Injury pdf - د. رامز

Dr. Ramez
Lec. 2

ABDOMINAL INCISIONS

WOUND HEALING

Tues. 3 / 3 / 2015

DONE BY : Ali Kareem

مكتب اشور لالستنساخ

2014 – 2015

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

ABDOMINAL INCISIONS

A cut produced surgically by a sharp instrument that creates an opening into the
abdomen .

When choosing an incision these three should be achieved :

  Accessibility
  Extensibility
  Security

Re-entry into the abdominal cavity is best done through the previous laparotomy
incision. This minimizes further loss of tensile strength of the abdominal wall by
avoiding the creation of additional fascial defects

CLASSIFICATIONS :

 Vertical incision

 Midline incisions
 Paramedian incisions

 Transverse and oblique incisions

  Kocher's subcostal Incision
   Chevron (roof top Modification )
  Mercedes Benz Modification
  Mc Burney’s grid iron or muscle splitting incision.
  Rutherford morison incision
  Pfannenstiel incision
  Maylard Transverse Muscle cutting Incision
  Transverse muscle dividing incision

 Thoracoabdominal incisions

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

MIDLINE

the most common incision

three types :

 Upper Midline Incision

 From xiphoid to above umbilicus.
 Skin



superficial and deep fascia



linea alba



extraperitoneal fat



peritonium.

 Lower Midline Incision

 From the SUPERIOR umbilicus to INFERIOR pubic symphysis

 Full Midline Incision

 From xiphoid to pubic symphysis inferiorly

Advantages :

  Adequate exposure of most if not all of the abdominal viscera
  It is almost bloodless.
   No muscle fibers are divided.
   No nerves are injured.
  It is very quick to make as well as to close.

Disadvantages :

  More painful.
   Chest complications.
   Wound infection, Ugly scar,  Incisional hernia, etc.

PARAMEDIAN

 2 to 5 cm lateral to the midline.
 skin



fascia



anterior rectus sheath



The posterior rectus sheath or

transversalis fascia



extraperitoneal fat and peritoneum are then excised

allowing entry to the abdominal cavity

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

 Skin and subcutaneous fat are divided along the length of the wound. The

medial portion of the rectus sheath then is dissected from the rectus muscle,
to which the anterior sheath adheres Once the rectus muscle is free of the
anterior sheath it can be retracted laterally because the posterior sheath is
not adherent to the rectus muscle. The posterior sheath and the peritoneum
which are adherent to each other, are excised vertically in the same plane as
the anterior fascial plane

Advantages :

 Provide an access to the lateral structure such as the spleen or the kidney
 The closure is theoretically more secure because the rectus muscle can act

as a support between the reapproximated posterior and anterior fascial
planes so lower risk of dehiscence and hernia as compared to midline
incision

Disadvantages :

  Takes longer to make and close
   results in atrophy of the muscle medial to the incision
  The incision is laborious and difficult to extend superiorly as is limited by

costal margin.

 Risk of epigastric vessels injury

TRANSVERSE AND OBLIQUE INCISIONS

KOCHER ‘S INCISION

 Incision parallel to the right costal margin. started at the midline, 2 to 5 cm

below the xiphoid and extends downwards, outwards and parallel to and
about 2.5 cm below the costal margin

 It shows excellent exposure to the gallbladder and biliary tract and can be

made on the left side to show access to the spleen.

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

CHEVRON (ROOF TOP)MODIFICATION

 The incision may be continued across the midline into a double Kocher

incision or roof top approach which provide excellent access to the upper
abdomen particularly in those with a broad costal margin

MERCEDEZ BENZ

 consists of bilateral low Kocher’s incision with an upper midline incision up

to the xiphisternum.

MCBURNEY GRID IRON

 Made at the junction of the middle third and outer thirds of a line running

from the umbilicus to the anterior superior iliac spine. (The McBurney
Point)

RUTHERFORD-MORRISON INCISION

 This is extension of the McBurney incision by division of the oblique fossa

PFANNESTIEL INCISION

 Used frequently by gynecologists and urologists for access to the pelvis

organs, bladder, prostate and for caesarean section.

 Usually 12 cm long and made in a skin fold approximately 5 cm above

symphysis pubis.

 skin



fascia



anterior rectus sheath



rectus muscle



transversalis

fascia



extraperitoneal fat



perineum.

 A convex incision which minimizing muscle parasthesia and paralysis post-

operatively. It also follows the cleavage lines in the skin resulting in less
scarring

 The incision offers Excellent cosmetic results because the scar is almost

always hidden by the pubic hair

 Limited exposure of the abdominal organs. Use of incision is therefore

restricted to the pelvic organs

 High risk of injury to the bladder
 Extension of the incision is difficult laterally

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

MAYLARD TRANSVERSE MUSCLE CUTTING INCISION

 It is placed above but parallel to the traditional placement of Pfannenstiel

incision.

 Gives excellent exposure of the pelvic organs.

SURGICAL PROCEDURES

Midline

Para media

Transverse & oblique

Thoracoabdominal

Vagotomy

Jejunostomy

Gastrectomy

Pancreatomy

Hysterectomy

LSCS

Cystotomy

Cystectomy

Salphingo

oopherectomy

Right

Cholecystectomy

Pyroplasty

Left

Splenectomy

pancreadectomy

Kocher

Cholecystostomy

Heptectomy

Chevron

Gastrectomy

Esophagectomy

Adrenalectomy

Mercedez benz

Liver transplant

Pancreatic transplant

McBurney

Appendectomy

Rutherford-morison

caecostomy or

sigmoid colostomy

Pfannestiel

Caesarean section

Hysterectomy

Hepatic resections

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

Kocher Incision: 1 Paramedian: 6

Midline: 2 Transverse: MUSCLE DIVIDING 7

McBurney: 3 Rutherford Morison: 8

Lanz: 5 Pfannenstiel 9

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

Wound healing

Phases of wound healing :

1.  Inflammatory phase
2.  Proliferative phase
3.  Remodeling phase

Inflammatory phase

A. Immediate to 2-5 days
B. Hemostasis

1.  Vasoconstriction – damaged blood vessels constrict
2.  Platelet aggregation – primary hemostasis
3.  Coagulation – fibrin – secondary hemostasis (clot – platelets + fibrin)

C. Inflammation

1. Vasodilation
2. Phagocytosis

Proliferative phase

A. 2 days to 3 weeks
B. Granulation

1. Fibroblasts lay a bed of collagen to fill the defect

C. Angiogenesis
D. Contraction

1. Wound edges pull together to reduce the defect

E. Epithelialization

1. Epithelial cells migrate across the new tissue to form a barrier between

the wound and the environment

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

Remodeling phase

A. 3 weeks to 2 years
B. New collagen forms which increases the tensile strength of the wound
C. Strength increases and becomes maximum but not as strong as original

tissue

D. Scar tissue is only 80% of the strength of the original tissue

Wound healing

 Wound healing is accomplished in one of the following two ways :

1. Healing by first intention (primary union)
2. Healing by second intention (secondary union)

 Healing of skin wounds is a classical example

Healing by first intention (primary union)

 Occurs in clean, incised wounds with good apposition of the edges –

particularly planned surgical incisions
 (clean wounds – no infections or foreign bodies)

 The incision causes only focal disruption of epithelial basement membrane

continuity and death of a relatively few epithelial and connective tissue cells.

 As a result, epithelial regeneration predominates over fibrosis

Sequence of events

Immediate

 The narrow incisional space rapidly fills

with fibrin clotted blood

 Dehydration at the surface produces a scab

to cover and protect the healing repair site

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

Within 24 hrs

 Movement and proliferation of epithelial cells

across the wound resulting in a thin, but
continuous epithelial layer

 Early inflammation close to the edges (neutrophils)

2-3 days

  Neutrophils replaced by macrophages
  Macrophages remove the blood clot
  Proliferation of epithelial cells
  Fibroblastic activity

10-14 days

  Scab loose (aka dry clot)
  Epithelial covering complete
  Fibrous union of edges
  Wound still weak
  vascularization

By the end of the first month

 Scar comprises of a cellular connective tissue

devoid of inflammatory infiltrate, covered by
intact epidermis

 Dermal appendages destroyed in the line of

incision are permanently lost

 Tensile strength of the wound increases and

reaches maximum

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

Healing by second intention (secondary union)

 This occurs in open wounds, particularly when there has been significant

loss of tissue, necrosis or large wounds with irregular margins

 Regeneration of parenchymal cells cannot completely reconstitute the

original architecture

 Abundant granulation tissue grows in from the margin to complete the

repair
 Granulation tissues consists of :

o  ECM fibroblasts
o  Macrophages, neutrophils
o  New blood vessels

Sequence of events

Early

A few days

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

1 week

2 weeks onwards

Months

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

Secondary union differs from primary union in several respects

1. Inflammatory reaction is more intense
2. Larger amounts of granulation tissue

formation

3. Larger scar
4. ***ound contraction

- Myofibroblasts: modified fibroblasts with

feature of SMC

- defect significantly decreases in size as

wound heals.

Wound Strength

 Skin wounds

- 1 week old; 10% of unwounded skin

o rapid increase in tensile strength as scar tissue accumulates over

2 months

- Completely healed; 70-80% of unwounded skin
- Scar tissue is never as strong as the original tissue !!

Factors that influence healing

Classified as :

A. Systemic
B. Local

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

Systemic Factors that Delay/Retard Wound Healing

 Nutrition

 Protein deficiency, Vitamin C deficiency

o Inhibit collagen synthesis

 Zn deficiency (cofactor in type III collagenase)

 Metabolic status

 Diabetes mellitus :

o Susceptibility to infection caused by impaired circulation and

increased glucose.

 Circulatory status

 Inadequate blood supply

o atherosclerosis, vascular defects

 Hormones

 Glucocorticoids inhibit collagen synthesis, decrease inflammation

Local Factors that Delay/Retard Wound Healing

 Infection

 Most important cause of delayed wound healing
 Persistent injury and inflammation

 Mechanical factors

 Motion early in healing

 Foreign material - like suture material and foreign bodies
 Size, location & type of wound

 Wounds in ↑ vascularized areas (face) heal faster than in poorly vasc

areas (tendon, feet)

 Small wounds heal faster than larger

 Incisions faster than blunt trauma (contusions)

Complications of wound healing

1. Deficient scar formation ( most important)

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

2. Excessive formation of repair components
3. Exaggerated contraction

Deficient scar formation

Can lead to two types of complications :

A. Wound Dehiscence (rupture of wound)

 most common after abdominal surgery

o coughing, vomiting

B. Ulceration - defect in the continuity

Wound Dehiscence

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

Excessive formation of repair components

1. Keloid / hypertrophic scar (excess collagen)
2. Exuberant granulation or proud flesh(excessive granulation tissue that

protrudes above the level of the surrounding skin and impairs the growth of
epithelium)

Keloid / hypertrophic scar

 Raised scars due to accumulation of excess amounts of collagen ( type III

– type I)

 Hypertrophic scars do not grow beyond the boundaries of the original

wound

 Keloids grow beyond the boundaries of the original wound (more

serious)

o Can result from a surgery, an accident, body piercing or can be

spontaneous

o  Genetic predisposition
o  More common in African – Americans
o  Commonly seen over face, shoulders and chest

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

Exuberant granulation (proud flesh)

  Excessive granulation tissue
  Protrudes above surrounding skin
  Prevents re -epithelialization

Exaggerated contraction

  deformation of surrounding tissue or wound
  Can compromise the movement of joints.
  most common on

- palms, soles, anterior thorax following

severe burns

Important Growth factors responsible for wound healing

 Platelet derived growth factor:

o Promotes migration and proliferation of fibroblasts
o Is chemotactic for monocytes

 Epidermal growth factor

o Promotes growth of endothelial, epithelial cells and fibroblasts

Growth factors in wound healing

 Fibroblast growth factor:

o Promotes synthesis of ECM proteins including fibronectin.

ABDOMINAL INCISIONS Dr. Ramez

3-3-2015

o Chemotactic for fibroblasts and endothelial cells
o Promotes angiogenesis

 Vascular Endothelial Growth Factor (VEGF)

o Angiogenesis

 Macrophage derived growth factors

o IL-1 and TNF

 Promote proliferation of fibroblasts and endothelial cells.

#END

Done by

Ali Kareem