Week 2: Types of Incisions

1. Upper Midline: The upper midline incision provides access to the esophagus, hiatus, stomach and duodenum, pancreas, and hepatobiliary system. If extended, it allows major hepatic resection, adrenalectomy, and splenectomy. Midline incisions are the most versatile incisions because easy extension superiorly or inferiorly allows access to all parts of the abdominal and retroperitoneal space without difficulty. Upper midline incisions are very painful and restrict pulmonary function, particularly vital capacity, by about 50 percent. 2. Subcostal (Kocher): The subcostal, or Kocher incision is used for open biliary surgery,such as cholecystectomy. The subcostal incision is also used for access to the liver for wedge resections; for the adrenal gland on either side; and the spleen if on the left side. When extended laterally on the right with the patient in a rotated position, the incision is used for portacaval shunts. The incision may be extended medially as an alternative to the upper midline incision. 3. Transverse: The transverse incision is made just above the umbilicus and divides one or both sides of the rectus muscle as necessary. Transverse incisions are most commonly used for access to the right colon (when placed on the right), duodenum, and access to the pancreas where the incision is carried across the midline. They provide excellent exposure to the subhepatic space and upper gastrointestinal tract, reportedly with less pain than a midline incision. However, in the current era, many surgeons have entirely replaced transverse incisions with midline incisions extended as necessary to gain lateral access to the abdominal and retroperitoneal viscera. 4. Lower Midline: Lower midline incisions are used for complex appendicitis, sigmoid colonic, rectal, urological, and gynecological procedures. The muscles at the midline often overlap obscuring the linea alba and making division of the muscle necessary in lower midline incisions. 5. McBurney: When the diagnosis of appendicitis is clear, the McBurney incision is one of two incisions used for appendectomy. The McBurney's Point is located one third of the distance from the anterior superior iliac crest to the umbilicus. This is the classic location of the appendix. Since the appendix is a mobile part of the body, it may be found in various places in the right lower quadrant. 6. Paramedian: This incision provides little additional exposure beyond a midline incision. The blood and nerve supply to the abdominal wall enters from either side and may cross the midline poorly. For this reason paramedian incisions have an increased risk of rendering part of the abdominal wall anesthetic and ischemic. The result is poor wound healing and increased risk of hernias. 7. Groin incision: They end medially at the level of the external ring, usually 1 to 2 finger breadths above the external ring. Laterally, these incisions usually extend for 10-12 cm, depending on the size of the patient, the size of the hernia, and prior surgery. Staying out of the inguinal crease reduces the risk of infection. Such incisions are closed in layers. The oblique inguinal incision may be on the right or left side and is used for hernia repair. The superficial epigastric vein is usually encountered in the subcutaneous tissue. It is ligated and divided. 8. Pfannenstiel, or "bikini incision": Pfannenstiel incisions are horizontal at the skin but divide the fascia and muscle of the abdominal wall vertically in the midline. They are principally used for urological and gynecological procedures because they minimize scarring. However, large skin flaps are developed under such incisions and with contamination, they may be more prone to infectious complications.