ABDOMINAL INCISIONS

&
INCISIONAL HERNIA
OUTLINES
• Principles of incision
• Types of abdominal incisions
• Incisional closure
• Incisional hernia
PRINCIPLES OF INCISION
Anatomy
• Skin
• Subcutaneous tissue
• Superficial Fascia
• Camper’s Fascia-fatty superficial layer
• Scarpa’s Fascia-deep fibrous layer
• Deep Fascia(Gallaudet’s Fascia)
• Musculoaponeurotic Layer
• External Oblique Muscle
• Internal Oblique Muscle
• Transverse Abdominal Muscle
• Rectus Abdominis-Pyramidalis Muscle
• Fascia Transversalis
• Preperitoneal Fatty Tissue
• Peritoneum
 Skin incision
• Should made with a scalpel with blade being pressed firmly down at right
angles to the skin and then drawn gently across the skin in desired
direction to create a clean incision.
• The site and extent which should planned by surgeon.
• Not to incise the skin obliquely as such shearing mechanism can lead to
necrosis of the undercut edge.
• Blades for skin incisions usually a curved cutting margin, while those used
for arteriotomy or drain site insertion have a sharp tip.
• Scalpels should at all times be passed in a kidney dish rather than by a
direct hand-to-hand process at this lead to a needle stick-like injury.
• Diathermy, laser and harmonic scalpel can be used instead of blades when
opening deeper tissues, as it can reduce blood loss and save operating
time, and may reduce postoperative pain.
 Skin incision
When planning a skin incision, 4 factors should be considered:
1. Skin tension lines (Langer’s lines): These lines represent the orientation of
dermal collagen fibres and any incision placed parallel to these lines result in a
better scar.
2. Anatomical structure: Incisions should avoid bony prominences and crossing
skin creases if possible, and take into consideration underlying structures, such
as nerves and vessels.
3. Cosmetic factors: Any incision should be made bearing in mind the ultimate
cosmetic result, especially in exposed parts of the body, as an incision is the
only part of the operation the patient sees.
4. Adequate access for the procedure: The incision must be functionally effective
for the procedure in hand as any compromise purely on cosmetic grounds may
render the operation ineffective or even dangerous.
 Abdominal incision
Dog ears
• areas of redundant skin and subcutaneous
tissue resulting from a wound margin being
longer on one side than the other dealt
with either by incremental oblique
placement of sutures to redistribute the
tension across the wound fusiform excision
of the dog ear with lengthens the scar
considerably

Removal of a ‘dog ear’

• skin defect is sutured until the “dog ear”
becomes apparent the “dog ear” is defined
with a skin
• hook and is incised round the base excess
skin is removed and the skin is sutured
Basic Surgical Skills of Wound Incision

1. Mark out important landmarks

2. Add cross hatches with the marking pen for accurate wound closure later
3. Apply gentle traction to the skin to avoid wrinkles
4. Apply enough pressure to the scalpel to cut through to subcutaneous fat
with one stroke
5. Always cut toward you in one motion
6. Do not use a sawing motion
7. Focus your attention on the segment already cut in order to continue in a
straight line and to adjust the required pressure
8. Avoid numerous cuts in different planes
TYPES OF ABDOMINAL
INCISION
1-Kocher Incision 6-Paramedian
2-Midline 7-Transverse: MUSCLE DIVIDING
3-McBurney 8-Rutherford Morison
5-Lanz 9-PfannenstieL
• Vertical incision
1. Midline incisions
2. Paramedian incisions

• Transverse and oblique incisions

1. Kocher's subcostal Incision
• Chevron (roof top Modification )
• Mercedes Benz Modification
2. Mc Burney’s grid iron or muscle splitting incision.
3. Rutherford morison incision
4. Pfannenstiel incision
5. Maylard Transverse Muscle cutting Incision
6. Transverse muscle dividing incision
7. Thoracoabdominal incisions.
Vertical Incision
Midline Incision
• Incision of choice
• Rapidly made and closed
• Offers adequate exposure to any part of abd
cavity including the retroperitoneum
• Almost avascular, allows preservation of
muscle fibers and avoid nerve injury
• Can be divided into upper and lower midline
incision
• UPPER MIDLINE – xiphoid till umbilicus
• LOWER MIDLINE – above umbilicus till lower
pubic symphysis
• Upper midline incision – Esophageal hiatus, abdominal esophagus,
stomach, duodenum, gallbladder, pancreas and spleen
• Lower midline incision – Sigmoid colon and rectum, pelvic organs

** when making an incision at the lower anterior abdominal wall, care should be given to avoid
bladder injury. Bladder should always be decompressed using a Foley’s catheter
Paramedian incision
• Incision 2.5-4.0 away from midline
• Provide access to lateral structures like spleen and
kidney
• Lower risk of dehisence and hernia

Disadvantage :
• Takes longer to make and close
• results in atrophy of the muscle medial to the
incision
• The incision is laborious and difficult to extend
superiorly as is limited by costal margin.
• Risk of epigastric vessels injury
TRANSVERSE
AND
OBLIQUE
INCISIONS
KOCHER ‘S INCISION
• Incision parallel to the right costal
margin. started at the midline, 2.5 to 5
cm below the xiphoid and extends
downwards, outwards and parallel to
and about 2.5 cm below the costal
margin
• It shows excellent exposure to the
gallbladder and biliary tract and can be
made on the left side to show access to
the spleen.
CHEVRON (ROOF TOP)MODIFICATION
• The incision may be continued across the midline
into a double Kocher incision or roof top
approach which provide excellent access to the
upper abdomen particularly in those with a
broad costal margin

MERCEDEZ BENZ
• consists of bilateral low Kocher’s incision with an
upper midline incision up to the xiphisternum.
MCBURNEY GRID IRON
• Made at the junction of the middle
third and outer thirds of a line running
from the umbilicus to the anterior
superior iliac spine. (The McBurney
Point)

RUTHERFORD-MORRISON INCISION
• This is extension of the McBurney
incision by division of the oblique fossa
MAYLARD TRANSVERSE MUSCLE CUTTING INCISION
• It is placed above but parallel to the traditional
placement of Pfannenstiel incision.
• Gives excellent exposure of the pelvic organs.

TRANSVERSE MUSCLE DIVIDING INCISION

• The operative technique used to make such an incision is
similar to that for the Kocher incision. In newborns and
infants, this incision is preferred. Also in obese patients
PFANNESTIEL INCISION (smile incision)
• Used frequently by gynecologists and urologists
for access to the pelvis organs, bladder, prostate
and for caesarean section.
• Usually 12 cm long and made in a skin fold
approximately 5 cm above symphysis pubis.
• Minimizing muscle parasthesia and paralysis
post-operatively
• Excellent cosmetic result
• Limited exposure of the abdominal organs. Use
of incision is therefore restricted to the pelvic
organs
• High risk of injury to the bladder
THORACOABDOMINAL INCISION

• Converts the pleural and peritoneal cavities into

one common cavity  excellent exposure.
• Left incision: Resection of the lower end of the
esophagus and proximal portion of the stomach.
• Right incision: elective and emergency hepatic
resections.
Incision Closure
• Suturing of any incision or wound needs to take into consideration
the site and tissue involved and technique for the closure should be
chosen accordingly
• Suture characteristics:
1. Physical structure
2. Strength
3. Tensile behavior
4. Absorbability
5. Biological behaviour
Types of Suture Materials
• Absorbable suture: degraded and eventually eliminated (eg; cut gut, vicryl,
monocryl)
• Non asorbable suture: does not degraded (eg; prolene, nylon, stainless steel)
• Natural suture: biological origin, may cause intense inflammatory reaction (eg;
cat gut, ceramic, silk)
• Synthetic suture: does not cause intense inflammatory reaction (eg; vicryl,
monocryl, nylon)
• Monofilament suture: grossly appears as single strand of suture materials; all
fibres run parallel, ties smoothly (eg; monocryl, prolene, nylon)
• Multifilament suture: fibres are twisted or braided together, greater resistance in
tissue (eg; vicryl (braided), chromic (twisted), silk (braided)
Suture material desired characteristics:
• Easy to handle
• Predictable behavior in tissue
• Predictable tensile strength
• Sterile
• Glides through tissues easily
• Secure knotting ability
• Inexpensive
• Minimal tissue reaction
• Non-allergenic
• Non-carcinogenic
• Non-electrolytic
• Non-shrinkage
Alternative to suture
• Skin adhesive strips
• Tissue glue
• Staples: skin slips + stappling devices
Needles
• Shaped needles allow easier access for
suturing. Examples are the J-shaped needle
useful in low-approach femoral hernia repair,
or the compound curve needle used in
ophthalmic surgery.
• Hand needles should be avoided because of
the risk of needle-stick injury.
• The tips of laparotomy closure needles are
deliberately blunted by some of the
manufacturers to reduce the risk of needle-
stick injury.
• Needles may come with a loop suture (to
avoid a knot at the end of a laparotomy) or as
double-ended sutures (to facilitate arterial
closure).
Knotting Techniques
• Knot must be tied firmly, but without strangulating tissues
• Knot must be unable to slip / unravel
• Knot must be as small as possible to minimise amount of foreign material
• Knot must be tightened without exerting any tension / pressure on tissues
being ligated
• Suture material must not be ‘sawed’ during tying  may weaken the
thread
• To prevent breakage / fracture of thread during tightening
• Suture material must be laid square during tying
• Thread should only be grasped at the free end when tying instrument knot
• End of suture should be left 1 – 2 mm long after knotting to prevent
unravelling
Type of Knots
• Reef knot
• Standard knot used
• 3rd throw for security (except for vascular surgery: 6 – 8 throws)
• Granny knot
• Slip knot involves 2 throws of same type of throw
• Useful in achieving right tension followed by a standard reef knot
for security
• Surgeon’s knot
• When added security is required by preventing slippage
• Aberdeen knot
• Used as final knot when using continuous suture technique
• Free end of suture is partially pulled through final loop several time
before final pull prior to cutting
Suture Technique
1) Interrupted suture
• Each stitch is tied separately
• Needle inserted at right angles to the incision and then to pass through both aspects of
the suture line and exit again at right angle
• The distance from the entry point of the needle to the edge of the wound should be
approximately the same as the depth of the tissue being sutured, and each successive
suture should be placed at twice this distance apart
• For biopsy / implant
• Adv: commonly used, preferable in urgent, easy to remove, inconsequential to others
• Disadv: do not bring all surfaces into contact, less supportive for healing of flap margins
Rule of Thumb: distance of insertion from the edge of
wound should correspond to thickness of tissue being
sutured. Each successive suture is placed at twice the
distance apart.
2) Continuous suture
• Aka running stitches
• Series of stitches taken with one strand of
material
• First suture is inserted in an identical manner to
an interrupted suture but the rest if the sutures
are inserted in a continuous manner until the far
end of the wound
• Each throw of the suture should be inserted at
right angles to the wound, the external observe
suture material will lie diagonal to the axis of the
wound
• For site where aesthetics is not important eg:
bone graft, reduction of tuberosity
• Adv: simple, can be perform rapidly, consume less
silk, opposition of skin
• Disadv: if one stich is untie  unable to maintain
strength of suture line, post-operative edema
take up slack in suture material
3) Mattress sutures
• Can be either vertical or horizontal
• Used to produce either eversion or inversion of the wound edge
• Vertical  used in anatomic locations which tends to evert (eg: posterior aspect
of neck, deeper wounds)
• Horizontal  for large distances between tissues, bone grafts and implants, and
for closure of extraction socket
• Adv: Good for hemostasis, less prominent scarring
• Disadv: Leave gap between flaps, difficult to remove
• Started with an interrupted suture and then the needle either moves horizontally
or vertically and traverses both edges of the wound once again
• Useful in producing accurate approximation of the wound edge (especially when
the edge to be anastomosed are irregular in depth or disposition)
4) Subcuticular sutures
• Used in skin where a cosmetic appearance
is important and where the skin edges
may be approximated easily
• Can use
• Absorbable: end secured by buried knot
• Non absorbable: end secured by collar or
bead, or tied loosely over wound
• Small bites of subcuticular tissue are taken
on alternate sites of the wound and then
gently pulled together thus approximating
the wound edges without the risk of cross
hatched markings of interrupted sutures.
• Adv: less visible, minimal redness of
suture line
• Disadv: slight lumpy appearance
temporarily, not suitable if tension on
wound
INCISIONAL HERNIA
 INCISIONAL HERNIA
• An incisional hernia is a hernia that occurs through a previously made incision in the abdominal wall.
• These arise through a defect in the musculofascial layers of the abdominal wall in the region of a postoperative scar. Thus they may
appear anywhere on the abdominal surface.
• It is common in old age and obese individuals.
RISK FACTORS AND HISTORY TAKING
• Incisional hernias have been reported in 10–50 per cent of laparotomy incisions and 1–5 per cent of laparoscopic port-site
incisions.
PATIENT FACTORS WOUND FACTORS SURGICAL FACTORS

• Obesity • Poor quality tissues • Inappropriate suture

• General poor healing • Wound Infection material
due to malnutrition • Incorrect suture
• Immunosuppression placement
• Steroid therapy
• Chronic cough
• Cancer

• Details of surgery that patient has undergone earlier. Duration after how long incisional hernia has occurred is important.
• History of wound infection, wound dehiscence, whether surgery done was an emergency or elective, and tension sutures
placed or not.
• History of pain, irreducibility and details of precipitating factors to be asked.
• Other precipitating factors are similar to inguinal hernia like smoking, urinary/respiratory/abdominal symptoms.
 PATHOPHYSIOLOGY
• An incisional hernia usually starts as disruption of the musculofascial layers of a
wound in the early postoperative period.

• The classic sign of wound disruption is a serosanguinous discharge .

• A hernia is defined as ‘the protrusion of a viscus, or part of a viscus through the
wall of the cavity in which it is contained’.
• The layers of the anterior abdominal wall are normally strong, and act to
maintain the integrity of the abdominal cavity. However, once these layers are
interrupted by a surgical incision, their continuity is disrupted and they are
structurally weakened.
• In the presence of increased intra-abdominal pressure and/or certain risk
factors, the contents of the abdomen are able to herniate through the
weakness, forming an incisional hernia.
• As with any hernia, complications can occur, such as incarceration (hernia is
irreducible), strangulation (blood supply to the hernia is compromised), or
bowel obstruction.
CLINICAL FEATURES
• The characteristic clinical feature of an incisional hernia is a non-
pulsatile, reducible, soft and non-tender swelling at or near
the site of a previous surgical wound.

• If the hernia is incarcerated, it can become painful, tender, and

erythematous. In cases of bowel obstruction, the patient may
also present with symptoms of abdominal distention, vomiting,
and/or absolute constipation.

• On examination, a mass is palpable at or near the site of the

surgical incision, which may be reducible (depending on its
severity). Assess the patient for any signs of bowel ischaemia
(strangulation) – such as rebound tenderness or involuntary
guarding.
INVESTIGATIONS
• In most cases of incisional hernia, the diagnosis is made on a clinical basis, with no laboratory or imaging studies required
(however any features of complications from the hernia should be investigated accordingly)
• Ultrasound or CT imaging can be used to investigate a hernia if the diagnosis is unclear, demonstrating the potential a
fascial gap with protruding abdominal contents.

MANAGEMENT
• Conservative Approach: If the neck of the incisional hernia is wide shows no signs of increase in size and patient has no
symptoms, it may be observed.
• Operative Treatment: The indications are:
Symptomatic hernia which is showing signs of increasing in size needs repair.
Large hernia with a small defect. Such hernia has a high chance of strangulation and needs to be repaired early. Subacute
intestinal obstruction, irreducibility and strangulation are definite indications for repair of incisional hernia.
 PRINCIPLE OF SURGERY
OPEN REPAIR ADVANTAGES
• Simple suture techniques without the use of prosthetic mesh for  Cost effective
reinforcement even with layered closure such as in Mayo, ‘keel’ or da  Less OT time
Silva repairs, are not recommended today because of the high risk of
recurrence.  Low rate of infection
• Hernia diameter is <3-4cm DISADVANTAGES
 Recurrence rate >50%
• The previous incision is opened along its full length to reveal any
clinically unsuspected defects.  Tension sutures
• The hernial sac, its neck and the margins of the defect are fully exposed.  High post operative pain

• The sac can be opened, contents reduced, local adhesions divided and  More seroma formation
any redundant sac excised to allow safe reclosure of the peritoneum.
• Non-absorbable monofilament continuous sutures placed ~1cm from
fascial edge and 1cm adjacent to the prior suture to avoid tight closure.
• Absorbable skin closure with monofilament sutures or staples or
adhesive glue (Dermabond)
 PRINCIPLE OF SURGERY
MESH PLACEMENT
 Hernia diameter is >4cm
 Open/Laparoscopic approach
 Synthetic mesh e.g. polypropylene, ePTFE
 Mesh can be placed above fascia (overlay/onlay),
 below (underlay/sublay) or in between fascial
edges (inlay).
 SUBLAY-GOLD
ADVANTAGES DISADVANTAGES
 Low recurrence rate 2-12%  High rate of infection
 Less seroma formation  Costly
 Low post operative pain  More OT time
 Tension free
 Reinforcement and
reconstruction
PRINCIPLE OF SURGERY
• Keel operation is done in large defect. Scar is excised and is dissected
beyond the margin of the defect. Sac is never opened unless there is
obstruction of the content. Sac in inverted using
continuous/interrupted inverting non-absorbable sutures, layer by
layer until the defect margins are apposed together which is then
again sutured with interrupted sutures.

• Nuttall’s operation is done for lower midline incisional hernia. Recti

attachments are detached from the pubic bones and are crossed over
to fix to opposite pubic bones so as to create a firm abdominal wall
support by crossed recti muscles.
TREATMENT
POST OPERATIVE CARE
• Antibiotics.
• Analgesics.
• Nasogastric aspiration.
• Abdominal binder for support.
• Prevention of paralytic ileus.
• Control of obesity and other precipitating factors.
• Stop smoking and treat other associated causes.
• Early ambulation.
• Fluid management, catheterisation.
• Drain should be kept until drainage becomes
minimal.
REFERENCES
• Bailey and Love’s Short Practice of Surgery 26th Edition