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General Surgery

General Surgery . Anatomy & Incisions. Incisions. A variety of incisions are used The type chosen is dependent on a number of factors Access desired Procedure Surgeon Extensibility (can we make it bigger?) Wound security. Layer by layer…. Abdominal wall layers: Skin Subcutaneous

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General Surgery

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  1. General Surgery Anatomy & Incisions

  2. Incisions • A variety of incisions are used • The type chosen is dependent on a number of factors • Access desired • Procedure • Surgeon • Extensibility (can we make it bigger?) • Wound security

  3. Layer by layer… • Abdominal wall layers: • Skin • Subcutaneous • Fascia • Muscles • Preperitoneal fat • Peritoneum

  4. Tissue Layers of the Abdominal Wall (Redrawn from Ethicon: Wound closure manual, Somerville, NJ, 2002, Ethicon, Inc.)

  5. Organs by Quadrants

  6. Incisions, continued Abdominal incisions (Modified from Rothrock JC: Alexander's care of the patient in surgery, ed 12, St Louis, 2003, Mosby.)

  7. The good, the bad and the scar tissue • Each incision type has advantages and disadvantages • Adequacy of exposure • Closure time • Disruption of blood and nerve supplies • Muscle damage • Wound hernia • Effect pulmonary function

  8. Other Factors • Other things may influence choice • Patient condition • Need for speed • Previous surgery • Minimize bleeding and trauma • Postop discomfort • Room to roam

  9. And yet more pain… • Cosmetics • Changes in the blood supplies to the anterior wall • Limit choices for future surgeries and reconstruction

  10. Vertical Midline Incision • Simple to perform • Good exposure to all of the abdominal cavity • Can be extended from the sternal notch to the symphysis pubis

  11. Paramedian • Vertical incision that is placed 2” off of the midline • Same indications as the vertical with the exception of trauma • Longer to create and close • Bleed more readily • Prone to herniation

  12. Oblique Incisions • Allow access to specific structures • Strong • However, • Splits muscles • Bleeding • Nerve damage

  13. Muscle-Splitting Incisions Surgical options for muscle (Redrawn from Ethicon: Wound closure manual, Somerville, NJ, 2002, Ethicon, Inc.)

  14. McBurney • Used most commonly for open appendectomy • Quick and easy to close • Firm closure • Poor exposure

  15. Oblique Inguinal • From the pubic tubercle to the iliac crest above the inguinal crease • Used for Inguinal Herniorraphy repair • May also be used for urologic, transplant or vascular procedures in this region

  16. Subcostal • Usually made on the right side (kocher) • Used for open gall bladder procedures • Left sub costal used for spleenectomy • Strong but painful • Limited exposure • Good cosmetic closure

  17. Transverse Incisions • Used to expose either the upper or lower regions of the abdomen • Same issues as the oblique incision

  18. Pfannenstiel • Used for pelvic surgery • Approximately ½” above the symphysis pubis • Most commonly used for OB/GYN • Excellent exposure • Cosmetic

  19. Midabdominal • Used for retroperitoneal approaches • Colectomy or colostomy

  20. Thoracoabdominal • Used for proximal stomach, distal esophagus, and anterior spine • Patient is in a lateral position • Begins at midpoint between xiphoid and umbilicus and extends to midscapular line into the chest

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