The choice of the approach for entering the abdominal cavity depends upon:
■ The accuracy of the preoperative diagnosis
■ The location and extent of the disease
■ Previous scars
■ The requirement of a possible extension of the incision
■ Anatomic structures, such as skin, fascia, muscles, nerves, and blood vessels.
The abdominal wall should stay functional. Whenever possible, incisions are placed along the skin split lines, also called the lines of Langer, and muscles and fascia are divided along their fibers
Mark the incision prior to cutting to prevent malpositioning
The midline incision is the most expedient choice for opening the abdomen and provides unrestricted access, regardless of the patient's size or shape (including exposure of the pelvis). The advantages of a midline incision are:
■ Can be extended into a median sternotomy
■ Minimal blood loss
■ No muscle fibers are divided
■ No nerves are injured
■ Is suitable for repeated celiotomies
■ Offers best exposure in an emergency situation with unclear diagnosis
■ Place skin incision exactly in the midline, above and below the umbilicus from the tip of the xiphoid to the pubis (extension as needed) (A-1)
■ Deflect the incision around the umbilicus to the left or the right. The evasion of the umbilicus on the left side is preferred, because of possible rudimentary umbilical vessels. In general, use the opposite side of the umbilicus if an ostomy is planned
■ The scalpel or the cautery can be used all the way
■ By pulling the wound, the fat spreads and the midline plane separates down to the fascia (A-2, A-3)
■ Apply digital pressure to minimize bleeding
■ Incise the fascia with the scalpel or cautery just above or below the umbilicus, as the linea alba is widest around the umbilicus
■ Gently lift up the peritoneum with pickups before opening to avoid small bowel lesions (A-4)
■ Care to incise the linea alba without exposing the rectus muscles markedly facilitates the closure
Subcostal Incision (A-1)
The subcostal incision is usually made for cholecystectomy or common bile duct exploration (right subcostal incision) and for elective splenectomy (left subcostal incision). The major advantage of the subcostal incisions over the upper midline incision are greater lateral exposure and less pain. The disadvantage is that the operation takes longer, because there are more layers to close. The subcostal incision generally heals well with little risk of hernia formation.
■ Place skin incision two finger breadths below the costal margin. This facilitates closure so that the incision line is not on or over the costal margin
■ Incise the anterior and posterior sheet of the rectus muscle. The muscle is cut slowly with the cautery (A-2); care should be taken to ligate or cauterize the inferior epigastric vessels
■ Laterally, the fascia of the transverse muscle may need to be cut
■ Try not to incise the fascia in the midline, but if necessary, extend the incision medially
Bilateral Subcostal Incision
The bilateral subcostal incision is used to access the liver for transplant and major liver resections. Also, most pancreas resections are performed with this incision. The exposure is often helped with a vertical extension to the xiphoid (the so-called "Mercedes star" incision).
■ Incision of skin and fascia as described above
■ For pancreas resections, the incision is generally placed three to four finger breadths below the costal margin
■ Mobilization of the liver begins with the division of the falciform ligament (the liver's reflection of peritoneum with the anterior wall)
■ Division of the round ligament (a fibrous cord resulting from the obliteration of the umbilical vein), which should be ligated to avoid bleeding, particularly in the presence of portal hypertension
■ It is preferable to mobilize the liver prior to the use of stationary retractors to reduce the necessity of frequent repositioning
The J-shaped incision is used most frequently for surgery on the right liver (see page 374 ). This incision provides a particularly good access to the area between the inferior vena cava and the right hepatic vein. The J-shaped incision can be extended laterally to a thoracotomy for better exposure.
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