Incisions and Sutures

The most common reason for a difficult operation is poor access.

Choice of Incision

  • Important things to consider:
    • Access to underlying organs/tissues
      • NB Important to note that length of incision should not affect recovery time, so access needn’t be compromised
    • Is closure by primary intention possible
    • Other things include
      • Orientation of skin tension lines and skin creases (e.g. Collar incision for thyroid surgery)
      • Strength and healing potential of tissues
        • e.g. in abdominal surgery- a midline incision through the linea alba will heal much stronger than a paramedian incision lateral to midline
      • Underlying anatomy/structures (especially nerves)
      • Cosmetic considerations
        • e.g. transverse suprapubic (or Pfannenstiel or bucket-handle) incision for C-section; periareolar incision for breast biopsy

Basic types of Incisions

  • Vertical incisions
    • Midline
      • Virtually any abdominal procedure; can be limited to above or below the umbillicus or can extend round the umbilicus
      • Cuts through skin, superficial (Camper’s) fascia; deep (Scarpa’s) fascia; linea alba; transversalis fascia; extraperitoneal fat and peritoneum
      • Advantages
        • Good exposure; minimal blood loss, nerve injury or muscle injury; can be performed quickly
      • Disadvantages
        • Care must be taken not to disrupt the falciform ligament just above the umbilicus
        • Herniation/dehiscence is possible
        • Not cosmetically pleasing- midline scar
    • Paramedian
      • May be preffered for kidney, spleen and adrenal surgeries.  Incision is usually 3-5cm to the side of the midline
      • Cuts through skin; anterior rectus sheath (med rectus retracted laterally); posterior rectus sheath (above arcuate line) or transversalis fascia (below); extraperitoneal fat; peritoneum
      • Advantages
        • Closure is often more secure than median
        • Access to lateral structures
      • Disadvantages
        • Longer to perform/close; increased risk of infection/intraoperative bleeding and nerve damage
        • Often compromises blood supply to medial structures
  • Transverse
    • e.g. Gable incision for liver transplant (superior ‘bucket-handle incision in the epigastric area); Lanz incision (iliac fossae for appendix (often appendicitis)+ caecum (right) or left colon (left)); Maylard incision (suprapubic for radical pelvic surgery); Pfannenstiel incision (reverse bucket handle- suprapubic for caesarean section);
    • More commonly used in children/obese patients
    • Advantages
      • Better cosmetically, stronger than vertical and less painful; less damage to other sections
    • Disadvantages
      • Time-consuming, more haemorrhagic, nerve injury, haematomas/damage to blood supply, more infections
  • Oblique incisions
    • e.g. Kocher incision (cholecystectomy) + Chevron modification (oesophagus, stomach, kidney, adrenals and liver)

Picture1

Presentation1

  1. Midline (layers: skin, fascia (Camper’s and Scarpa’s), linea alba, transversalis fascia, extraperitoneal fat and peritoneum)
    1. Pros: Provides good access; can be extended easily; quick to make and close; relatively avascular, little muscle and little nerve damage possible
    2. Cons: More painful than transverse; crosses Langer’s lines (tension lines) so has poor cosmetic outcomes; below the umbilicus the linea alba is very narrow; some vasculature crosses the midline; potential damage to the bladder
  2. Subumbilical (used for repair of paraumbilical hernia and laparoscopic port)
  3. Paramedian (~1.5cm from midline through rectus abdominus sheath) (layers: skin and fascia (as per midline), anterior rectus muscle has to be freed from the sheath, posterior rectus sheath (if above arcuate line) or transversalis fascia (if below), extraperitoneal fat and peritoneum)
    1. Not commonly used now as it takes longer to make and close, has a poor cosmetic result, higher risk of infection, can risk nerve injury, requires dissection/splitting of the rectus muscle and tendinous insertions and can cause permanent damage to these structures.  Can, however, provide better access to lateral structures e.g. adrenals/kidneys.
    2. Can be extended superior and curved towards the xiphoid (Mayo-Robson incision)
  4. Pararectal/Battle’s incision (not routinely used due to nerve damage)
  5. Kocher’s incision (3cm below and parallel to costal margin from midline to rectus border) (layers: skin, rectus sheath, rectus muscle, internal oblique, transversus abdominus, transversalis fascia, extraperitoneal fat and peritoneum)
    1. Used most offen for open cholecystectomy or splenectomy (need to be careful of thoracic nerve branches laterally. Pros: good exposure, less painful than midlin, less post-op complications, heals well (Cons: takes longer to open/close due to layers)
  6. Double Kocher’s/Rooftop/Chevron
    1. Useful for access to both liver and spleen (occasionally for radical procedures e.g. Whipple’s/gastrectomy/bilat adrenalectomy)
  7. Transverse
    1. Pros
      1. Less pain; can have good access to upper GI structures; tend to cause less damage to muscle and nerve structures (as they run parallel so can be split/rejoined
      2. More advantageous in obese patients or children due to relatively larger transverse length of the abdomen
    2. Cons
      1. Limited lateral access
      2. Higher risk of infections and haematomas (increased risk of bleeding)
  8. McBurney’s/Gridiron (two thirds from the umbilicus to the ASIS and at a right angle to this line) (layers: skin, fascia, internal oblique medially and external oblique laterally, transversus abdominus, transversalis fascia, extraperitoneal fat and peritoneum)
    1. Classically used for appendicectomy (note requires dissection/splitting of the external oblique (in line); internal oblique and transversus abdominis muscles (transversely)
    2. Note to be weary of iliohypogastric and ilioinguinal nerves, and the deep circumflex artery.  Also if the incision is not horizontal, scarring can be poor.
  9. Lanz
    1. Better cosmetic result than McBurney’s but more likely to devide the nerves- particularly ilioinguinal and iliohypogastric- (as with McBurneys) which can cause deneration of the inguinal canal
  10. Pfannenstiel (convex 10-14cm incision at suprapubic skin crease/around 5cm above the pubic symphysis) (layers: skin, fascia, anterior rectus sheath, rectus muscle, transversalis fascia, extraperitoneal fat and peritoneum)
    1. Allows good access to lower GI and GUS organs as well as pelvic and reproductive organs (most common incision for caesarean section)
    2. Pros: generally good aesthetic result and minimises nerve damage
    3. Cons: exposure of abdominal structures is limited and ability to extend incision is also limited (tends to be for pelvic organs only).  Deep exploration can also be difficult.  Can risk damage to the bladder.
  11. Transverse incisions crossing the midline are rarely performed
  12. Thoraco-abdominal oblique incisions
    1. Can be used for exploration of both peritoneal and pleural cavities.  Can give good access to the spleen, lungs, and liver, as well as the stomach and oesophagus.

Sutures

Classifications

  • Absorbable vs Non-absorbable
    • Absorbable sutures will lose their strength as they are absorbed- i.e. their effect is temporary.  Materials/types include chromic gut (natural collagen lasting 2-3 weeks); vicryl/monocryl (synthetic absorbable materials usually lasting 7-10 days in the case of vicryl and longer for monocryl)
    • Non absorbable sutures are not broken down and so maintain their strength unless they are physically removed (can be used in abdominal gut repairs; large skin closures; skin closures with a lot of tension e.g. amputation stumps).  Types include prolene (often used for contaminated wounds), ethilon, nylon (synthetics) and silk sutures.
  • Monofilament vs multifilament
    • Monofilament sutures tend to pass through tissues easier and elicit less tissue reaction
    • Multifilament sutures are braided and tend to give better knot security
  • Size; synthetic vs natural; coated vs uncoated
Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s