ABDOMINAL INCISION

AND
COMPLICATIONS

Selonan Susang Obeng

Digestive Surgeon
Maranatha Christian University/Imanuel Hospital
Bandung
 JAS MERAH
JANGAN MELUPAKAN SEJARAH

THEODOR BILROTH (1829-1894) Carl Johann August Langenbuch (1846 -1901)

AHLI BEDAH PERTAMA INDONESIA
• An INCISION is a fine cut
made by a surgeon during
surgery.
• Abdominal incision aka
Laparotomy -> Incision on
abdominal wall to enter
the abdomen.
 INTRODUCTION
KNOWLEDGE OF ANATOMY
IS ESSENTIAL :
• TO AVOID OR SECURE
MAJOR VESSEL
• TO ENHANCE
APPROPRIATE REPAIR
• TO REDUCE THE RISK OF
INCISIONAL OR WOUND
DEHISCENCE
ABDOMINAL WALL
 ANATOMY
ABDOMINAL WALL
o 3 flat muscles
• External Oblique
• Internal Oblique
• Transersus
abdominis

o 2 vertical muscles
• Rectus abdominis
• Pyramidalis
 Comparison of upper and lower three-fourths of
anterior abdominal wall
Upper Midline Lower Midline

Linea alba well Linea alba poorly

developed developed

Right and left recti Right and left recti

well separated close together

Anterior and Only anterior layer of

posterior layers of sheath present
sheath present

Aponeurosis of Aponeurosis of
external oblique external oblique
weak or absent strong and well
developed
 ANATOMY
LANGER’s LINE
• Also called CLEAVAGE LINE,
the direction within the
human skin along which the
skin has the least flexibility.
These lines correspond to the
alignment of collagen fibers
within the dermis.
• Incisions made parallel to
Langer's lines may heal better
and produce less scarring
than those that cut across.
 CHOOSING THE INCISION
The choice of laparotomy incision
depends on :
• the area that needs to be
exposed,
• the elective or emergency
nature of the operation and,
• personal preference.
• Type of incision may however
have its influence on the
occurrence of post-operative
wound complications.
 ELIS PRINCIPLES

• ACCESEBILITY
• EXTENSEBILITY
• SECURITY
COSMESIS
Prof. Harold Elis (1926- )
 “Pray before surgery, but
remember this: GOD will not
alter a faulty incision.”
Keeney’s Dictum
 Abdominal & Pelvic incisions

Vertical
Transverse & Oblique Incisions
Incisions Abdominothoracic Incisions

-Kochler Subcostal Incision

-Transverse Muscle Dividing
-Midline
-McBurney Incisions
-Paramedian
-Oblique Muscle cutting
-Pfannenstiel Incision
-Maylard Incision
COMMON ABDOMINAL INCISION
 VERTICAL INCISION
MIDLINE INCISION

ADVANTAGE :
• Very quick to make & close
• Almost bloodles
• No muscle fibers devided
• No nerves are injured
• Extendable
 EMERGENCY LAPAROTOMIES,
COLONIC RESECTION, MILES’ PROCEDURE
• UPPER MIDLINE ABDOMINAL INCISION
Hiatal hernia, esophagus, stomach, liver,
gallbladder, spleen
• LOWER MIDLINE ABDOMINAL INCISION
Sygmoid, colon, pelvic organs.
EXTENDED MIDLINE INCISION
 MIDLINE INCISION
DISADVENTAGES
• The incision is “non anatomic”. It cuts across
the apponeurotic fibers, as oppose to
transverse incision which cut paralel to the
fiber.
• Contraction of the abdominal wall causes
laterally directed tension on the closure 
suture material cut through by separation of
the transversely oriented fibers.
• More chance of incisional hernia, less cosmesis
• The rate of dehiscence is higher.
 COMPARISON OF
VERTICAL AND TRANSVERSE INCISION
 VERTICAL INCISION
PARAMEDIAN INCISION
• It is made 2-5cm lateral to
umbilicus.
• Provided acces to lateral.
DISADVANTAGES :
• Comparatively more bleeding.
• Difficult to extent superiorly.
• It doesn’t give good acces to
contralateral structure.
• Atrophy of muscle medial to
the incision.
Paramedian Incision
 VERTICAL INCISION
Pararectus Incision (Kammerer-Battle)
 VERTICAL INCISION
MIDRECTUS INCISION
 TRANSVERSE INCISION
ADVANTAGES
- best cosmetic results
- less painful-faster healing postoperative
- greater strength

DISADVANTAGES
- more time-consuming
- more haemorrhagic
- compromised ability to explore upper abdominal
cavity
- division of multiple layers of fascia and muscleand
nerves, may result with haematoma or seroma in
potential spaces.
 TRANSVERSE INCISION
KOCHER INCISION

EMIL THEODOR KOCHER

(1841-1917)
 TRANSVERSE INCISION
KOCHER SUBCOSTAL INCISION
• Is started at midline, 2 to 5 cm below the
xyphoid, and extends downwards
outwards and parallel to and about 2.5
cm below costal margin
• It affords excellent exposure to gall bladder
and biliary tract and can be extended to
the left side for splenectomy.
• Especially used in cholecystectomy, CBD
exporation.
Extension of Kocher subcostal incision can be extended to
the left , called CHEVRON (ROOF TOP) INCISION, used
forgastrectomy, oesophagectomy, pancreatectomy, hepatic
resection, and liver transplantation. Upper midline
extension called MERCEDEZ INCISION.
 TRANSVERSE INCISION
CHEVRON INCISION IN LIVER SURGERY
 TRANSVERSE INCISION
FOR APPENDICTOMY

CHARLES HEBER McBURNEY

(1845-1913)
TRANSVERSE LOWER ABDOMINAL
INCISION
 TRANSVER LOWER ABDOMINAL INCISION
PFANNENSTIEL INCISION
• Used frequently by gynecologist and
urologist for
• access to pelvic organ, bladder, prostate and
for c-section.
• is usually 12 cm long and is made in skin
fold
• approximately 5 cm above symphysis pubis.
THORACOABDOMINAL INCISION
 THORACOABDOMINAL INCISION
• Converts pleural and peritoneal cavities into
one common cavity. Thereby gives excellent
exposure.
• Right incision: useful in elective
andemergency hepatic resections.
• Left incision: may be used in resection of
lower end of esophagus and proximal portion
of stomach.
• Incision is extended along line of 8th
intercostal space. The pace immediately distal
to inferior pole of scapula.
LUMBOTOMY
ABDOMINAL CLOSURE
 SPECIAL INCISION
INCISION IN LAPAROSCOPY SURGERY
(Key Hole Surgery)
 SPECIAL INCISION
NATURAL ORIFICE TRANSLUMINAL
ENDOSCOPIC SURGERY (NOTES)
 SPECIAL INCISIO
ROBOTIC SURGERY
 COMPLICATION IN
GI SURGERY

Specific Intraoperative -Wound infection Adhesion

Haemorrhage -Anastomotic leak -Stricture

-Intra-abd.abscess - hernia

General to anaeshesia -MI -Pumonary collapse - PE

-Anaphylactic Reaction -DVT

-Cannula phlebitis

- UTI
 COMPLICATION
FEVER AFTER GI SURGERY
 COMPLICATION
SURGICAL SITE INFECTION
 COMPLICATION
BURST ABDOMEN
• Partial or complete post
operative separation of an
abdominal wound closure with
protrusion or evisceration of
the abdominal contents
• Most commonly occurs
from the POD #5-8 when
the strength of wound is at
its weakest
• Usually sutures opposing the
deep layers, i.e, peritoneum
and rectus sheath tear through
causing burst abdomen
 COMPLICATION
INCISIONAL HERNIA
COMPLICATION
INTESTINAL ADHESION
From every wound there is a scar,
and every scar tells a story.
A story that says,
“ I have survived”.

THANK YOU