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102 Part II Abdominal Wall
A
right iliac fossa incision known as the McBurney incision is well
suited for appendectomy. is incision is oriented obliquely. e
McBurney incision has largely been supplanted by the RockeyDavis incision, which is oriented transversely as opposed to
obliquely, allowing for better cosmesis (Fig. 6-7).
e suspected position of the appendix and the thickness
of the abdominal wall inuence the placement of the incision
as well as its length. Examination of the anesthetized patient’s
abdomen will often reveal a mass, guiding placement of the
incision directly over the appendix. If no mass is palpable, the
incision is centered over McBurney’s point at the junction of
the middle and outer thirds of the line between the umbilicus
and the anterior superior iliac spine. If the patient is obese, or
if extension of the incision is anticipated, the incision should
be placed obliquely, allowing ready lateral extension.
After skin and subcutaneous tissues are incised, the
external oblique aponeurosis is exposed and divided parallel to the direction of its bers to reveal the underlying
internal oblique muscle. At a point adjacent to the lateral
border of the rectus sheath, a small incision is made in the
internal oblique muscle, which is similarly opened in the
direction of its bers. Once the underlying transversalis
muscle is exposed, it is split to reveal the transversalis fascia
and peritoneum. ese are sharply divided and the appendix and cecum are exposed (Fig. 6-8). If further exposure is
necessary, the wound can be enlarged by dividing the rectus
sheath, retracting the rectus muscle medially, and extending the peritoneal defect. If the operation requires extension
of the wound laterally, this can be accomplished through
division of the oblique muscles.
B
FIGURE 6-4 A. Paramedian incision: dissection of the rectus mus-
cle from the anterior rectus sheath. B. Paramedian incision in transverse section.
e standard subcostal incision begins at the midline, two
ngerbreadths below the xiphoid process and is extended laterally and inferiorly, parallel to the costal margin (Fig. 6-6). e
incision should not be placed too far superiorly as sucient
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.
e peritoneum is then divided in the plane of the skin incision. e incision can be extended beyond the lateral aspect of
the rectus muscle if necessary to facilitate exposure.
McBurney and Rockey-Davis Incisions. Originally
described by Charles McBurney in 1894,
11
the muscle-splitting
Pfannenstiel Incision. e Pfannenstiel incision is used
frequently for gynecologic operations and for access to the
retropubic space (eg, for extraperitoneal retropubic prostatectomy). e skin incision is placed in the interspinous
crease above the symphysis pubis. e anterior rectus sheath
is exposed and divided transversely. e superior and inferior
leaets of the divided sheath are dissected from the underlying rectus muscles superiorly to the umbilicus and inferiorly to the pubic symphysis. e recti are retracted laterally
and the peritoneum is opened vertically in the midline. At
the inferior aspect of the wound, the bladder is protected to
avoid injury (Fig. 6-9). An advantage of this incision is that it
aords a cosmetic closure because it is placed in a skin crease
at the level of the belt line; however, exposure may be somewhat limited.
ABDOMINOTHORACIC INCISIONS
e thoracoabdominal incision provides enhanced exposure
of upper abdominal organs. A left thoracoabdominal incision
is useful for access to the left hemidiaphragm, gastroesophageal junction, gastric cardia and stomach, distal pancreas
and spleen, left kidney and adrenal gland, and aorta. Aright
thoracoabdominal incision can be used to expose the right
hemidiaphragm, esophagus, liver, portal triad, inferior vena
cava, right kidney, right adrenal gland, and proximal pancreas.
Chapter 6 Incisions, Closures, and Management of the Abdominal Wound 103
D
F
A
B
E
C
FIGURE 6-5 Lower paramedian incision. A. Surface markings. B. Incision of the rectus sheath. C. Retraction of the rectus abdominis muscle.
D. Location of the branches of the inferior epigastric vessels that run across the lower portion of the incision. E. Peritoneum opened. F. e
peritoneum is incised for the full length of the wound.
104 Part II Abdominal Wall
A
B
FIGURE 6-6 Kocher incision. A. Surface markings. B. Division of
the rectus and medial portions of the lateral abdominal muscles.
ese incisions are reserved for circumstances in which an
operation cannot safely be performed through an abdominal
incision, as they are theoretically associated with increased
morbidity relating to a more dicult pulmonary recovery
and risk of phrenic nerve injury.
e patient is placed in the “corkscrew” position on the
operating room table to enhance access to both the abdominal
and thoracic cavities. e abdomen is tilted approximately
45 degrees from the horizontal plane and the thorax is oriented in full lateral position (Fig. 6-10A). Positioning is
aided by the use of a bean bag. e abdominal part of the
incision may consist of a midline or upper paramedian incision, which allows exploration of the abdomen. e incision
is extended obliquely along the line of the eighth interspace
A
B
FIGURE 6-7 Surface markings of the right iliac fossa appendectomy
incisions. A. e classic McBurney incision is obliquely placed. B. e
Rockey-Davis incision is transversely placed in a skin crease.
just beneath the inferior pole of the scapula (Fig. 6-10B).
Alternatively, an oblique upper abdominal incision can be
used and extended directly into the thoracic portion of the
incision.
After entry into the peritoneal cavity through the abdominal portion of the incision, the incision is extended onto the
chest wall and the latissimus dorsi and serratus anterior muscles, and then the external oblique muscle and aponeurosis
are divided. e intercostal muscles of the eighth interspace
are divided to allow entry into the chest cavity and the incision is extended across the costal margin, which is divided
with a scalpel. It is often useful to resect a short segment of
costal cartilage to facilitate closure of the chest wall. A selfretaining rib retractor is inserted and the intercostal space is
gently spread. e diaphragm is either incised radially toward
the esophageal or aortic hiatus, or in a curvilinear fashion if
less exposure is required. is incision also preserves phrenic
nerve function and is useful for patients with pulmonary
compromise.
12
At the completion of the operation, chest tubes placed
in the pleural cavity are brought out through the chest
or upper abdominal wall through separate incisions. e
diaphragm is repaired in two layers using nonresorbable
sutures. Pericostal sutures are placed to reapproximate the
ribs. e chest muscles and abdominal wall are then closed
in layers.
RETROPERITONEAL AND
EXTRAPERITONEAL INCISIONS
Retroperitoneal and extraperitoneal approaches to the abdomen have several advantages over transperitoneal exposures.
Manipulation and retraction of intraabdominal viscera are
limited and postoperative ileus is reduced. Hemorrhage is
more likely to be tamponaded in the retroperitoneum than
when it occurs in the peritoneal cavity. Retroperitoneal and
Chapter 6 Incisions, Closures, and Management of the Abdominal Wound 105
A
D
FIGURE 6-8 McBurney muscle-splitting incision. A. Division of the external oblique aponeurosis. B. e internal oblique and transversus
muscles are split. C. e index ngers of each hand enlarge the opening. D. Incision of the peritoneum. E. Exposure of the appendix.
extraperitoneal approaches can be used for operations on the
kidney, ureter, adrenal gland, bladder, splenic artery and vein,
B
E
place and the muscles of the abdominal wall are reapproximated in layers.
C
vena cava, lumbar sympathetic chain, abdominal aorta, iliac
vessels, and on groin hernias.
Posterior Approach to the Adrenal Glands. With the
posterior approach, dissection is performed entirely in the
Retroperitoneal Approach to the Lumbar Area. e
retroperitoneal approach to the lumbar area is frequently
used for aortic surgery, nephrectomy, lumbar symphathectomy, and ureterolithomy. e patient is positioned with the
operative side elevated 30–45 degrees with the knees and hips
exed. e incision extends from the lateral margin of the
rectus sheath at the level of the umbilicus toward the twelfth
rib for approximately 12–14 cm (Fig. 6-11). A portion of
the twelfth rib is resected if necessary. e external oblique,
internal oblique, and transversalis muscles are exposed, and
divided in the direction of their bers. e retroperitoneum is
entered and the peritoneum and retroperitoneal fat are swept
anteriorly. e lower pole of the kidney, ureter, and sympathetic chain are easily identied. e vena cava is exposed
on the right and the aorta is exposed on the left. If the peritoneum is unintentionally entered, it is closed immediately
with continuous absorbable suture. At the conclusion of the
procedure, the retroperitoneal fat and viscera fall back into
retroperitoneal space. e patient is placed in the prone jackknife position. A curvilinear incision is made beginning on
the tenth rib approximately three ngerbreadths lateral to the
midline and carried inferiorly and laterally toward the iliac
crest, ending approximately four ngerbreadths lateral to the
midline (Fig. 6-12). e subcutaneous tissues are divided to
expose the posterior layer of the lumbodorsal fascia. is fascia
and the bers of the latissimus dorsi muscle, which originate
from it, are divided. e erector spinae muscle is exposed and
retracted medially to uncover the twelfth rib and the middle
layer of the lumbodorsal fascia. e attachments of the erector spinae to the twelfth rib are divided with electrocautery;
the vessels and nerves that penetrate the fascia are secured
with clamps and ligated. e twelfth rib is then resected.
Gerota’s fascia is exposed by incising the lumbodorsal fascia
along the lateral margin of the quadratus lumborum muscle.
e intercostal neurovascular bundle should now become
visible directly below the bed of the resected twelfth rib.
106 Part II Abdominal Wall
A
B
C
D
E
F
G
FIGURE 6-9 Pfannenstiel incision. A. Skin incision. B. Horizontal division of the anterior rectus sheath and developing fascial ap. C. Dividing
in the midline and entering the peritoneal cavity. D. Opening midline. E. Lateral retractors are placed for exposure. F. Inferior retractors placed for
exposure. G. Closure midline and inferior rectus.
Chapter 6 Incisions, Closures, and Management of the Abdominal Wound 107
BA
C
D
FIGURE 6-10 Anterolateral thoracoabdominal incision. A. e “corkscrew” position, with the thorax in the lateral position and the abdomen at
45degrees from the horizontal plane. Appropriate positioning on the operating table is essential to prevent injury to the brachial plexus and minimize
pressure on peripheral nerves. B. e abdominal incision is made rst; usually a vertical midline incision that is extended into the chest through the
eighth intercostal space. e pleural space is then entered. C. e diaphragm is usually opened in a radial fashion with an incision directed toward
the esophageal or aortic hiatus. D. e diaphragm can alternatively be opened with a hemielliptical incision 2–3 cm from the lateral chest wall; this
incision preserves phrenic nerve function, of particular importance in patients with impaired pulmonary function.
Penn I, Baker RJ. Abdominal wall incisions and repair. In: Baker RJ, Fischer JE, eds. Mastery of Surgery. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:197.)
(Reproduced, with permission, from
108 Part II Abdominal Wall
A B
FIGURE 6-11 A. Left lumbar approach to the retroperitoneum. B. e peritoneum has been bluntly dissected from the retroperitoneal structures
with the preperitoneal fat and soft tissue. Origins of the celiac, superior mesenteric, left renal, and inferior mesenteric arteries are shown.
duced, with permission, from Penn I, Baker RJ. Abdominal wall incisions and repair. In: Baker RJ, Fischer JE, eds. Mastery of Surgery. 4th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2001:194.)
eintercostal vessels are clamped, divided, and ligated and
the intercostal nerve is retracted downward. e posterior
bers of the diaphragm are identied and divided where they
insert on the periosteum of the twelfth rib. e lower margin
of the lung will enter the eld with hyperination. If the
pleura are inadvertently injured, the resulting pneumothorax
is handled at closure by insertion of a large-bore rubber catheter into the pleural cavity, which is brought out through the
wound. After closure of the fascial bers around the catheter,
the lung is hyperinated evacuating all air from the pleural
to a point just lateral to the pubic symphysis (Fig. 6-13). e
incision can also be extended superiorly as far as the costal
margin, if necessary. e external oblique, internal oblique,
and transversus abdominis muscles are divided in line with
the skin incision. e retroperitoneum is entered and the
retroperitoneal fat and peritoneum are swept superomedially.
If the peritoneum is inadvertently entered, it is closed immediately. At the conclusion of the procedure, the retroperitoneal fat and viscera fall back into place and the muscles of the
abdominal wall are reapproximated in layers.
(Repro-
space, and the catheter is briskly removed.
Retroperitoneal Approach to the Iliac Fossa. e ret-
roperitoneal approach to the iliac fossa provides access to the
bladder, distal ureter, and common, internal, and external iliac
vessels. It is often employed for surgery on the iliac arteries
and for kidney transplantation. It may also be used to drain
psoas or retrocecal abscesses and to resect retroperitoneal
tumors. e skin incision is oriented obliquely and extends
from approximately 2 cm above the anterosuperior iliac spine
LAPAROSCOPIC INCISIONS
As with open abdominal incisions, laparoscopic access must
allow optimal exposure without unnecessarily compromising
abdominal wall function or cosmesis. Laparoscopic incisions
may be placed anywhere on the abdominal wall. When appropriate, laparoscopic incisions should allow for ready extension should conversion to open operation become necessary.
Additionally, laparoscopic access may be combined with small
Chapter 6 Incisions, Closures, and Management of the Abdominal Wound 109
B
A
FIGURE 6-12 e posterior approach to the kidney and adrenal. A. J-shaped incision over the tenth to twelfth ribs, extending inferiorly 6–10
cm below the twelfth rib. B. Resection of the twelfth rib facilitates exposure. C. e diaphragmatic attachment to the twelfth rib is taken down,
with care taken not to enter the pleura. If the pleura are opened, the wound closure is performed over a pleural suction catheter, which is removed
with simultaneous positive airway pressure by the anesthetist as the skin is being closed.
incisions and repair. In: Baker RJ, Fischer JE, eds. Mastery of Surgery. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:195.)
open incisions that accommodate appliances through which
a hand can be inserted into the peritoneal cavity without the
loss of pneumoperitoneum. Such hand-assisted laparoscopic
approaches are frequently associated with shorter operative
C
(Reproduced, with permission, from Penn I, Baker RJ. Abdominal wall
wall and a central location from which all quadrants of the
abdominal cavity can be visualized. Other sites are preferable
in specic circumstances (eg, left upper quadrant access in a
patient with a previous midline incision).
times than are purely laparoscopic approaches and may have
particular advantages for operation in which a larger incision
is necessary to remove the surgical specimen (eg, laparoscopic
13
colectomy) and more complex procedures.
e initial step
of any laparoscopic procedure is the establishment of pneumoperitoneum. is can be achieved using an open or closed
technique. Access is most often obtained at a site just above or
below the umbilicus; the thinnest portion of the abdominal
INITIAL ACCESS
e open approach involves the creation of a small incision,
generally 1.5 cm, through which the abdominal fascia is
grasped with straight clamps and elevated toward the wound.
Exposure of the fascia is often enhanced with the use of
S-shaped retractors. e fascia and then peritoneum are
110 Part II Abdominal Wall
A B
FIGURE 6-13 Right lower quadrant extraperitoneal approach to the iliac vessels, ureter, and bladder. A. e skin incision may be shorter than
depicted in thinner patients or if an abscess is to be drained. B. Peritoneum is retracted medially by blunt dissection, which exposes the psoas muscle
and gonadal artery and vein, shown anterior to the ureter.
Fischer JE, eds. Mastery of Surgery. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:196.)
(Reproduced, with permission, from Penn I, Baker RJ. Abdominal wall incisions and repair. In: Baker RJ,
divided under direct vision. Abdominal entry is conrmed by
digital palpation. Heavy stay sutures are then placed in each
fascial edge and are lifted up while a blunt-tipped (Hasson)
obturator and cannula are inserted through the opening in
the abdominal wall. e stay sutures are then wrapped around
the struts on the cannula to secure it in position. Insuation
tubing is then attached to the cannula and the obturator is
withdrawn. Carbon dioxide is insuated into the abdomen
to a pressure of 12–15 mm Hg.
e closed technique involves the passage of a sharp
needle (Veress needle) through the abdominal wall into the
abdominal cavity. A small skin incision is made in the skin
through which the needle is inserted, generally at an angle of
45 degrees to the abdominal wall; an angle of 90 degrees is
sometimes necessary in the obese patient. As the needle passes
through the fascia and then the peritoneum, a sensation of
overcoming resistance is appreciated, often reinforced by an
audible click as the blunt tip of the needle springs forward.
A 10 cc syringe containing 5 cc of saline is attached to the
end of the needle and is aspirated. If enteric contents, blood
or urine, are not aspirated, the saline is instilled through the
needle. If the needle is appropriately placed in the peritoneal
cavity, saline should pass through the needle without resistance and the meniscus should descend down the hub of
the needle when the syringe is detached (the so-called drop
test); free descent of the meniscus sometimes requires manual
elevation of the abdominal wall. e presence of signicant
resistance in the syringe or failure of the meniscus to descend
usually indicates extraperitoneal placement or apposition
of the needle against the underlying omentum and usually
mandates replacement. Insuation tubing is then attached
to the needle. An initial pressure reading of less than 10 mm
Hg further suggests appropriate placement, whereas higher
pressures generally indicate extraperitoneal placement. Once
satisfactory placement of the needle has been achieved, CO
is insuated through the needle to a pressure of 12–15
mm Hg. e needle is then removed and a cannula and
sharp trocar are inserted though an appropriately sized skin
incision.
A variety of instrumentation has been developed to
facilitate the closed approach. is includes expandable
sheaths, which are introduced over the needle and can
accommodate larger ports which dilate open the fascial
opening (or radially expanding trocars), and devices that
dilate the fascial opening under direct vision (or optical
access trocars). Such instrumentation may also obviate formal fascial closure because the resulting fascial defect is
small after removal of the port.
e open approach holds the theoretical advantage of minimizing the potential for injury to intra-abdominal visceral
and vascular structures. Disadvantages include the generally
longer-associated operative time and the occasional need for
larger skin incisions, particularly in obese patients. In contrast,
the closed approach is generally faster and may allow better
cosmesis. Contraindications to the closed approach include
the suspected or known presence of extensive intra-abdominal
adhesions and pregnancy. However, in patients who have had
limited prior surgery, the closed approach may be used to
gain access at a site remote from the previous surgical site.
e safety of open and closed approaches has been compared
in several studies. A large retrospective review of closed laparoscopy in 489,335 patients and open laparoscopy in 12,444
2
Chapter 6 Incisions, Closures, and Management of the Abdominal Wound 111
suggested higher rates of visceral and vascular injury in
closed laparoscopy. Rates of visceral and vascular injury were
0.083% and 0.075% after closed laparoscopy, and 0.048%
and 0% open laparoscopy, respectively ( p = 0.002). Mortality
rates after closed and open laparoscopy were not statistically
14
di erent.
several other meta-analyses.
Notably, this small di erence was not evident in
15,
16
PLACEMENT OF ADDITIONAL PORTS
e approach to the placement of secondary cannulas is
highly surgeon and operation speci c. Some basic principles,
however, should always be adhered to. ese include: (1)all
cannulas should be inserted with the aid of laparoscopic
visualization; (2) cannulas must be placed far apart from one
another to avoid frequent crossing of instruments (generally
10 cm or more apart); and (3) the cannulas should be placed
at a distance from the operative site, which maximizes range
of motion at the cannula site and minimizes operator discomfort (approximately 15 cm). Additionally, skin incisions,
while often small, should never compromise easy passage of
trocars through the abdominal fascia. Undue resistance at the
level of the skin can undermine the surgeon’s control of the
trocar as it passes through the peritoneum and lead to injury
of underlying viscera or vascular structures.
CLOSURE OF ABDOMINAL INCISIONS
As noted above, wound complications make a dominant contribution to surgical morbidity. Indeed, wound infection is
the most common early complication and incisional hernia is
the most common long-term complication of open abdominal surgery. Multiple factors contribute to the incidence of
wound failure, including diabetes mellitus, malnutrition,
obesity, and corticosteroid use. Surgical technique also
appears to in uence rates of wound failure; however, there
has been little consensus regarding the optimal approach to
closure. An evolving literature focuses on the relative merits
of multiple-layered versus single-layer closure, closure with
di erent suture materials, and interrupted versus continuous
closures.
Closure of the Fascia
e abdomen can be closed in multiple layers or en mass.
e former technique reconstructs the anterior and posterior aponeurotic sheaths separately with the posterior
layer generally incorporating the peritoneum. Mass closure
involves a single-layer closure of all layers and may or may
not include the peritoneum. Numerous clinical trials have
compared multiple-layered closure to mass abdominal closure. Some studies have shown an increased incidence of
dehiscence and incisional hernia formation with multiplelayered closure,
in the incidences of these complications.
17,
18 while other studies show no di erence
19
Given the shorter
TABLE 6-1: RATE OF RESORPTION
OF DIFFERENT SUTURE MATERIALS
Suture Material
Rapidly resorbable
Catgut 15
Chromic catgut 90
Polyglycolic acid (Dexon) 20
Polyglactin 910 (Vicryl) 60–90
Slowly resorbable
Polydioxanone (PDS) 180
Polyglyconate (Maxon) 180
Nonresorbable
Nylon (Nurulon)
Polypropylene (Prolene)
Polyethylene (Ethibond)
Polyamide (Ethilon)
Dexon (Davis and Geck, Wayne, NJ, USA), Vicryl (Ethicon,
Somerville, NJ, USA), PDS (Ethicon), Maxon (Davis and Geck),
Nurulon (Ethicon), Prolene (Ethicon), Ethibond (Ethicon), Ethilon
(Ethicon).
Modi ed from van’t Riet, et al. 32
Time Until Total
Resorption (days)
−
−
−
−
time required to close the fascial layers en mass, this method
is generally preferred.
e relative advantages of resorbable versus nonresorbable
suture for use in closing the fascia have long been debated.
Opponents of closure with nonresorbable suture invoke
higher rates of suture sinus formation and increased postoperative pain; the incidences of these complications have
been estimated at 8% and 17%, respectively. In contrast, it
has been suggested that closure with resorbable suture may
lead to increased incidences of dehiscence and hernia formation owing to an intrinsic loss of tensile strength during
the postoperative period. While these complications are
certainly seen with increased frequency when absorbable
19
catgut suture is used,
the literature has not consistently
borne out an association between wound failure and the
use of resorbable sutures such as polyglycolic acid (Dexon),
polyglactic acid (Vicryl), polydioxanone (PDS), and polygly-
20–25
conate (Maxon).
In particular, several studies comparing
permanent (Prolene, Ethicon, or Nylon) and slowly absorbable suture (PDS and Maxon) have failed to demonstrate
any advantage to the use of nonresorbable suture. ere may
be some advantage to the use of slowly resorbable compared
to rapidly resorbable suture; one study demonstrated a signi cant decrease in the rate of hernia formation when slowly
resorbable suture (PDS and Maxon) were used compared to
more rapidly resorbable sutures (catgut, Dexon, and Vicryl)
25,
( p = 0.009).
26 Nonresorbable suture does appear to be
associated with a higher incidence of suture sinus formation. is association may be greatest with multi lament
permanent suture, which may abet bacterial ingrowth and
21,
infection.
24 Table 6-1 shows the rates of resorption for dif-
ferent suture materials.