Surgical Incisions pdf - D. Alaa

THI-QAR MEDICAL COLLEGE

2015-2016

GENERAL SURGERY

YEAR

Surgical incisions

General  principles
To select   appropriate  incision  should   be :-
1-  near  by    the    suspected    target  (  i.e    grid  iron    in
appendecectomy )
2-extensiblty  for  exposure    so  in explorative  laparotomy
do midline incision
3-rapidity such  as top emergency or  critical  cases
4- less complication , (hernia  , infection
-Security    avoid    injury      to  vessels  or    nerve    or    5-  avoid
important  structure (nerve,
6- cosmetic  skin creases

Abdominal incisions

I -Vertical
1- Medline incision
Through  linea alba
            Advantages :  a vascular   field  , opened readily & closed easily
    Enlarged  quickly ,  dose not damage muscles Usually  used  in explorative  laparotomy

Disadvantage :- high post op hernia specially in lower abdomen

2-paramedian Incision
Through rectus sheath 2.5 cm from midline
can extended to thorax ( thoracoabdominal incision ) & to flank

II - transverse incision

1-Upper  abdomen used   in  children  ,  cholicystectomy ,  or  any
upper  abdominal  pathology
  2-Supraumbelical  &    infraublical    :-    used      in  paraumblical
hernia , first  incision  of  laparoscopy
3-  Pfannenstiel  ´s  incision    :-      in    gynecological      &  pelvis
operation s
4- Lance :- is  more  or  less transvers  or oblique ,  its   cosmotic
incision  for appendicectomy

III- oblique incisions

1-Kocher(sub costal)  at   Rt  for gallbladder & liver   operation
While  Lt for  spleen   op
  2-Grid iron  is incision  which  cruses  on line between umbilical  &  sup. Iliac spine at  Mc
Berny  point   lat.  to  rectus  sheath  on ext. & int. & transv . abdominal  muscles  usually
splitting  of  muscle ,   used  in apendecectomy , its good  incision less post op  hernia
3- Retherford  Morriss  is  extended   grid  iron   up  or down   with  muscle  cutting  ,
used in complicated  apendecectomy
4- Lumber Moressian   sub costal  at  lumber  area  used  in renal  & uretric surgery
5-Inguainal  incision  used  for inguinal  hernia

Thoracic incisions

1-Thoracostomy(chest  tube )
5th  ICS  at ant ant. axillary line
  In heamo- or  pyothorax
2-Mediastenial vertical incision  used  for cardiac  op
3-Intercostals at  5th ICS & 8th ICS
4-Thoracoabdominal  extended to Rt or Lt paramedian    used  for oesophagial   op



Breast incisions

1- Circumareolar incision : - around areola , used in lumpectomy , gynecomastia

2- Mastectomy incisions :- there is many types of incisions (Steward for simple
Mastectomy , Orr , Grey for radical (Halisid ) op …. )

Neck & face incisions

1-Coller  incision  transverse  incision  at
lower  neck  2.5  cm  above  suprastrnal
notch for thyroid & parathyroid   surgery
2- Neck dissection  for   radical neck  LN
dissections

a) Mac Fee incision (2 horizontal

incisions 1st from mastoid to
hyoid , 2nd above clavicle 2cm

3-Periauricular    for parotidectomy
Other    face    incisions  should    be    with
skin  creases for good  cosmotics

Complications of incisional wound

Early
1-Wound infection & seroma
  open  stitch  and  evacuation of  pus or  serous   fluid ,  daily dressing
2-skin   allergy  from plaster, dressing or content  of  wound discharge
3- stitch abscess ( Rx  :-  removal of  infected stitch)
4-Wound   dehiscence
  if  partial  can  use  plastering  and  delay  removal  of  stitches
  if  major  should  reoperation  and  close  it  again with  use  tension   suture
5-non    or    bad  healing    due    to  bad    technique  (over  lap  ,  everted    ,  enverted  )  or  poor
immunity(DM ,uremic …) or early  removal

Late:
1-Incisional Hernia
2-Hypertrophic scar  or  kiloid
3- Chronic Pain ( specially  if nerve  entrapment
4-Hyper- or hypopegmentation
This complication  due  to :-
--Pt  causes ( poor immunity , post  op.  cough ,near by  source  of
infection   like   colostomy

keloid

--Surgeon  causes (  use  inappropriate   stitches , poor  handling  …)
--Nurses causes (  poor and  inappropriate  dressing
--Operation  causes ( poor sterilization )

Suture materials

Classification according   to :-
Absorbtion :-
1- Absorbable   like  plain  or  chromic  catgut
2-delay  Absorbable (  PDS , vicryl ,
3- Non absorbable  ( silk ,  nylon ,metalic  clips)
Biological or synthetic
--Biological    like
    . cutgut  from  sheep  intestine
    . silk  from silkwarm larva, cotton
--Synthetic  vicryl ,  nylon ,  PDS , metalic  clip
Coated or   non  coated

Suture Packaging

Methods of anastomosis

End  to  end
End  to  side
Side  to side

Removal of  suture
Early as possible , depend  on
Site :- face   &neck  3-5  days , while  in abdomen   7-8d , In joint  more

assesst.prof Dr. alaa jamel

MRCSI

C.A.B.S. MBCHB