Mamiek Dwi Putro Departemen / SMF Ilmu Bedah FK Unair / RSU Dr Soetomo Surabaya

Accessibility : provide direct exposure to the diseased or injured anatomy and sufficient space for the procedure to be well performed. Flexibility : amenable to extension if the complexity of the procedure demand greater exposure than orginally anticipated

Security

: closure of the wound must be strong and reliable

Vertical :

medline, medial paramedian, lateral paramedian.

Transverse and Oblique

Abdomino thoracic Retroperitoneal and extraperitoneal

The organ of interest and anticipated procedure The body habitus of patients and degree of obesity The urgency of procedure The presence of previous abdominal incisions The preference and experience of the surgeon

a.Midline Incisions

Fastest approach toward the peritoneal cavity Adequate exposure to the abdominal cavity and retroperitoneum Nearly bloodless Not require division of muscle fibres The upper midline / epigastric midline incision The lower midline / infraumbilical

The Upper Midline : - incision from the xiphoid process to 1 cm above umbilicus - the incision is carried down to the linea alba, extra peritoneal fat and peritoneum - with small incision is enlarged to admit 2 fingers to protect the underlying viscera The Infra Umbilical Midline : incision from 1 cm sub umbilical to symp pubic in the same manner The Full Length Incision : Midline laparotomy

Medial Paramedian Incisions

An Upper PI : begun at the costal margin 2,5 cm from midline on either the right or left side of the abdomen, to 2 cm below umbilicus An Lower PI :1 cm below umbilicus to 8cm below umbilicus .
The anterior rectus sheath is incisied, then diseccted off the rectus muscle to its medial edge

The inferior and superior epigastric vessels will be dissected ( divided and tied)

A. Paramedian incision: dissection of the rectus muscle from the anterior rectus sheath.

B. Paramedian incision in transverse section.

Lateral Paramedian Incisions

- Modification of standard PI ( Guillou Incision) - Incision is placed at the junction of the middle and outer thirds of rectus sheath - The rectus muscle is retracted laterally, posterior sheath , peritoneum are divided as the same plane as the anterior sheath

Vertical Muscle Splitting Incision : The same way as the traditional paramedian incision except the rectus muscle is split longitudinally in its median one third to one sixth The posterior rectus sheath and peritoneum are incised in the same line

Lower paramedian incision. A. Surface markings

Retraction of the rectus abdominis muscle

B. Incision of the rectus sheath

D. Location of the branches of the inferior epigastric vessels that run across the lower portion of the incision.

F. The peritoneum is incised for the full length of the wound. E. Peritoneum opened

B. Lateral paramedian and conventional paramedian incisions compared in transverse section

A. Lateral paramedian incision compared with conventional paramedian incision. Note that the upper or lower extension may be angled medially (darker lines) for greater access.

C. Closure of the lateral paramedian incision; it is sufficient to suture the anterior rectus sheath, leaving the posterior sheath open.

There are several variation, can be strictly horizontal or may curve to varying degree. The wound may be limited to lateral oblique muscle abd. wall, divide portion of one rectus or complete width of both rectus Generally folow Langers line

On Infra umbilical transverse incision , exposure is limited when pathology is located in both the upper and lower abdomen

Kocher Subcostal Incisions : - There are right subcostal incision and left subcostal incision or may be carried across the midline as bilateral sub costal incision. - The standard subcostal incision commences in the midline about 2.55 cm below the xiphoid process (approximately onethird of the way between the xiphoid and the umbilicus

- It is extended laterally and inferiorly about 2.5 cm below the costal margin for approximately 12 cm, although the length will vary with the build of the patient -The incision should leave sufficient room from the costal margin that if a hernia develops, adequate superior abdominal wall tissues are available for repair.

-The incision can be continued on to the lateral abdominal muscles

Kocher incision. A. Surface markings

B. Division of the rectus and medial portions of the lateral abdominal muscles.

Double Kocher Incision

Originally described by Charles McBurney in 1894,17 the muscle-splitting right iliac fossa incision is well suited for appendectomy.

- The classic McBurney incision is made in an oblique direction.

-

Most surgeons today use the Rockey-Davis incision. It is a modification of the time-honored McBurney incision that employs a cosmetically superior transverse incision in the line of the skin crease

-Tranverse incision on Mc Burney so called Lanz Incision ( Otto Lanz from Amsterdam )

- Incision is used frequently for gynecologic operations and for access to the retropubic space in the male for extraperitoneal retropubic prostatectomy. - The skin incision is placed in the curving interspinous crease that lies approximately 5 cm superior to the symphysis pubis and 12 cm in length.

- Both anterior rectus sheaths are exposed and divided transversely for the entire length of the wound, that are widely separated from the underlying rectus muscles superiorly to the umbilicus and inferiorly to the pubic symphysis. The recti are retracted laterally and the peritoneum is opened vertically in the midline.
-Care must be taken to protect the bladder at the lower end of the wound

B. Horizontal division of the anterior rectus sheath and developing fascial flap Pfannenstiel incision. A. Skin incision

C. Dividing in the midline and entering the peritoneal cavity

Opening midline Inferior retractors placed for exposure.

Closure midline and inferior rectus. Lateral retractors are placed for exposure

- The thoracoabdominal incision provides excellent exposure by converting the peritoneal and pleural spaces into one common cavity - Two variations : Left and Right Abdominothoracic Incision - The patient is placed in the "corkscrew" position on the operating room table for maximal access into both the abdominal and thoracic cavities. - The abdomen is tilted approximately 45 degrees from the horizontal by using sandbags, and the thorax is twisted into the full lateral position

- The abdominal part of the incision may consist of a midline or upper paramedian incision,which allows preliminary exploration of the abdomen.

- An obliquely placed limb of the abdominal incision is then added to continue along the line of the eighth inter space, identified easily where it is immediately caudal to the inferior pole of the scapula

A. The "corkscrew" position, with the thorax in the lateral position and the abdomen at 45 degrees from the horizontal. Very careful positioning on the operating table is essential to prevent injury to the brachial plexus or pressure on peripheral nerves and should be closely supervised by the surgeon.

B. The abdominal incision is ordinarily made first, to determine operability and be certain that the thoracic extension is needed. This is usually done with a vertical midline incision that is extended into the chest through the eighth intercostal space. The abdomen has been opened and the pleural space is being entered.

C. The diaphragm is usually opened in a radial fashion with an incision directed toward the esophageal or aortic hiatus.

D. The diaphragm can be opened with a hemielliptical incision 23 cm from the lateral chest wall; this incision is longer than a straight phrenicotomy but preserves phrenic nerve function, of importance in patients with chronic pulmonary disease or less than optimal pulmonary function.

Terima kasih Selamat belajar

A. J-shaped incision over the tenth to twelfth ribs, extending inferiorly 610 cm below the twelfth rib. B. Resection of the twelfth rib facilitates exposure. C. The diaphragmatic attachment to the twelfth rib is taken down, with care taken not to enter the pleura. If the pleura is opened, the wound closure is done over a pleural suction catheter, which is removed with simultaneous positive airway pressure by the anesthetist as the skin is being closed.

A. The skin incision may be shorter than depicted in thinner patients or if an abscess is to be drained. B. Peritoneum is retracted medially by blunt dissection, which exposes the psoas muscle and gonadal artery and vein, shown anterior to the ureter