What scar is this?
Midline laparotomy scar
What are the advantages and disadvantages of a midline laparotomy incision
Pros:
- Provides good access
- Can be extended easily
- Quick to make and close
- Relatively avascular
Cons:
- More painful than transverse incisions
- Crosses Langer’s lines so poor cosmetic appearance
- Narrow linea alba below umblicus
- Some vessels cross the midline
- Can cause bladder damage
What layers of the abdominal wall are cut through with a midline incision
Skin
Fascia
Linea alba
Transversalis fascia
Extraperitoneal fat
Peritoneum
What scar is this?
Paramedian
Allows access to lateral structures:
- Kidney
- Adrenals
- Spleen
What are the advantages and disadvantages of a paramedian incision
Pros:
- Provides access to lateral structures
- Rectus muscle not divided
- Closure is more secure
- Can be easily extended
Cons:
- Takes longer to make and close
- Incision needs to be closed in layers
- Causes atrophy of the muscle medial to the incision
What layers of the abdominal wall are cut through in a paramedian incision
Skin
Fascia
Anterior rectus sheath
Posterior rectus sheath (if above arcuate line) or transversalis fascia (if below arcuate line)
Extraperitoneal fat
Peritoneum
What scar is this
McBurney’s
Most common for open appendicectomies
Made at McBurney’s point
What are the advantages and disadvantages of McBurney’s incision
Pros:
- Aesthetically pleasing as they follow Langer’s skin lines
- Room for extension
- Minimal damage to muscles using muscle splitting techniques
- Avoids damage to local nerves
Cons:
- Bleeding from the deep circumflex artery
What scar is this
Lanz
For appendicectomy
What are the advantages and disadvantages of a Lanz incision
Pros
- More aesthetically pleasing as the scar is concealed by the bikini
Cons
- Tends to divide iliohypogastric and ilioinguinal nerves
- Leading to denervation of inguinal canal mechanism –> increased risk of inguinal hernias
What layers of the abdominal wall do McBurney’s and Lanz incisions cut through
Skin
Fascia
Internal oblique medially
External oblique laterally
Transversus abdominus
Transversalis fascia
Extraperitoneal fat
Peritoneum
What scar is this
Nephrectomy
For kidney removal
What scar is this
Kocher
3cm below and parallel to costal margin, from midline to rectus border
Used for:
- Cholecystectomy
- Splenectomy (if on the left)
What are the advantages and disadvantages of a Kocher’s incision
Pros:
- Greater lateral exposure
- Less painful than midline incision
- Less post-operative complications than midline incision
- Heals well
Cons:
- Longer operation time
- Must be careful of the epigastric vessels
- If extended too laterally, too many intercostal nerves are severed
What layers of the abdominal wall are cut through in a Kocher’s incision
Skin
Rectus sheath
Rectus muscle
Internal oblique
Transversus abdominus
Transversalis fascia
Extraperitoneal fat
Peritoneum
What scar is this
Rooftop (double Kocher’s)
Used in:
- Pancreatic resection
- Radical gastric operation
- Intrahepatic surgery
- Bilateral adrenalectomy
What scar is this
Mercedes Benz
Used for:
- Liver transplant
What scar is this
Rutherford-Morrison
For renal transplant
What scar is this
Pfannenstiel
At the suprapubic skin crease
Used for:
- Caesarean section
- Bladder operations
- Prostate operations
What are the advantages and disadvantages of a Pfannenstiel incision
Pros:
- Minimal muscle parasthesis and paralysis post-operatively
- Hidden in the pubic hairline
Cons:
- Limited exposure of the abdominal organs
- High risk of injury to the bladder
- Lateral extension of the incision is difficult
What layers of the abdominal wall are cut through in a Pfannenstiel incision
Skin
Fascia
Anterior rectus sheath
Rectus muscle
Transversalis fascia
Extraperitoneal fat
Perineum
