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Abdominal incisions and laparoscopic access

Abdominal incisions

  • Abdominal incisions are based on anatomical principles
  • They must allow adequate assess to the abdomen
  • They should be capable of being extended if required
  • Ideally muscle fibres should be split rather than cut
  • Nerves should not be divided
  • The rectus muscle has a segmental nerve supply
  • It can be cut transversely without weakening a denervated segment
  • Above the umbilicus tendinous intersections prevent retraction of the muscle

Abdominal incisions

Midline incision

  • Midline incisions are the commonest approach to the abdomen

  • The following structures are divided:

    • Skin

    • Linea alba

    • Transversalis fascia

    • Extraperitoneal fat

    • Peritoneum

  • The incision can be extended by cutting through or around the umbilicus

  • Above the umbilicus the Falciform ligament should be avoided

  • The bladder can be accessed via an extraperitoneal approach through the space of Retzius

  • The wound can be closed using a mass closure technique

  • The most popular sutures are either non-absorbable or absorbable monofilaments

  • At least 1 cm bits should be taken 1 cm apart

  • Requires the use of one or more sutures four times the wound length

A midline incision

Paramedian incision

  • A paramedian incision is made parallel to and approximately 3 cm from the midline

  • The incision transverse:

    • Skin

    • Anterior rectus sheath

    • Rectus - retracted laterally

    • Posterior rectus sheath - above the arcuate line

    • Transversalis fascia

    • Extraperitoneal fat

    • Peritoneum

  • The potential advantages of this incision are:

    • The rectus muscle is not divided

    • The incisions in the anterior and posterior rectus sheath are separated by muscle

  • The incision is closed in layers

  • Takes longer to make and close

  • Had a lower incidence of incisional hernia (when sutures were not so good)

A paramedian incision

Bibliography

Burger J W,  van't Riet M,  Jeekel J.  Abdominal incisions:  technique and postoperative complications.  Scan J Surg 2002;  91:  351-321.

 

 
 

Last updated: 05 January 2008

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