 18-22: Counting mops properly is very important prior to closure. Number of mops taken to theatre table shouldbe written inthe theatre board.

PARAMEDIAN INCISION

Inoldendaysparamedianincisionwasthemostcommonlyadvocated one; but now it is not commonly used. Paramedian incision is placed vertically parallel and 2.5 cm away from midline. It can extend from costal margin to pubis.

Right upper paramedian incision is used for cholecystectomy, biliary surgery, pyloroplasty, approach to right adrenal gland and liver cyst. Right mid-paramedian is used for laparotomy in doubtful/ unknown/unsurediagnosis,approachtointestinesandthisapproach islaterextended dependingon thepathology foundafteropeningthe abdomen. Right lower paramedian is used in burst appendicitis with peritonitis, right hemicolectomy. Left upper paramedian incision is usedinvagotomy,gastrectomy,hiatusherniarepairandsplenectomy. Left lower paramedian incision is used in left hemicolectomy (Fig. 18-23).

Skin, subcutaneous tissue, super cial fascia, external oblique fascia, anterior rectus sheath are incised layer by layer using no. 22 blade with no. 4 knife handle. Medial edge of the anterior rectus sheath is held upwards using series of haemostats. Rectus muscle is retraced laterally. In the upper part anterior rectus sheath is adherent to muscle on the medial part through tendinous intersections. These intersections should be released using monopolar cautery or sharp dissection. Posterior rectus sheath is

Fig. 18-23: Left paramedian incision scar.

visible behind rectus muscle. Vessels and nerves are in the middle level of the rectus muscle. Vessels run vertically. Segmental nerves after piercing posterior rectus sheath run laterally in front of the vessels and enter the muscle at same level just lateral to the middle of the rectus muscle. Posterior rectus sheath is de cient below the arcuate line. Fascia transversalis and extraperitoneal fat is incised; peritoneum is held using two haemostats and incised using blade after con rming that no content is present; cut edges are held using haemostats and by guarding abdominal contents using two ngers peritoneum is openedat both ends along its entire length of incision

(Figs 18-24 to 18-27).

Modi cations of Paramedian Incision

Rectusmusclemaybesplitinthelineofincisiononthemedialpartofthe musclebulk toavoidinjurytonervesandalsobeusedforquickaccess.

Battle’s incision which is pararectal incision will injure these nerves causing weakening of the rectus muscle and so is avoided.

Mayo–Robsonincision: Right upperparamedian incision may extend upwards towards xiphoid process in midline as Mayo–Robson incision. One should ensure that in such extension, superior epigastric arteryisnotinjuredorotherwiseshouldbe securelyligated toprevent troublesome haemorrhage.

Paramedian incision can be extended into the thorax whenever needed as thoracoabdominal incision (Fig. 18-28).

Closure of Paramedian Incision

Paramedian incision is closed in layers. First posterior rectus sheath with peritoneum is closed using mono lament nonabsorbable or delayed absorbable like vicryl suture material. Anterior rectus sheath is closed using mono lament nonabsorbable suture no. zero polyethylene or polypropylene or nylon as continuous sutures.

Advantages

Paramedian incision is safe without cutting the muscle. It creates strong scar with ‘trap door’ e ect.

Disadvantages

Rectus muscle is exposed and dissected and so there are chances of muscle getting atrophied. Incision is laborious and time consuming and di cult to extend above and below which invariably damages muscleandoftennerves.Accesstothecontralateralabdomenisusually inadequate.

TRANSVERSE INCISIONS

It may be upper transverse or lower transverse incision. It is the incision used in infants and early childhood. It is muscle cutting incision. Muscle is cut in line of incision.

Upper Transverse Abdominal Incision

It is placed at transpyloric plane or midway between xiphoid and umbilicus. It is muscle cutting incision. Rectus muscle is cut; but its nerve supply is not interfered as it has got segmental nerve supply. Rectus muscle in upper abdomen after cutting will not retract due to tendinous intersections. It extends from anterior axillary line on one side to other side; but length depends on the side of the pathology which can be variable as needed. Skin, subcutaneous tissue, fascia, super cial fascia, anterior rectus sheath on both sides, recti on both sides, external and internal oblique muscles on both sides, transverse abdominis muscles on both sides are cut. Vessels deeper to rectus muscle are ligated securely. Posterior rectus sheath and transversalis fasciaareincised.Peritoneumisheldwithtwohaemostatsandincised. It is cut in the line of incision transversely. Muscles are cut using monopolar cautery. Postoperative pain is less and chances of wound dehiscence and incisional hernia are rare.

In infants and early childhood, costal angle is obtuse, abdomen is small and wide, muscles are thin, and pelvis is not yet developed and sonot deep. Approachtoentire abdomenis possible; contracture will not occur compared to vertical scar; cosmetically better. Umbilical vein infalciformligamentmay be patent andsorequires rm ligation. (In infants while putting infraumbilical transverse incision, one has to be aware of that two umbilical arteries in paramedian positions on either side may be patent and so needs ligation).

Closure of upper transverse incision is done either as layer by layer usingvicryl;orlateralmusclesareclosedasmassclosurewithsuturing posterior rectus sheath, rectus muscle and anterior rectus sheath.

Fig. 18-27: Right paramedian incision.

Fig. 18-28: Extensions which can be done in paramedian incision.

Fig. 18-29: Different types of lower abdomen transverse incisions.

Advantages

It gives good exposure of the upper abdomen. Healing is supported by muscle contraction which pulls it transversely. Segmental nerve supplyispreserved.Scarcontractureislessherecomparedtovertical.

Disadvantages

Bleedingfromepigastricandmuscularvesselsistroublesome.Ittakes long time to complete the incision.

Lower Transverse Abdominal Incisions

Itisnotcommonlyused;insteadPfannenstielincisionisused.Lower infraumbilicaltransverseincisionisoftenusedininfantsandchildren; here posterior rectus sheath is not formed; recti muscles will retract as there are no tendinous intersections; and so often cause di culty in apposing the recti rmly. Layers are closed in similar fashion as upper transverse incision (Fig. 18-29).

Pfannenstiel Incision (Pfannenstiel Hermann

Johann 1862–1909; German Gynaecologist)

It is rectus muscle separating/retracting transverse incision. It is used to approach pelvis. It is commonly used in gynaecological surgery like caesarean section or hysterectomy. In urology procedures also this incision is used like in retropubic urethroplasty.

Incision is placed in suprapubic region 1 cm above the pubis with slight convexity downwards. Laterally incision extends beyond outer margin of the rectus muscle. Skin, subcutaneous tissue and super cial fascia are incised. Anterior rectus sheath is incised in the line of incision; upper ap of the sheath is raised upwards towards umbilicus using scissor; lower ap is raised up to the pubis. Recti are separated from midline laterally. Peritoneum is visualised with extraperitoneal pad of fat. Urinary bladder is visible in the lower part. Peritoneum is held with two haemostats in the upper part midline. It is incised and opened vertically in both directions above and below. Below it is incised until the dome of the urinary bladder. One should be careful below not to incise urinary bladder. Head down position with self retaining retractor facilitates further operative steps (Figs 18-30 and 18-31).

Closure of Pfannenstiel Incision

Closure of Pfannenstiel incision is done layer by layer; peritoneum vertically using vicrylcontinuoussuture;rectusmuscle is justapposed using few interrupted vicryl sutures (it should not be very tight so as to strangulate the muscle); anterior rectus sheath is closed using continuous mono lament nonabsorbable sutures. Subcutaneous tissue is closed using interrupted 3 zero vicryl; skin is closed using subcuticular suture.

Advantages

It is cosmetically better; less painful; heals rapidly; less chance of incisional hernia compared lower midline incision.

Disadvantages

Itisdi culttoextendmorelaterallyifneededincaselargegynaecological tumours. It may cause injury to inferior epigastric vessels causing troublesomebleeding.ItmayinjuretheT11nerve,iliohypogastricnerve andsubcostalnervecausingmuscleweakness.Entrapmentofilioinguinal or iliohypogastric nerve can occur. Lateral extension may predispose to inguinal hernia. Haematoma, seroma, abscess formation can occur. Femoral nerveinjurycan occur occasionally. is incision shouldnotbe usedinoncologicalsurgeryduetolimitedaccesstolymphnodeclearance. Its proximity to infected area (perineum) may predispose sepsis.

Joel Cohen’s Straight Transverse Lower

Abdominal Incision

It is used for caesarean section delivery. It is a straight transverse incision through skin only,3 cm below theleveloftheanteriorsuperior iliac spines (higher than thePfannenstiel incision). e subcutaneous tissue is opened only in the middle 3 cm. The fascia is incised transversely in the midline then extended laterally with blunt finger dissection. Finger dissection is used to separate the rectus muscles vertically and outwards laterally and to open the peritoneum. All the layers of the abdominal wall are stretched manually to the extent of the skin incision. e urinary bladder is pushed below by gentle blunt nger dissection. e uterine muscle is incised transversely

in the midline but not to breach the amniotic sac, then opened and extended laterally with finger dissection. It is found that this approach for caesarean section delivery reduces the operating time, blood loss and postoperative hospital stay.

Cherney’s Incision

Incision islikePfannenstiel but still lowerthan it withtendondetaching approach. After incising the skin and subcutaneous tissue above the pubic symphysis, anterior rectus sheath is incised transversely which is separated from underlying rectus and pyramidalis muscles above and below. Posteriorly these muscles are separated from the urinary bladder by blunt nger dissection. Tendons of these muscles are cut 5 mm above the pubic symphysis. Muscles with tendons are retraced and reflected above to expose the peritoneum which is incised transversely. Cherney’s incision provides excellent access and exposureto theretropubic space of Retzius for retropubic urethropexy and paravaginal repair. Exposure is the main advantage to Cherney’s incision. It is more time consuming due to the dissection required to separate the muscles and tendons from the underlying tissues. Injury to inferior epigastric arteries is a possibility. Reattachment of the tendons to the pubic symphysis is a must during closure which is tedious.

Maylard’s Incision

It is muscle cutting transverse incision. It is also called as Mackenrodt incision. Incision is placed at the level of anterior superior iliac spine with convexity downwards. Anterior rectus sheath is incised but not separatedfromthe rectusmuscleto prevent itfromgettingretractedon either sides; (often after cutting the rectus muscle, its edge is sutured to cut edge of the anterior rectus sheath to prevent retraction using mattress vicryl sutures). Incision over the anterior rectus sheath is extended laterally through the aponeurosis of the abdominal wall up to 2 cm medial to the anterior iliac crest. Rectus muscle is cut transversely using cautery or scalpel. Inferior epigastric vessels are dissected, ligated and divided. Transversalis fascia and peritoneum are incised transverselyto exposetheabdomen. All layersare cut at the level of anterior superior iliac spine. Here exposure to lateral pelvis is excellent andso oncological procedures likepelvic lymphadenectomy and staging can be done exponentially. It is also very useful for pelvic endometriosis. is incision should be placed with a preoperative plan. Pfannenstiel incision cannot be modi ed as Maylard’s incision. Drain is keptusually after Maylard’s exposure as oozingand collection is common in this incision.

Disadvantages: Haemorrhage, haematoma, seroma formation and infection can occur. Injury to ilioinguinal and iliohypogastric nerves or their entrapment during closure can occur. Lateral femoral cutaneous, genitofemoral and femoral nerves can get compressed during retraction causing neuropraxia.

Kustner’s Incision

A transverse incision is made 5 cm above the symphysis pubis and below the anterior iliac spine. The subcutaneous tissue is then separated in the midline to expose the linea alba. A vertical midline incision is made through the linea alba. Superficial epigastric vessels are ligated. is incision is not commonly used as there are no advantages over Pfannenstiel incision and it limits in adequate exposure and cannot extend if needed also.