The Incision*
Moshe Schein
Incisions heal from side to side, not from end to end, but length does matter.
When entering the abdomen, your finger is the best and safest instrument.
The patient now lies on the table,anesthetized and ready for your knife.Before you scrub, carefully examine the relaxed abdomen. Now you can feel things which were impossible to feel in the tense and tender belly. You may feel a distended gall- bladder in a patient diagnosed as an acute appendicitis, or an appendiceal mass in a patient booked for a cholecystectomy. Yes, this may also occur in the era of ultra- sound and CT.
Traditionally, abdominal entry in an emergency situation or for exploratory purposes has been through a generous and easily extensible vertical incision, es- pecially the midline one. Generally speaking, the trans linea alba midline incision is swiftly effected and relatively bloodless. On the other hand, transverse incisions are a little more time- and blood-consuming but are associated with a lower inci- dence of wound dehiscence and incisional hernia formation. In addition, transverse incisions are known to be “easier” on the patient and his lung function in the post- operative period. (It seems that vertical paramedian incisions belong to history).
Keeping this in mind,we should be pragmatic rather than dogmatic and tailor the incision to the individual patient and his or her disease process.We should take into consideration the urgency of the situation,the site and nature of the condition, the confidence in (or uncertainty about) the preoperative diagnosis, and the build of the patient.
Common sense dictates that the most direct access to the specific intra-abdomi- nal pathology is preferable. Thus, the biliary system is often best approached through a transverse, right subcostal incision. Transverse incisions are easily lengthened, to offer additional exposure; a right subcostal incision can be extended into the left side (as a “chevron”),offering an excellent view of the entire abdomen.When a normal ap- pendix is uncovered through a limited, transverse, muscle-splitting, right lower qua- drant incision,one can extend it by cutting the muscles across the midline to deal with any intestinal or pelvic condition.Alternatively, when an upper abdominal process is found, it is perfectly reasonable to close the small right iliac fossa incision and place a new, more appropriate, one.Two good incisions are better than one, poorly placed.
10
* Asher Hirshberg, MD contributed to this chapter in the 1st edition of the book.
The midline incision – bloodless,rapid,and easily extended – affords superior exposure and versatility; it remains the classic “incision of indecision”when the site of the abdominal catastrophe is unknown and is the safest approach in trauma.
This is an occasion to mention that an emergency laparotomy without a diagnosis is not a sin! Do not surrender to the prevailing dogma that the patient cannot enter the operating theater without a ticket from the CT scanner. A clinical acute abdomen – when “other diagnoses” have been ruled out (see > Chaps. 3 and 4) – remains an indication for laparotomy and on many occasions the abdominal wall is the only structure separating the surgeon from an accurate diagnosis.
At What Level Must the Midline Incision Start and How Long Should It Be? (> Fig. 10.1)
The macho surgeons of previous generations often screamed: “Make it long.
It heals from side to side, not from end to end”. Today, in the era of minimal access surgery, we are familiar with the advantages of shorter incisions. In the absence of any obvious urgency, enter the abdomen through a short incision and then extend as necessary; but never accept less than adequate exposure or strive for keyhole surgery. Begin with an upper or lower midline incision, directed by your clinical assessment; when in doubt, start near the level of the umbilicus and “sniff ” around from there, then extend towards the pathology. Just remember what the famous 84 Moshe Schein
Fig. 10.1. “Which incision?”
Swiss surgeon Theodor Kocher said more than 100 years ago:“The incision must be as long as necessary and as short as possible”.
Should You Extend Your Incision into the Thorax?
Very rarely! In the vast majority of cases, infra-diaphragmatic pathology is approachable through abdominal incisions. The combination of a subcostal and upper midline incision offers an excellent exposure for almost all emergency hepatic procedures, with the exception of retrohepatic venous injuries where insertion of a trans-atrial vena cava shunt necessitates a median sternotomy – usually a futile exercise, anyway. Thoracoabdominal incisions are mainly reserved for combined thoracoabdominal trauma.
Knife or Diathermy?
A few studies suggest that the latter is a few minutes slower while the former sheds a few more drops of blood; otherwise results are comparable. We use either.
In extreme urgency, gain immediate entry with a few swift strokes of the knife;
otherwise, diathermy is convenient, especially when performing transverse muscle- cutting incisions. Adequate hemostasis is a crucial surgical principle but do not go overboard chasing individual erythrocytes and avoid reducing the subcutaneous fat or skin to charcoal. The hypothesis that “You can tell how bad the surgeon is by the stink of the Bovie in his OR”has not been proven by a double-blind randomized trial but makes sense nonetheless.
Subcutaneous hemostatic ligatures behave like a foreign body and are almost never necessary. In fact, most incisional “oozers” stop spontaneously, after a few minutes, under the pressure of a moist lap pad. It is also unnecessary to “clean” the fascia by sweeping the fat laterally:the more you dissect and “burn”, the more inflammation and infection-generating dead tissue you create!
Keep in Mind Special Circumstances
If a stoma is anticipated then place the incision away from its planned loca- tion.Abdominal re-entry into the “hostile abdomen”of a previously operated patient can be problematic; you may spend more time, sweat and blood, but the real danger is creating inadvertent enterotomies in intestine adherent to the previous incisional scar. This is a common cause of postoperative external bowel fistula! (> Chap. 45).
The prevailing opinion is to use the previous incision for re-entry, if possible.When 85 10 The Incision
doing so, however, start a few centimeters below or above the old incision and gain entry into the abdomen through virgin territory. Then insert your finger into the peritoneal cavity and navigate your way safely in, taking down adhesions to the abdominal wall,which hamper the insertion of a self-retaining retractor.Essentially, you are finished “getting in” when you are able to place a self-retaining retractor to open the abdomen wide. In a dire emergency or when you expect the abdomen to be exceptionally scarred, it may be prudent to stay away from trouble and create an entirely fresh incision. In this situation beware of parallel incisions in close proximity to one another because the intervening skin may be at risk of necrosis, particularly if the first incision is relatively recent.
Pitfalls
When in haste, do not forget that the liver lies in the upper extremity of the long midline incision, and the urinary bladder at its lowermost. Be careful not to damage either.
When approaching the upper abdomen divide and ligate the round hepatic ligament. Leave it long: it could be used to elevate and retract on the liver. Take the opportunity to divide the bloodless falciform ligament,which runs from the anterior abdominal wall and the diaphragm to the liver. If left intact it may “tear”off the liver causing irritating bleeding.
When performing any transverse incision across the midline, do not forget to ligate or transfix the epigastric vessels just behind the rectus abdominis muscles.
They may retract and cause a delayed abdominal wall hematoma.
In the very obese patient, in the upright position, the umbilicus commonly reaches the level of the pubis.After elevating the fat paniculus you can place a lower midline incision between the pubis and umbilicus but after the operation it will be macerated by the sweaty paniculus. Thus, in the super-fat, a supra-umbilical midline incision would provide a better access into the lower abdomen.
“Pray before surgery, but remember God will not alter a faulty incision.”
(Arthur H. Keeney) 86 Moshe Schein
