'Surgical Incisions on Abdominal Wall', a Surgical Anatomy Seminar by 1st yr MBBS students of Venkateswara Institute of Medical Science, Galraula, UP. India

1. ARPITA SINGH
AAYUSH SHARMA
PRERNA YADAV
1st YEAR MBBS, VENKATESHWARA INSTITUE OF MEDICAL SCIENCE,GAJRAULA, UP, INDIA
DEPARTMENT OF ANATOMY

2. CONTENTS
▪INTRODUCTION TO ANTERIOR
ABDOMINAL WALL
▪DIVISIONS OF ANTERIOR
ABDOMINAL WALL
▪DIATHERMY
▪INCISIONS
▪CLASSIFICATION OF ABDOMINAL
INCISIONS
▪PRINCIPLE OF WOUND CLOSURE
▪COMPLICATIONS OF INCISIONS

3. INTRODUCTION
• The anterior abdominal wall constitutes a hexagonal area:
Superiorly – by the costal margins and xiphoid process
Laterally – by the mid axillary line and
Inferiorly – by the iliac crest and pubis symphysis
• The abdomen houses several viscera responsible for different functions. The
anterior abdominal wall is well crafted to keep these viscera in place and
protected from the external environment.
• However with aberration involving the intra-abdominal contents, the anterior
abdominal wall serves as a gateway to the abdomen, where several important
and lifesaving incisions could be made to access the impaired viscera.

4. DIVISIONS OF THE ANTERIOR
ABDOMINAL WALL
• Divided into nine regions by two
paramedian vertical and
horizontal lines.
• Paramedian line, lies in a plane
joining the midclavicular line to
the mid-inguinal line bilaterally.
• The upper transverse line, lies in
the transpyloric plane.
• Lower transverse line lies in the
intertubercular plane.

5. LANGER’S LINE
• Langer’s lines/ Langer’s lines of
skin tension/ cleavage lines, are
topological lines drawn on a map
of the human body . They are
parallel to the natural orientation
of collagen fibers in the dermis.
• Langer’s lines have relevance to
the development of surgical
techniques.
• Knowing the direction of Langer’s
lines within a specific area of the
skin is important for surgical
operations.

6. DIATHERMY

7. INCISIONS
• Incisions are surgical wounds made on the
skin and deepened to gain access to an
internal structure or organ.
• Surgical incisions are planned based on
the expected extent of
exposure needed for the specific operation
planned. Often, multiple incisions are
possible for an operation.
• In doing so, three essentialities should be
achieved:
1. Accessibility
2. Extensibility
3. Security

8. Principles Of
Abdominal
Incision:
oIncision should be long enough for good
exposure.
oSplitting is better than cutting.
oIt should provide minimal damage to
neuromuscular bundles and muscles.
oAvoid cutting of nerves and vessels.
oTransverse incisions better than vertical
incisions.
oProvide a cosmetically acceptable scar.
oPeritoneal drainage tubes should
be inserted through a separate incision.
oWound should be closed in layers.

9. Choice of incision :
Depends upon
➢Type of surgery [elective/emergency]
➢Target organ
➢Surgeons own experience and preference and
➢Previous surgery history
The ideal incision allows :
➢Ease of access to the desired structures.
➢Can be extended if needed.
➢Ideally muscles should be split rather than cut.
➢Heals quickly with minimal scarring.

10. CLASSIFICATION OF INCISSION
ABDOMINAL INCISIONS
Transverse &
Oblique Incisions
Vertical Incisions Abdominothoracic
Incisions
▪ Midline incision
▪ Paramedian
incision
▪ Kocher's Subcostal Incision
▪ Transverse Muscle Dividing Incision
▪ McBurney's Incision
▪ Lanz Incision
▪ Pfannenstiel Incision
▪ Maylard Incision

11. Vertical Incisions
Midline Incision
• Used in almost all operations in the abdomen
and retroperitoneum.
Advantages:
(1) Almost bloodless
(2) no muscle fibers are divided
(3) no nerves are injured
(4) good access to the upper abdominal
viscera
(5) very quick to make as well as close
(6) can be extended full length of abdomen
curving around umbilical scar.
Paramedian Incision
• It offsets vertical incision to right
or left providing access to lateral
structures such as spleen or
kidney.
• Its closure is theoretically more
secure because rectus muscle can
act as buttress between
reapproximated posterior and
anterior fascial planes

13. Transverse Incisions
Kocher Subcostal Incision
• It affords excellent exposure to gall bladder and biliary tract and
can also afford access to spleen if made on the left side.
• It is started at midline below the xiphoid and extends
downwards, outwards and parallel to and about 2.5cm below
costal margin.
Transverse Muscle Dividing Incision
• In newborn and infants, this incision is preferred because
more abdominal exposure is gained than the vertical incision.
• Because infant's abdomen is longer transversely than vertical
girth.

14. McBurney Incision (Muscle Split)
• This is the choice of incision in the cases of appendectomy.
• It is made at the junction of middle third and outer third of a line running from umbilicus to anterior
superior iliac spine, McBurney point.
• The level and length of incision will vary according to the thickness of abdominal wall and suspected
position of appendix
• This incision is parallel to the external oblique muscle to be split in the direction of its fibers, decreasing
healing time and scar tissue formation.
Lanz Incision
• A variation of the traditional Mc Burney's incision, which was made at McBurney's point on the
abdomen.
• The Lanz incision is made at the same point along the transverse plane and deemed cosmetically
better. It is typically used to perform an open appendectomy.
• Variations exist on the method used to locate the incision.

16. Pfannenstiel Incision
• It is used frequently by gynecologist and urologist for
access to pelvic organ, bladder, prostate and for C-section.
• It is usually 12cm long and is made in skin fold
approximately 2cm above pubis symphysis.
• The incision offers excellent cosmetic results because the
scar is almost always hidden by the pubic hair.
• It is the commonly used incision because it provides
limited exposure of the abdomen.
Maylard Transverse Muscle Cutting Incision
• Gives excellent exposure to pelvic organ.
• Skin incision is placed above but parallel to traditional placement of Pfannenstiel incision.
• In this incision rectus abdominis muscle is sectioned transversely to permit wider access
to pelvis.

17. Thoracoabdominal Incisions
• Either right or left.
• Converts pleural and peritoneal cavities into one common cavity.
• Right incision may be particularly useful in elective and
emergency hepatic resections.
• Left incision may be used in resection of lower end of esophagus and
proximal portion of stomach
• Incision is extended along the line of 8th intercostal space, the space
immediately distal to inferior pole of scapula

18. Principle Of
Wound
Closure
• GOAL:
• Maintain a sterile and aseptic technique to
prevent infection.
• Proper choice of suture materials and
technique
• Estimation of dead space
• Closing with sufficient tension (tight
enough to seal wound but not strangulate)
• Proper immobilization of wound.

19. Complications
Of Incisions Keloid Incisional hernia
Nerve Injury Hematoma formation​
Surgical site infection​
Wound dehiscence
and burst abdomen​

20. KELOID
• Keloid is a form of scarring.
• It is the result of the body’s attempt to repair
itself.
• It may appear on skin as red, raised formation of
fibrous scar tissue, caused by excessive collagen
formation in the skin layer (dermis) during the
process of connective tissue repair, after any
trauma or injury to skin.
• Keloids are firm, rubbery lesions or shiny,
fibrous nodules, and can vary from pink to the
color of the person's skin or red to dark brown
in color.

21. SIGNS AND SYMPTOMS:
• Keloids expand in claw-like growths over
normal skin.
• Keloids form within scar
tissue. Collagen, used in wound repair,
tends to overgrow in this area,
sometimes producing a lump many
times larger than that of the original
scar.
• They can occur as a result of
severe acne or chickenpox scarring.

22. INCISIONAL HERNIA
• Incisional hernias can develop after abdominal surgery.
• They happen after up to 15 to 20 percent of abdominal
operations involving incisions.
• An incisional hernia happens when a prior surgical
incision that has weakened the abdominal wall, allows
intra-abdominal content to push through.
• Hernias are often categorized as reducible or
irreducible:
Reducible hernias can be pushed back in. They may
also shrink when you lie down.
Irreducible hernias happen when part of your
intestine pushes into the hernia, making it hard to push
the hernia back in.

23. SIGNS AND SYMPTOMS:
• A bulge in the affected area.
• Pain (ranging from a dull ache to severe
pain), especially when coughing , sneezing or
lifting heavy objects.
• Bloating and constipation.
RISK FACTORS:
• The primary risk factor is weakness at the incisional
site of a prior abdominal surgery.
• obesity
• Smoking
• Diabetes
• Steroids, chemotherapy or other medications that
weaken the immune system.
• Heavy lifting or other strenuous activities.

24. THANK YOU FOR GIVING US YOUR
VALUABLE TIME
Special thanks to Dr B B Gosai, Professor and
Dr B Bora, Assoc. Prof for their guidance.