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4 Fundamentals ofPatient Positioning andSkin Prep
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77
abdominal skin) and by three log10 at moist sites
(e.g., groin), when tested at both 10min and 6h.
Besides hand hygiene and sterile gloves and
instruments, proper patient’s skin preparation
contributes to reduce the risk of surgical wound
contamination. The rst antiseptic agent used
from Lister was phenol, promptly replaced by
cresol which was ten times more active and less
corrosive on living tissues.
Respectively, in 1950 and 1955, chlorhexidine
gluconate and povidone-iodine solutions were
introduced into commercial use, and they are still
widely used as antiseptic agents in the surgical
eld.
4.4.1 Preoperative Home
Shower/Bath
Preoperative home showering with antiseptic
agents is considered a well-accepted procedure for
reducing skin microora, but its efcacy in ultimately reducing surgical site infection is debated.
The most used antiseptic for this purpose is by
far chlorhexidine gluconate.
Chlebicki etal. selected 16 prospective randomized or quasi-randomized trials comparing preoperative chlorhexidine baths versus non- antiseptic soap
baths or no baths, focusing on surgical site infection
outcomes [12]. They found the incidence of developing a surgical site infection to be statistically nonsignicant between the two groups, as 6.8% of the
patients developed SSIs in the chlorhexidine group
versus 7.2% in the control group.
The authors also concluded that these results
could be biased by different antibiotic prophylaxis
and/or by patients’ lack of bathing instructions.
In fact, Paulson etal. showed that a daily 4%
chlorhexidine gluconate for 5 days progressively
reduced the microbial load of abdominal and
inguinal region [13].
Chlorhexidine is found to have a cumulative
antibacterial effect that lasts longer than other
antiseptic agents.
Despite this ndings, WHO’s global guidelines for the prevention of surgical site infections
still advise to bathe or shower with either plain or
antimicrobial soap before surgery [14].
4.4.2 Hair Trimming
According to WHO, hair should not be removed
from the patient’s surgical eld. If necessary, they
should be trimmed with a clipper preoperatively
or in the operative room, as shaving is strongly
discouraged at all times. In fact, in a review from
2011, the authors identied three trials that compared shaving with clipping and showed that the
incidence of SSIs was signicantly higher in the
shaving groups (RR 2.09). Probably this evidence
could be elucidated by less skin trauma caused by
the clipper compared to the razor [15]. However,
the same review showed no statistically signicant difference in SSI rates between hair removal
and no hair removal [14].
4.4.3 Surgical Site Preparation
The purpose of the presurgical treatment of intact
skin in the OR is to reduce as much as possible
the load of skin bacteria before incision of the
skin barrier. The three important variables contributing to a surgical site infection are the dose
of bacterial contamination, the virulence of the
bacteria, and the resistance of the host. Surgical
skin preparation can affect only the rst of such
variables [16]. It has been shown how the risk for
surgical site infection increases signicantly if
the wound is contaminated with more than 105
microorganisms per gram of tissue. Whenever a
foreign body is present at the surgical site, however, this amount is much lower however (100
staphylococci per gram of tissue on braded
suture).
The skin is not a sterile surface; bacteria
tend to colonize the deeper layers of the stratum
corneum and therefore cannot be shed by simple desquamation. Antiseptics bind to the stratum corneum to prolong their chemical action,
together with a mechanical action, in order to
kill and inhibit contaminating and colonizing
ora. Commensal ora comprises Staphylococci,
Pseudomonas, Propionibacteria, and diphtheroid
organisms which can lead to harmful infection if
they are allowed to grow and overcome host’s
defenses.
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Fig. 4.16 Surgical site preparation (taken from web)
A thorough preoperative skin preparation is
thus recommended routinely, and its efcacy is
thought to be dependent to the antiseptic used
and the method of application. According to the
Center for Disease Control and Prevention
(CDC), the patient’s surgical site should be
prepped as follows [17]:
• The skin must be primarily cleaned from gross
contamination (dirt, soil, etc.).
• The site of the area prepared should be suf-
cient to include any potential incision different
from the main incision site, including drains.
• The solution should be applied in concentric
circles.
• A dedicated instrument should be used
(sponge, swab), and the applicator should be
discarded once the periphery has been
reached.
• Time should be allowed for the solution to dry,
as alcohol-based solutions are ammable, and
to achieve a complete antimicrobial effect, as
per manufacturer.
Also the Association of periOperative
Registered Nurses (AORN) stated that the applicator used should be sterile and the solution
should be applied with friction and extend from
the incision site to the periphery (Fig.4.16) [18].
In fact, friction increases the antibacterial effect
of an antiseptic. For instance, alcohol applied
without friction reduces bacterial counts by 1.0–
1.2 log10 CFU, as compared with 1.9–3.0
log10CFU when friction is used.
G. Giambartolomei et al.
4.4.4 Antiseptic Solutions
The ideal antiseptic agent should have the following properties:
• Kill all bacteria, fungi, protozoa, viruses,
tubercle bacilli, and spores.
• Nontoxic.
• Hypoallergenic.
• Safe to use in all body regions.
• Not be absorbed.
• Present residual activity.
• Safe for repetitive use.
Lately two kinds of antiseptics have been uti-
lized for surgical skin preparation:
– Iodine-/iodophor-based solutions: effective
against a wide spectrum of Gram-positive and
Gram-negative bacteria, tubercle bacillus,
viruses, and fungi. The mechanism of action
comprises free iodine molecules bound to a
polymer (povidone) that can penetrate cell
walls and oxidize microbial contents. It is
soluble in both water and alcohol. The risk of
side effects, such as staining, tissue irritation,
and iodine absorption, is lower with iodophors than with aqueous iodine. Increased
serum iodine levels have been found in
patients, so other products should be considered for patients with thyroid dysfunction.
The efcacy of iodophors is reduced in the
presence of organic material such as the
blood. They are, however, preferred for antisepsis of mucous membranes and open
wounds.
– Chlorhexidine gluconate-based solutions:
aqueous or alcoholic; it is effective against a
wide range of Gram-positive and Gramnegative bacteria, yeasts, and some viruses. It
is most commonly formulated as a 4% aqueous solution, but the alcoholic version seems
to result in having a superior antimicrobial
activity. Chlorhexidine gluconate destroys the
bacterial cell membrane, resulting in a bactericidal effect, especially for vegetative Grampositive and Gram-negative bacteria. In
addition, it has a durable antimicrobial action
4 Fundamentals ofPatient Positioning andSkin Prep
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79
for up to 6h. However, chlorhexidine has little
activity against bacterial and fungal spores.
The alcoholic compounds are not suitable for
use at or in close proximity to mucous membranes or the eyes.
A recent Cochrane review (2015) highlighted
how 0.5% chlorhexidine in methylated spirit was
superior to povidone-iodine paint only in one
study [15] out of 13 clinical trials where it
achieved a statistically signicant result in terms
of SSI rate [15]. They recruited 542 patients
undergoing clean surgery classied as “hernia,
genitalia, veins and other clean operations” and
showed a 13% of SSI rate in the povidone-iodine
versus 6.3% in the chlorhexidine group. It is
important to note, though, that they did not report
the concentration of povidone-iodine paint.
All other trials reported in the review were
based on comparison either of two different antiseptics or different concentrations of the same
antiseptic, and no statistical signicance in term
of SSI rate was found.
However, the WHO global guidelines for the
prevention of SSI strongly recommend the utilization of alcohol-based antiseptic solutions with
chlorhexidine gluconate for surgical site skin preparation in patients undergoing surgical procedures,
in spite of low to moderate level of evidence.
Ostomies and open wounds require special
consideration. First of all, no chlorhexidine products can be used. Sponges used to prep open
wounds, and intestinal stomas, should be used
once and then discarded. The intact skin should be
prepped rst, before open wounds and ostomies.
For intestinal ostomies that are not part of the
surgical eld, seal off the ostomy with a sterile
adhesive drape, prior to the surgical site preparation. If the ostomy is in the surgical eld, place a
soaked sponge over the stoma before the intact
skin is prepped, and then discard at the end of the
prep. The mucin and organic matter can inhibit
the effectiveness of antiseptic agents, and it
should be mechanically removed along with the
residual of the adhesive material of the ostomy
bag. Some surgeons elect to close the skin of the
mucocutaneous junction with running sutures to
avoid spillage, using a separate prep and surgical
tray. This is especially helpful during ostomy
takedown during the dissection around the
ostomy itself. Urostomies can be gently cannulated with red rubber catheters secured with sterile adhesive drapes. Prepare the ostomy gently in
order to avoid mucosal injuries.
Open wounds, especially if traumatic, should be
mechanically debrided using normal saline with a
drip sheet under the wound. The surrounding area
should be prepped rst, while the open wound is
packed with sterile gauze. The gauze should then
be discarded, and the open wound prepped last.
4.4.5 Antiseptic-Related Fires
A general concern regarding alcohol-based solutions has always been their potential ammability, which is highly increased in the presence of
other two components such as oxygen and heat
that are largely present in the operative room
[19]. These concepts will be further expanded
upon in Chap. 25.
As clearly illustrated in the surgical triangle of
re showed below (Fig. 4.17), there are many
factors that contribute to initiate a re in the operating room, and all must be taken into considerations. Alcohol preparations account for the fuel
aspect, especially when they are pooled or are not
allowed to dry correctly or are spilled largely
over drapes and gowns.
Vo et al. reported their own case of a thirddegree burn occurred in a urologic procedure,
which required the intervention of a plastic surgeon afterward [20]. The solution used was 2%
chlorhexidine in 70% isopropyl alcohol. They
also reported other six cases of accidental res
occurred during surgery, and they nally proposed best practice recommendations:
1. Before the application of chlorhexidine, the
surgeon should ensure that no absorptive
materials are present or should remove them
after the patient has been prepped.
2. A sufcient amount of visibly dyed chlorhexi-
dine should only be used to prevent pooling.
Application of chlorhexidine-soaked sponges
should be avoided.
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G. Giambartolomei et al.
Common Fuels in the OR:
• Alcohol skin preps
• Drapes
• Gowns
• Gauze
• Hair
Oxidizers in the OR:
• Oxygen
• Nitrous Oxide
Fig. 4.17 Surgical triangle of re (taken from web)
3. Ensure complete evaporation of chlorhexidine
by allowing a longer drying time than what is
recommended by the manufacturer (2min to
3min); 5min is preferred.
4. Residual chlorhexidine should be dried with a
surgical towel.
5. Surgical drapes should only be applied once
chlorhexidine has completely evaporated.
Adhesive drapes should be used and arranged
so that residual chlorhexidine vapor is directed
away from the surgical eld.
6. The electrocautery unit should be used with
the lowest possible setting and should be
placed in its quiver when it is not being used.
4.4.6 Preoperative Sterilization
Sterilization is a process aimed to eliminate all
microorganisms and spores from an instrument
or device. There are different levels of sterilization based on the different degrees of resistance
of the microorganisms. The capacity of the
microorganism to resist sterilization depends,
in terms, on the presence, composition, and
thickness of the cell wall or viral envelope, the
OR Heat Sources:
also called Ignition Source
• Electrosurgical units
e.g., the “Bovie”
• Lasers
• Fiberoptic light source
ability to form spores, and the sensitivity to
heat, chemicals, and disinfectants. Since the
bacterial spores are among the most difcult to
eliminate, the
process capable of eliminating
such spores is considered sufcient to eliminate
other infectious agents. If bacterial spores are
not eliminated, the process cannot be named
sterilization but “high- level disinfection.”
The process of sterilization is composed of
several phases.
Initially the instruments have to be cleaned by
mechanically removing the gross contamination
of organic and inorganic matter. This process is
called decontamination. In fact, the presence of
mechanical matter can decrease the efcacy of
microbicidal agents.
The next step is the inspection to assure that
the gross matter has been effectively removed.
The instruments are then assembled in trays
and packed specically to allow the sterilizing
agents to be effective. The packaging system
should be permeable to the sterilizing agent but
resistant to traction and manipulation.
4.1 summarizes the different types of
Table
sterilizing agents with their advantages and
limitations.
4 Fundamentals ofPatient Positioning andSkin Prep
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Table 4.1 Summary of the different sterilizing agents with their advantages and limitation
Method Advantages Limitations
Heat (steam
sterilization)
Heat (dry air)
Ethylene oxide
Hydrogen
peroxide
plasma
Liquid
peracetic acid
in automatic
equipment
Formaldehyde
From WHO Library Cataloguing-in-Publication Data WHO guidelines for safe surgery: 2009: safe surgery saves lives.
ISBN 978 92 4 159855 2 (NLM classication: WO 178) © World Health Organization 2009. Requests for permission
to reproduce should be addressed to WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27,
Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4806; e-mail: permissions@who.int). Permission not requested
• Short exposure • Not compatible with thermolabile items
• Effective for prions • Does not eliminate pyrogens
• Not toxic for humans or the environment • Cannot be used for oils or powders
• Easy certication
• Low cost
• Widely available
• Easy to operate
• Not corrosive • Long exposure
• Deep penetration • Not compatible with thermolabile items
• Not toxic for humans or the environment • Hard to certify
• Easy to operate • High cost
• Widely available • Efcacy against prions not known
• Compatible with thermolabile items • Long exposure
• Penetrates certain plastics • Not effective for prions
• Easy to operate • Toxic for humans and
• the environment
• Compatible with thermolabile items • Not all materials are compatible
• Short exposure • Not effective for prions
• Not toxic for humans or the environment • Does not reach the center of long lumens
effectively
• Easy to operate
• Short exposure • Useful only for materials that can be immersed
• Easy to operate • In existing equipment, few containers can be
processed
• Not toxic for the environment • Not effective for prions
• Processed items must be used immediately
• Compatible with thermolabile items • Not all materials are compatible
• Short exposure • Not effective for prions
• Easy certication
81
Take-Home Points
• The patients’ safety in the OR is guaranteed
via a systematic approach by the entire operative team.
• The utilization of team huddles and preoperative checklists and time-out has become the
standard approach currently followed in operating rooms.
• A thorough knowledge of the pathophysiology and etiology of potential position-related
injuries should be part of a well-rounded
surgeon.
• Simply taping the eyelids during general anesthesia can prevent minor damages secondary
to anesthesia-related reduction of tears.
• Ulnar neuropathy is the most common peripheral neuropathy.
• Besides hand hygiene and sterile gloves and
instruments, proper patient’s skin preparation
contributes to reduce the risk of surgical
wound contamination.
• Antiseptics bind to the stratum corneum to
prolong their chemical action, together with a
mechanical action, in order to kill and inhibit
contaminating and colonizing ora.
Editors’ Comments
• Appropriate patient positioning is a critical
part of any operation. Residents should be
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G. Giambartolomei et al.
knowledgeable about the benet and risks
associated with having any patient rest on the
operating room table in a specic position for
any given time. A surgical trainee should
study the specic position required for a procedure with the same focus they use with any
other step of the operation.
• The operating room table—with its several
additional components—is a part of the operating room the surgical trainee needs to be
familiar with it to allow for maximum benet
to be derived from its use.
Suggested Readings
Warner MA.Perioperative neuropathies. Mayo Clin Proc.
1998;73(6):567–74.
O’Connell MP.Positioning impact on the surgical patient.
Nurs Clin North Am. 2006;41(2):173–92, v
Dumville JC, McFarlane E, Edwards P, Lipp A,
Holmes A, Liu Z. Preoperative skin antiseptics
for preventing surgical wound infections after
clean surgery. Cochrane Database Syst Rev.
2015;4:CD003949.
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis
WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices
Advisory Committee. Infection control and hospital
epidemiology. 1999;20(4):250–78; quiz 79–80.
References
1. Manfredini M, Ferrante R, Gildone A, Massari
L.Unilateral blindness as a complication of intraoperative positioning for cervical spinal surgery. J Spinal
Disord. 2000;13(3):271–2.
2. Cheney FW, Domino KB, Caplan RA, Posner
KL.Nerve injury associated with anesthesia: a closed
claims analysis. Anesthesiology. 1999;90(4):1062–9.
3. Warner MA. Perioperative neuropathies. Mayo Clin
Proc. 1998;73(6):567–74.
4. Warner MA, Warner ME, Martin JT. Ulnar neu-
ropathy. Incidence, outcome, and risk factors in
sedated or anesthetized patients. Anesthesiology.
1994;81(6):1332–40.
5. O’Connell MP. Positioning impact on the surgical
patient. Nurs Clin North Am. 2006;41(2):173–92.
6. King CA, Bridges E.Comparison of pressure relief
properties of operating room surfaces. Perioper Nurs
Clin. 2006;1(3):261–5.
7. Primiano M, Friend M, McClure C, et al. Pressure
ulcer prevalence and risk factors during prolonged surgical procedures. AORN J. 2011;94(6):
555–66.
8. Slater MS, Mullins RJ.Rhabdomyolysis and myoglobinuric renal failure in trauma and surgical patients: a
review. J Am Coll Surg. 1998;186(6):693–716.
9. Furnas H, Canales F, Buncke GM, Rosen
JM. Complications with the use of an axillary roll.
Ann Plast Surg. 1990;25(3):208–9.
10. Graling PR, Colvin DB. The lithotomy position in
colon surgery. AORN J. 1992;55(4):1029–39.
11. Global guidelines for the prevention of surgical site
infection. Geneva: World Health Organization; 2016.
Available from: https://www.ncbi.nlm.nih.gov/books/
NBK401132/.
12. Chlebicki MP, Safdar N, O’Horo JC, Maki
DG. Preoperative chlorhexidine shower or bath for
prevention of surgical site infection: a meta-analysis.
Am J Infect Control. 2013;41(2):167–73.
13. Paulson DS. Efcacy evaluation of a 4% chlorhexidine gluconate as a full-body shower wash. Am J
Infect Control. 1993;21(4):205–9.
14. Byrne DJ, Napier A, Cuschieri A. Rationalizing
whole body disinfection. J Hosp Infect. 1990;15(2):
183–7.
15. Tanner J, Norrie P, Melen K. Preoperative hair
removal to reduce surgical site infection. Cochrane
Database Syst Rev. 2011; (11):Cd004122.
16. Dumville JC, McFarlane E, Edwards P, Lipp A,
Holmes A, Liu Z. Preoperative skin antiseptics
for preventing surgical wound infections after
clean surgery. Cochrane Database Syst Rev. 2015;
(4):CD003949.
17. Mangram AJ, Horan TC, Pearson ML, Silver LC,
Jarvis WR.Guideline for prevention of surgical site
infection, 1999. Hospital Infection Control Practices
Advisory Committee. Infection control and hospital epidemiology 1999; 20(4): 250–78; quiz
79–80.
18. Girard NJ. Standards, recommended practices, and
guidelines. AORN J. 2006;83(2):307–8.
19. WHO guidelines for safe surgery: 2009: safe surgery
saves lives. ISBN 978 92 4 159855 2 (NLM classication: WO 178) © World Health Organization. 2009.
20. Vo A, Bengezi O.Third-degree burns caused by ignition of chlorhexidine: a case report and systematic
review of the literature. Plast Surg (Oakville, ON).
2014;22(4):264–6.
Fundamentals ofIncisions
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andSkin Closures
FolasadeO.Imeokparia, MichaelE.Villarreal,
andLawrenceA.Shirley
5
5.1 Introduction
Every operation is punctuated by what may
appear to be the most basic of surgical actions, the
creation and closure of the incision. Basic as these
may seem, a sound understanding of anatomy and
physiology for the creation and re- approximation
of wounds is required to successfully complete
the operation planned, allow the patient the best
opportunity for wound closure, and avoid costly,
physically, and/or mentally burdening postoperative morbidities.
The general concepts of modern-day incision
and closure were rst described in the mid- to
late nineteenth century. The Austrian anatomist,
Karl Langer, is credited with the description of
scar orientation based on local collagen congurations. Known as “Langer lines,” these orientation patterns served as unofcial guidelines for
surgical incisions (Fig.5.1a). However, Langer’s
descriptions were largely applicable to the cadaveric tissue he studied. In practice, invivo wounds
and scars varied from the anticipated results predicted with “Langer lines.” Austrian-born plastic
surgeon, Cornelius Kraissl, was later attributed
F. O. Imeokparia · M. E. Villarreal • L. A. Shirley (*)
Department of Surgery, The Ohio State University
Wexner Medical Center, Columbus, OH, USA
e-mail: Lawrence.Shirley@osumc.edu
with describing the more optimal placement of
incisions along tissue folds. This orientation
allowed for an individual’s natural folds to act as
a guideline for incisions given that the perpendicular muscle contractions in relation to the skin
would create folds unique to an individual
(Fig.5.1b). The use of skin folds minimizes the
less appealing scarring from following “Langer
lines” in live tissue. Consequently, the modernday verbiage “Langer lines” is often conated
with the more optimal orientation described by
Kraissl.
While the tenets of successful incisions and
closure have evolved since the days of Langer
and Kraissl, a strong understanding of anatomy,
wound behavior, and healing still applies. This
chapter will address the principles of incision and
closure of routine general surgery procedures.
5.2 General Concepts
The anatomic considerations of incisions and
closures begin with an understanding of the skin
structure and properties. The largest organ of the
body, the skin, oversees several functions: protection of the internal organs from the environment (e.g., trauma and pathogens), temperature
regulation, as well as neurosensory interface
(pain, temperature, pressure).
© Springer International Publishing AG, part of Springer Nature 2018
F. Palazzo (ed.), Fundamentals of General Surgery, https://doi.org/10.1007/978-3-319-75656-1_5
83
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F. O. Imeokparia et al.
a
b
Fig. 5.1 (a) Langer lines (via Basic Techniques in
Pediatric Surgery. Carachi R, Agarwala S, Bradnock TJ
(Eds). Springer-Verlag Berlin Heidelberg 2013. Chapter
A7: Skin Lines and Wound Healing; pg 34-35). (b) Kraissl
The skin is divided into three main layers: the
(a) epidermis, (b) dermis, and (c) subcutaneous
tissue (Fig.5.2).
The epidermis consists of four layers (from
deepest to supercial): stratum basale, stratum spinosum, stratum granulosum, and stratum corneum.
Some regions of the skin contain an additional layer
known as the stratum lucidum that lies between the
stratum granulosum and corneum. This is most
commonly found in areas of the body with dense
thickness, such as the bottom of the feet and the
palms of the hands. The stratum basale houses the
melanocytes that give the skin its pigmentation.
Within the epidermis, there are no blood vessels.
The dermis hosts blood vessels, nerve receptors, sweat and sebaceous glands, as well as hair
lines (via Borges AF, Alexander JE.Relaxed skin tension
lines, Z-plasties on scars, and fusiform excision of lesions.
Br J Plast Surg. 1962;15:242-254)
follicles. This layer is known for its protective
function. The dermis contains abundant broblast cells that produce collagen. Collagen creates the strong tensile strength of the skin. The
subcutaneous tissue has two components, a
supercial fatty layer (Camper’s fascia) and a
membranous deep layer (Scarpa’s fascia).
The physiologic considerations pertaining to
incisions and closures center around wound healing. This process involves three phases: inammatory, proliferative, and remodeling. The
inammatory period is characterized by epithelialization. The proliferative period is notable for
collagen deposition, granulation deposition, and
neovascularization. Lastly, the remodeling period
consists of collagen cross-link formation.
e
5 Fundamentals ofIncisions andSkin Closures
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Fig. 5.2 Layers of the
skin (via Plastic and
Reconstructive Surgery.
Siemionow, M,
Eisenmann-Klein, M
(Eds.). Springer-Verlag
London Limited 2010.
Chapter 7: Grafts,
Local and Regional
Flap; pg 69)
85
Epidermis
Dermis
Subcutaneous tissu
Muscle
Factors that inhibit wound healing include
desiccated environments, hypoxemia or frank
ischemia, and the presence of devitalized or
necrotic tissue. With these concepts in mind, creation and closure of an incision require attention
to conrming hemostasis, preserving surrounding structural integrity, and maintaining sterility.
The process of wound healing begins in the rst
24h after a wound is created and lasts for up to
1year. During this time, the tensile strength of a
wound will increase as collagen is formed. At
approximately 3weeks after an incision or wound
is created, the tissue has about 20% of the original
strength of the tissue. Between 6 and 8weeks, the
tissue will have about 70% of the original strength
of the tissue. Through the remainder of the healing
process, the wound will only increase to a maxi-
mum of 80% of the original strength of the tissue.
5.3 Technical/Practical
Considerations/Safety
Precautions
5.3.1 Incisions: General
Considerations
The major goal in choosing the optimal surgical
incision is assuring adequate exposure. Simply
identifying the most advantageous access point
for the specic target organ while keeping in mind
potential additional components to the procedure
is an essential piece to selecting the right incision;
for example, a pathology’s lateral position within
a cavity may alter the benet of certain incisions;
similarly planned or potential stomas should be
considered for preoperative marking. Given the
breadth of general surgery, there is a wide range
of possible operative sites and incisions.
Careful handling of tissue is also important
during incision. The use of tools that result in
crushing of the skin should be avoided as this may
lead to unsightly scarring from damage to the epidermis. The least damaging method for handling
or retraction of the skin should be employed such
as that achieved with ne skin hooks or Adson
forceps. If pursuing exploration or a planned procedure on a prior surgical site, it is recommended
to follow the scar of the previous incision. Parallel
or adjacent incisions should be avoided because
the intervening tissue between the previous scar
and the new incision is susceptible to ischemia
and/or necrosis from interrupted blood supply.
Moreover, it is ideal to avoid creating multiple
defects, knowing that each defect only achieves
80% of the original tissue strength.
5.3.2 Incisions: Technical
andPractical Considerations
When making an incision, one should stretch and
apply tension to the skin at the starting point with
the non-dominant hand and, with the belly of the
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blade (if using sharp dissection), draw the scalpel
perpendicular along the line of the planned incision with the dominant hand. If possible, this
should be accomplished with a single sweep of
the scalpel. Multiple sweeps will result in
detached or ragged edges of the skin and subcutaneous tissue at different levels within the incision that may result in delayed wound healing or
necrosis. The pressure utilized should be enough
to incise through the epidermal and dermal layers. Once through the dermal layer, the additional
tissue may be further dissected sharply with the
scalpel or with electrosurgical energy.
Whether sharp dissection with a scalpel or
electrosurgical energy is used for the creation of
a skin incision has been a question posed and
investigated over many years. A meta-analysis of
these randomized controlled trials by Ly showed
no difference in wound complication rates or
pain scores between the two modalities but did
nd electrosurgical energy to result in less blood
loss and shorter incision time [1].
The following content will highlight common
incisions of the abdomen, retroperitoneum, neck,
and breast.
5.3.3 Incisions: Abdomen
After incising through the skin and subcutaneous
fat, the abdominal fascia is encountered: a small
incision created sharply with knife, scissors, or
electrosurgical energy should be used to begin
opening of this layer. Once the bers of the fascia
are divided, the opposing sides can then be gently
grasped with clamps and then lifted upward while
concurrently being pulled slightly apart by an
assistant. This maneuver will bring the peritoneum into view so that it may be sharply incised
exposing a small window into the peritoneal cavity. This window should be spread or further
incised so it is wide enough to t two ngers
inside the intra-abdominal space. Using electrosurgical energy or sharply with scissors, the
length of the remainder of fascia can be opened
using an assistant’s hands or the surgeon’s opposite hand to guide and gently lift the abdominal
tissue upward for direct visualization and avoid
injury to structures in the abdominal cavity. If
possible, extending the incision a short distance
superiorly or inferiorly will allow for entrance
into the intra-abdominal space through an area
where adhesions are less likely to be encountered. Many incisions can be used to access the
peritoneal and retroperitoneal spaces of the abdomen (Fig.5.3).
5.3.3.1 Vertical Midline
Abdominal pathologies of the upper and lower
intraperitoneal cavity are generally suitable for a
vertical midline incision. This incision should
follow the linea alba through its length. The linea
alba is the band of connective tissue separating
the bilateral muscle pairings of the rectus abdominis in the anterior abdominal wall. A true midline vertical incision will avoid entrance into
muscle or damage to major vessels or nerves and
is a convenient avascular plane. Two anatomic
structures to be aware of in the entry through a
midline incision include the falciform ligament
superiorly and the bladder inferiorly. Superiorly,
the falciform ligament may require ligation to
accommodate visualization in the upper abdominal structures, while incisions extending to the
suprapubic region should include careful visualization or palpation of the bladder to avoid inadvertent injury in the suprapubic space. As a
midline incision extends caudally, the umbilicus
can be followed with a slight curvilinear deviation to either the left or the right and brought back
to midline. When pathologies are anticipated in
the upper abdominal cavity such as with the distal esophagus, stomach, proximal duodenum,
liver, and pancreas, the incision can be limited to
superior to the umbilicus. Similarly, when the target organ is in the lower abdominal cavity such as
with the sigmoid, rectum, or bladder, the incision
can be kept inferior to the umbilicus. Although
midline incisions are the mainstay for abdominal
operations, several other incisions hold specic
benets (Table5.1).
5.3.3.2 Paramedian
The less often-used paramedian abdominal incision is created 2 to 5 centimeters lateral from the
midline. The incision remains vertical through its
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