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92 Part I Introduction
A laparoscopically assisted method is suitable in thin
patients. Two stay sutures are placed on either side of the
anastomotic defect. ese sutures are cut long. e 12-mm
trocar is removed, and the incision is enlarged to 20 mm.
Using retraction on the stay sutures, the newly created biliary-enteric anastomosis can be exteriorized and the enterotomy closed in a standard fashion. When this is completed,
the bowel is returned to the abdominal cavity, and the wound
is closed. e abdomen is reinsuated and the anastomosis inspected. is technique allows for the construction of
a 2.5-cm cholecystojejunal anastomosis without any bowel
narrowing. No intra-abdominal drains are used.
e technique for fashioning a gastrojejunostomy is
similar. In this case, a proximal loop of jejunum is brought
in an antecolic position to the stomach. e left upper
quadrant 5-mm laparoscopic trocar is converted to a 12-mm
trocar. Two 3-0 coated, braided lactomer sutures (Polysorb,
US Surgical) are used to approximate the jejunum to the
stomach. Enterotomies are made in both stomach and jejunum. In cases in which there has been a signicant period of
gastric obstruction, the gastric wall may be hypertrophied,
making creation of the gastrotomy dicult. Conrmation
that one is inside the stomach is required before placement
of the stapler. When this is achieved, a 30-mm linear stapler is inserted through the 12-mm left upper quadrant port
and manipulated into both enterotomies. e instrument is
positioned and red. e stapler is removed and reloaded,
returned into the anastomosis, and rered. is creates an
anastomosis approximately 5 cm in length. e anterior
defect can be closed in a fashion similar to the cholecystojejunostomy (Fig. 5-19). Any defects in the anastomosis can
be repaired with individual 3-0 sutures.
e ideal palliative procedure for biliary or gastric obstruction should be eective in relieving jaundice or GOO, have
minimal morbidity, be associated with a short hospital stay,
have a low symptomatic recurrence, and maintain quality of
life. Laparoscopic procedures have the potential to achieve
FIGURE 5-19 Laparoscopic gastrojejunostomy.
these goals, although data do not support prophylactic
bypass procedures in patients who do not otherwise require
surgery.
SUMMARY
Laparoscopy is no longer a tool of limited use and now has
widespread indications within surgical oncologic practice.
Despite improvements in noninvasive imaging, there is still
an added value to use LS in selected patients with upper
gastrointestinal cancers. In the future, the combination of
NOTES technology and MIS techniques oers further exciting potential to enhance staging of these patients.
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ABDOMINAL WALL
II
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INCISIONS, CLOSURES, AND MANAGEMENT OF THE ABDOMINAL WOUND
Robert E. Roses • Jon B. Morris
6
INCISIONS
e impact that the planning, execution, and closure of
an incision has on the outcome of an abdominal operation
should not be underestimated. e high combined incidence
of surgical site infection (SSI), wound dehiscence, and hernia formation suggests a dominant contribution of wound
complications to surgical morbidity. Moreover, the quality
of exposure provided by an incision in uences the ease and
safety with which an operation can be undertaken and the
outcome in ways which defy easy quanti cation.
An incision must provide access to the site of abdominal
pathology and allow easy extension if greater exposure than
originally anticipated 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. ese principles apply to both
open and laparoscopic incisions. While the vertical midline
incision remains most popular, and is, perhaps the most exible, a variety of other incisions may have distinct advantages
in speci c settings.
Choice of Incision
Abdominal incisions can be vertically, transversely, or obliquely
oriented. e avascular linea alba a ords the vertical midline
its superior exibility. Indeed, when optimal exposure of the
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. 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 four 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 Rockey-Davis incisions for appendectomy.
A bilateral subcostal incision a ords 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.
e relative merit of vertical versus transverse incisions
remains a topic of active debate. Proponents of transverse
incisions argue that they anticipate a more secure closure
than do vertical incisions, a hypothesis supported by anatomic and surgical principle. e fascial bers of the anterior abdominal wall are oriented transversely or obliquely.
erefore, transverse incisions parallel the direction of the
fascial bers and allow for ready reapproximation with
sutures placed perpendicular to these bers. In contrast,
vertical incisions disrupt fascial bers and must be reapproximated with sutures placed between bers.
ter case, the absence of an anatomic barrier may predispose
such sutures to pull through tissue resulting in dehiscence
or hernia formation. Despite these concerns, little evidence
supports a substantial bene t of transverse incisions. 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).
data has been less de nitive, however. One randomized controlled trial compared vertical and transverse incisions with
regards to the frequency of evisceration; no signi cant difference in outcome was observed with either technique.
a more recent prospective randomized trial, no signi cant
di erences in 30-day mortality, pulmonary complications,
median length of hospital stay, median time to tolerate
1
In the lat-
1
Prospective
2
In
99
100 Part II Abdominal Wall
solid food, and incisional hernia formation at 1 year were
observed. More wound infections were seen with transverse
incisions.
3
Likewise, some controversy persists regarding the relative
advantages of midline versus paramedian incisions. e 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
found to be adherent to the posterior sheath incision and
does not eectively buttress the wound. e potential advantages of the paramedian incision have also been investigated
in prospective randomized trials which fail to demonstrate
any advantage with regards to wound failure rates when
4
compared to midline or transverse incisions.
A “lateral
paramedian incision” refers to a vertical incision created
several centimeters lateral to the location of the traditional
5
paramedian incision.
One randomized prospective study
suggested a statistically signicant decrease in the incidence
incisions (0%) compared to medial paramedian incisions
6
(14.9%)
and midline incisions (6.9%).7 A disadvantage of
the paramedian incision is the greater length of time needed
to create the wound, which increases with the distance from
the midline.
In the patient who has had prior abdominal surgery, the
cosmetic advantages of re-entering the abdomen through a
preexisting scar must be balanced against the challenges associated with dissection in a reoperative eld. 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.
Preparation of the Surgical Site
Incisions: Technical Considerations
VERTICAL INCISIONS
Midline Incision. e 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
bers or nerves. e 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. 6-1). e 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. e skin is then incised with a scalpel. Gauze
pads are applied to the skin edges to tamponade bleeding
cutaneous vessels and lateral traction is placed on the subcutaneous fat on both sides of the incision. e incision is
then carried down to the linea alba using either electrocautery or a scalpel; the decussation of fascial bers in the upper
abdomen serves as an important landmark for the midline.
e 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. e peritoneum itself
is best divided with scissors or scalpel to avoid coagulation
injury to underlying intraabdominal organs. Additionally, safe entry may be facilitated by picking up a fold of
peritoneum, palpating it to ensure that no bowel hasbeen
drawn up, and sharply incising the raised fold. e falciform ligament is best avoided by entering the peritoneum
to the left or right of the midline in the upper abdomen.
Prior to incision, the surgical eld 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 SSI and should, therefore, be avoided. If hair at the
surgical site will interfere with accurate wound closure or
precludes thorough application of the sterile preparation,
8
the use of clippers is preferred to a razor.
A variety of antiseptic solutions are commonly used to prepare the skin,
including povidone-iodine, alcohol, and chlorhexidene.
e ecacy of povidine-iodine depends on the release of the
active iodine from a carrier molecule. e solution should,
therefore, be applied several minutes prior to incision to
maximize its ecacy. e use of chlorhexidine gluconate
has been associated with greater reductions in skin bacterial
counts and lower rates of SSI when compared to povidine-
6,9,10
iodine in a number of studies
and is emerging as the
preferred skin antiseptic.
FIGURE 6-1 Epigastric midline incision: surface markings.
Chapter 6 Incisions, Closures, and Management of the Abdominal Wound 101
FIGURE 6-3 Upper paramedian incision: surface markings.
Additional exposure can be obtained by sloping the upper portion of
the incision upward toward the xiphoid process.
FIGURE 6-2 Vertical midline incision: the linea alba and peritoneum
are divided.
Toavoid 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 two
ngers that are then used to protect the underlying viscera
as the peritoneum is further divided along the length of the
wound (Fig. 6-2).
Paramedian Incision. Paramedian incisions are vertical inci-
sions placed either to the right or the 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 curving the upper portion of the
incision along the costal margin toward the xiphoid process
(Fig. 6-3). e anterior border of the rectus sheath is exposed
and incised across the entire length of the wound. e medial
aspect of the anterior rectus sheath is then dissected away from
the rectus muscle to its medial edge (Fig. 6-4). 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. ese
vessels should be clipped or ligated when encountered to avoid
signicant bleeding. Once free, the rectus muscle is retracted
laterally. e 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. 6-5).
Vertical Muscle-Splitting Incision. e 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. is 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 dicult. Longer incisions
should be avoided, however, because they result in signicantly
more bleeding and sacrice of nerves that may lead to weakening of the corresponding area of the abdominal wall.
TRANSVERSE AND OBLIQUE INCISIONS
Transverse and oblique incisions generally follow Langer’s
lines of tension and usually allow a more cosmetic closure
than do vertical incisions. Importantly, the rectus muscle has a
segmental nerve supply derived from intercostal nerves, which
enter the rectus sheath laterally. Transverse or slightly oblique
incisions through the rectus most often spare these nerves.
Provided that the anterior and posterior sheaths are closed,
the rectus muscle can therefore be divided transversely without signicantly compromising the integrity of the abdominal
wall. Although properly placed transverse incisions can provide exposure of specic organs, they may be limiting when
pathology is located in both the upper and lower abdomen.
Kocher Subcostal Incision. A right subcostal incision is
used commonly for operations in which exposure of the gallbladder and biliary tree is necessary. e left-sided subcostal
incision is used less often, mainly for splenectomy. A bilateral
subcostal incision provides excellent exposure of the upper
abdomen and can be employed for hepatic resections, liver
transplantation, total gastrectomy, and for anterior access to
both adrenal glands.