surgical incisions and surgical positions in general surgery by dr chandrakant sabale

1. INCISIONS AND POSITION IN
GENERAL SURGERY
DR CHANDRAKANT SABALE
MS GENERAL SURGERY
ASSISTANT PROFESSOR IN GRANT GOVERNMENT MEDICAL COLLEGE

2. SURGICAL INCISIONS
Surgical incision Is cut made through The skin to facilitate operation Or
procedure.
It should be the aim of surgeon to employ type of incision Considered
to be most suitable for that operation to be performed.
In doing surgical incisions Three important Things to be achieved.
1. Accessibility
2. Extensibility
3. Security

3. PRINCIPLES
• Incision should be long enough for good exposure.
• Splitting is better than cutting.
• Avoid cutting muscles and nerves.
• Choose correct position
• Retract muscles And abdominal organs towards neuromuscular
bundles.
• Insert drains through separate incisions.
• Close the wound layer by layer.

4. CHOICE OF INCISION AND IDEAL INCISION
• Type of surgery – elective or emergency
• Target organ
• Previous surgery
• Grade of patient obesity
• Surgeon own experience and preferences.

5. LANGER’S LINES
• Langer’s line correspond to the
natural orientation Of collagen fibres
in dermis And are generally parallel to
the Orientation of underlying muscle
fibres.
• Incisions made parallel to langer’s line
heal better and produces less scarring
than those cut across.

6. COMMON ABDOMINAL AND PELVIC INCISIONS
• Vertical - Midline
paramedian
• Transverse - Transverse muscle deviding
pfannensteil incision
Maylord incision
• oblique - Kochers subcostal incision
Mcburney incision
Oblique muscle cutting
Inguinal incision
• Abdominothoracic incisions
• Retroperitoneal and extraperitoneal approach

7. VERTICAL MIDLINE INCISIONS
• Vertical incision which follows the Linea Alba. It
may be
1. Upper Midline
2. Lower Midline
3. Single incision
Signicance : It is favored In diagnostic laparotomy, as
it allows wide access in abdominal cavity.

8. UPPER MIDLINE INCISION
• From xiphoid to above umbilicus.
• Division of Peritoneum is best performed
at the lower end of incision , just above
umbilicus So that falciform ligament can
be seen and avoided.

9. LOWER MIDLINE INCISION
• From umbilicus superiorly to Public
symphysis inferiorly.
• Allows access to pelvic organs
• The peritoneum should be opened in
uppermost area to avoid injury to bladder.

10. KOCHERS SUBCOSTAL INCISION
• It affords excellent exposure to gall bladder,
biliary tract and can be made on left side to
have access to spleen.
• It is started at Midline 2 to 5 cm below the
xiphoid and extends downwards,outwards and
parallel to and About 2.5 cm below costal
margin.
• Especially used in cholecystectomy.
• There are 2 modifications
1. Chevron / rooftop modification
2. Mercedes modification

12. TRANSVERSE MUSCLE DIVIDING
• In newborn and infant this incision is
preferred because more abdominal
exposure is gained per length of incision
than with vertical exposure.
• Because infants abdomen is longer
Transversely than vertically.
• Also true for short obese adults.

13. TRANSVERSE INCISION
Pfannensteil
Cherney
Maylard
Kustner

16. INGUINAL INCISION
• Inguinal incision is done for
1. Inguinal hernia
2. Testicular cancer
3. Varicose
4. UDT
5. Orchidectomy

17. INCISIONS FOR RADICAL INGUINAL LYMPHADENECTOMY
• Single incision approaches:
• A) oblique
• B) S-shaped
• C) vertical
• D) double incision; lower midline and
inguinal
• E) for unilateral pelvic
lymphadenectomy, oblique abdominal
incision combined with inguinal
incision.

18. NECK INCISIONS
• A) Modified crime
• B) Martin /double Y
• C)MacFee
• D)Schechter

19. THYROIDECTOMY INCISION

20. INCISIONS FOR MRM

21. • Classic Orr oblique incision for ca
upper outer quadrant
Variation of Orr incision for lower
Inner and vertical

22. THORACIC INCISIONS
• Thoracic incisions for trauma
include
(A) median sternotomy,
(B) book thoracotomy,
(C) posterolateral thoracotomy,
(D) anterolateral thoracotomy
(E) extension of an
anterolateral thoracotomy
across the sternum.

24. THORACOABDOMINAL INCISIONS
• Converts Pleural and
peritoneal cavity into One
common cavity.
• Right side used for hepatic
resection.
• Left side for Lower esophagus
and proximal stomach

25. INCISIONS FOR RETROPERITONEAL APPROACH
• Incisions Begins at level of
umbilicus At the margin of
rectus sheath and extended
into flank towards 12 th rib for
12 to 20 cm.
• Patient positioned in supine
position with left side elevated
to 30 to 45 degrees And with
left knee , thigh flexed .

26. SURGICAL POSITION
• Patient positioning depends on two factors.
1. The site of operation Or the organ to operated upon
2. The other determining factor is surgeons Choice or decision .
• Surgical positions
• Supine - prone
• Lateral - left Lateral
- Trendelenberg - Reverse Trendelenberg
- Fowlers - semi fowlers
- Kidney - Lithotomy
- Sims -Jack knife

27. • One must be aware of the anatomic and physiologic changes associated with anesthesia,
patient positioning, and the procedure.
•The following criteria should be met to prevent injury from pressure, obstruction, or stretching
–No interference with respiration
–No interference with circulation
–No pressure on peripheral nerves
– Minimal skin pressure
– Accessibility to operative site
– Accessibility for anesthetic administration
–No undue musculoskeletal discomfort
– Maintenance of individual requirements

28. SUPINE
•Placed on back with legs extended and uncrossed at the
ankles
• Arms either on arm boards abducted <90* with palms up or
tucked (not touching metal or constricted)
• Spinal column should be in alignment with legs parallel to
the OR bed –Head in line with the spine and the face is
upward –Hips are parallel to the spine
• Padding is placed under the head, arms, and heels with a
pillow placed under the knees
•Safety belt placed 2” above the knees while not impeding
circulation

29. SUPINE CONCERNS
•Greatest concerns are circulation and pressure points
•Most Common Nerve Damage:
– Brachial Plexus: positioning the arm >90*
–Radial and Ulnar: compression against the OR bed,
metal attachments, or when team members lean against the
arms during the procedure
– Peroneal and Tibial: Crossing of feet and plantar flexion
of ankle
• Vulnerable Bony Prominences – Occiput, spine, scapula,
Olecranon, Sacrum, Calcaneous

30. VARIATION
LAWN CHAIR POSITION
•Back of the bed is raised
•Legs below the knees are lowered to an equivalent
angle
• Slight trendelenburg tilt
ADVANTAGES:
• Better tolerated by awake patient or under
monitored anesthesia care
•Venous drainage from lower extremities enhanced
• Xiphoid to pubic distance reduced and easing closure
of laparotomy incisions

31. TRENDELENBERG
•The patient is placed in the supine position while the OR bed is
modified to a head‐down tilt of 35 to 45 degrees resulting in the
head being lower than the pelvis
• Arms are in a comfortable position –either at the side or on
bilateral arm boards
•The foot of the OR bed is lowered to a desired angle
• ADVANTAGES
To increase V.R after spinal anesthesia
To increase central venous volume to facilitate central
cannulation
To minimise aspiration during regurgitation

32. REVERSE TRENDELENBERG
•The entire OR bed is tilted so the head is higher than the feet
•Used for head and neck, laproscopic procedures
• Facilitates exposure, aids in breathing and decreases blood
supply to the area
•A padded footboard is used to prevent the patient from sliding
toward the foot
• Reduces venous return therefore hypotension
• Laproscopic cholecystectomy : reverse trendelenburg position
with right up

33. PRONE
• Access to the posterior fossa of the skull, the posterior spine, the buttocks and perirectal area, and the
lower extremities

34. LATERAL
• Shoulder & hips turned simultaneously to prevent
torsion of the spine &great vessels
•Lower leg is flexed at the hip; upper leg is straight
•Head must be in cervical alignment with the spine
• Axillary roll placed caudal to axilla of the downside
arm .
• Padding placed under lower leg, to ankle and foot
of upper leg, and tolower arm (palm up) and upper
arm
• Pillow placed lengthwise between legs and
between arms.

35. LATERAL POSITION WITH KIDNEY BRIDGE
• Flexed lateral decubitus position.
Point of flexion should lie under
iliac crest, rather than the flank or
lower ribs, to optimize ventilation of
the dependent lung.

36. LITHOTOMY
•With the patient in the supine position, the hips are flexed to
80‐100 degree from the torso so that legs are parallel to it and legs
are abducted by 30‐45 degree expose the perineal region
•The patient’s buttocks are even with the lower break in theOR
bed..
•The legs are raised, positioned, and lowered slowly
andsimultaneously, with the permission of the anesthesiologist.
• Adequate padding and support for the legs/feet should
eliminate pressure on joints and nerve plexus
•The position must be symmetrical
•The perineum should be in line with the longitudinal axis ofthe
OR bed

38. JACK KNIFE
• Used for anal
surgeries,
pilonidal sinus

39. KNEE CHEST
• Further exaggeration of
Jack knife position.
• Used for Sigmoidoscopies

40. THANK YOU .