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Saturday, January 22, 2011

ABDOMINAL SURGERY AND ITS FEW TYPES

ABDOMINAL SURGICAL INCISIONS:

The Abdominal wall extends from Xiphisternum to the inguinal ligament.

Incision: A surgical wound made on the soft parts made with a knife.



Layers of abdominal wall:
1. Skin 2.subcutaneous tissue 3.anterior rectus sheath 4.Muscle 5.posterior rectus sheath 6.peritoneum.

Quality of incision:
It should be made straight
Damage to muscle and other parts should be minimum
Damage to nerves should be minimum.
Bleeding should be less
It should cause minimum discomfort to patient.
Two cut parts should be approximated
It should be done quickly.

Parts of abdomen: abdomen is divided in to nine parts by two horizontal and two vertical lines the parts are:

TYPES OF ABDOMINAL INCISON:

Abdominal Incision

1.Vertical Incision 2.oblique Incision 3.Transverse Incision

VERTICAL INCISION

1. Paramedian rectus
Upper – Rt /Lt
Lower – Rt / Lt

2.Midline vertical
Upper abdominal
Lower abdominal

3.Rectus splitting Incision

4. Battle’s Para rectal Incision

OBLIQUE INCISION:

1. Mc.Burney’s muscle splitting

a.Gridrian Incision
b.Lanz Incision
c.Ruther ford Incision
2. Subcostal/ Kocher’s Incision
a.Kochers Right /left

TRANSVERSE INCISION:

Pfennestial Incision
Mid abdominal transverse Incision
Thoraco abdominal
Inverted U shaped incision.


VERTICAL INCISION:

1. Paramedian Rectus Incision: The incision is made parallel to midline at a distance of about 1” lateral to left

Structure: skin, subcutaneous tissue. Anterior rectus sheath, rectus abdominus, posterior rectus sheath, peritoneum.
Organ; Liver, duodenum. Gall bladder, bile duct

PROCEDURE:
The skin, subcutaneous tissue and anterior rectus sheath are divided along the line of incision. The rectus muscle is retracted laterally .The posterior rectus sheath, Transversalis fascia and peritoneum are incised in one layer.

CLOSURE:
The Incision is closed in three layers peritoneum, transverse fascia, the posterior rectus sheath and the anterior rectus sheath is sutured as the second layer.

Advantage:

The scar will be strong
The chance if Incisional hernia is removed.

2. Midline vertical Incision: The incision is given from xiphoid process to pubic symphysis.
Structure: skin, subcutaneous tissue, Linea Alba, peritoneum.

ORGAN: Gastric surgery, liver, pancreas, duodenum, stomach.

PROCEDURE: The incision goes through three layers – skin, Linea Alba and peritoneum covered by transversalis fascia.

Closure: This is done by suturing three layers peritoneum with transversalis fascia, linea alba and skin.
ADVANTAGE:

Incisional hernia is less in this incision. Less bleeding since linea alba is a vascular area, this is equally asses on both sides of abdomen. Number of layers divided in the incision is less. The incision can be made quicker.

III.RECTUS MUSCLE SPLITTING INCISION: The incision is made about 3-4 cm lateral and parallel to the midline.

STRUCTURE: Skin, subcutaneous tissue, anterior rectus sheath, transverse fascia, posterior rectus sheath, peritoneum.

PROCEDURE: The skin, subcutaneous tissue and anterior rectus sheath are divided along line of incision. The rectus muscle split longitudinally along the line of incision .and finally the posterior rectus sheath fascia and peritoneum are divided in one layer.

CLOSURE: similar to that of paramedian incision
ADVANTAGE: It can be performed quicker, it provide a string scar.

IV. BATTLE’S PARARECTAL INCISION: The incision is made mostly on the lower abdomen over the lateral part of the rectus muscle.

STRUCTURE: Skin, subcutaneous tissue, anterior rectus sheath, fascia, posterior rectus sheath.
ORGAN: Previously used for appendectomy and for unilateral gynaecological operations .PROCEDURE: The skin, subcutaneous tissue and anterior rectus sheath are divided in the same line. The rectus muscle is retracted medially to expose the posterior rectus sheath in6the upper part of incision and fascia transversalis in lower part of incision.

OBLIQUE INCISION:

1.a. GRIDIRAN INCISION: The incision is an oblique one perpendicular to the right spine, umbilical line which extends from the right anterior superior iliac spine to the umbilicus through Mc.Burney’s point I.e. junction between lateral 1/3 and medial 2/3 at 3-4’’ length.

STRUCTURE: Skin, fascia of camper, fascia of scarpa; external oblique aponeurosis, internal oblique aponeurosis, transversalis abdominus.

ORGAN: Vermiform appendix.

PROCEDURE: The skin, fascia of camper and scarpa are incised along the line of incision the fibres of external oblique aponeurosis are split the fibres of internal oblique lie perpendicularly to the line of incision, the transversalis abdominis are running in the same direction and splited by inverting the tip of artery and forceps.
CLOSURE: It’s done by four layers
First layer includes peritoneum and transverse facia
Second layer is the muscular layer composed of split fibres of the internal oblique transverses.
Third layer is aponeurotic layer of external oblique
Fourth layer is the course of skin and subcutaneous tissue.

ADVANTAGES: It does not damage any nerve being muscle splitting it heals quickly.

2. LANZ INCISION: It is the cosmetic counter part at Mc.Burney’s incision.

PROCEDURE: The deep layer are incised and split in to the same fashion as that of Mc. Burney’s incision. Instead of making an oblique incision as the gridiran a transverse incision is made on the inter spinous area.

ORGAN: Vermiform appendix.
CLOSURE: Similar to Mc. Burney’s incision ( gridiran).

C. RUTHERFORD MORRISON’S MUSCLE SPLITTING INCISION:
It is a muscle cutting incision.

PROCEDURE; It is mainly used for exposure of the ureter and can be performed on both sides of the abdomen. This is also used for exposure of external iliac vessels.

CLOSURE: It is carried out in the same way as described as Mc. Burney’s incision.

2 SUBCOSTAL / KOCHER’S INCISION: This incision is done below the xiphoid process.

STRUCTURE: skin , subcutaneous tissue, ,external internal ,transverse oblique and facia rectus sheath ,rectus muscle.

ORGAN: Right subcostal – liver, gall bladder, bile duct, left subcostal spleen.
PROCEDURE: Incision starts in the midline below the xihoid process and runs downwards and laterally about 2 cm below and parallel to the costal margin. The incison is divided along the line and the peritoneum is opened a few intercostals nerves are damaged.

Closure: a. The first layer comprises the peritoneum, transversalis facia and posterior rectus sheath .

b. The midline layer comprises the muscles.

c. The final layer is the skin and subcutaneous tissue

ADVANTAGE: Better assess to the the lateral side of abdomen.
TRANSVERSE INCISION:
PFENNESTIAL INCISION – It’s a transverse incision with a slight curve downwards just above the pubis and below the hair line.

STRUCTURE: Skin, subcutaneous tissue, anterior rectus sheath, transversalis fascia, posterior rectus sheath, and peritoneum.

ORGAN: Mostly used for gynecological purpose and hysterectomy

ADVANTAGE: Cosmetically good; consumes more time.

2.Mid abdominal transverse incision: Mainly used to reach the retro peritoneal, used for kidney operations. Either above or below the umbilicus extend up to lumbar region.

3.Thoraco abdominal incision: operation on lower part of oesophagus , lower part of thorax and upper part of badomen.

4.Inverted Us haped : very surely used incision now a days this type is not used as common one.

COMPLICATIONS OF ABDOMINAL INCISION:

Hiccough due to irritation of diaphrahgm
vomiting
abdominal distension
retension of urine
respiratory complications
deep vein thrombosis
Renal failure
Burst abdomen
Post operative peritonitis.Bookmark

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