Abdominal incisions and laparoscopic access

Abdominal incisions Abdominal incisions are based on anatomical principles They must allow adequate assess to the abdomen They should be capable of being extended if required Ideally muscle fibres should be split rather than cut Nerves should not be divided The rectus muscle has a segmental nerve supply It can be cut transversely without weakening a denervated segment Above the umbilicus tendinous intersections prevent retraction of the muscle

Midline incision

• Midline incisions are the commonest approach to the abdomen
• The following structures are divided:
  • Skin
  • Linea alba
  • Transversalis fascia
  • Extraperitoneal fat
  • Peritoneum
• The incision can be extended by cutting through or around the umbilicus
• Above the umbilicus the Falciform ligament should be avoided
• The bladder can be accessed via an extraperitoneal approach through the space of Retzius
• The wound can be closed using a mass closure technique
• The most popular sutures are either non-absorbable or absorbable monofilaments
• At least 1 cm bits should be taken 1 cm apart
• Requires the use of one or more sutures four times the wound length

Paramedian incision

• A paramedian incision is made parallel to and approximately 3 cm from the midline
• The incision transverse:
  • Skin
  • Anterior rectus sheath
  • Rectus - retracted laterally
  • Posterior rectus sheath - above the arcuate line
  • Transversalis fascia
  • Extraperitoneal fat
  • Peritoneum
• The potential advantages of this incision are:
  • The rectus muscle is not divided
  • The incisions in the anterior and posterior rectus sheath are separated by muscle
• The incision is closed in layers
• Takes longer to make and close
• Had a lower incidence of incisional hernia (when sutures were not so good)