Abdominal incisions.
DEFINITION
Abdominal incision is the vector illustration of surgical incisions of the abdominal cavity.
(1) Supraumbilical midline incision
• Layers to cut :
– skin
– Subcutaneous tissue
– Linea Alba
– Transversalis fascia.
– Peritoneum
• Indications :
– Any surgery of the stomach like gastrojejunostomy
– partial gastrectomy
– Liver abscess
– Cholecystostomy
– Cholecystectomy
• Advantages
– Easy to open
– Done in emergency conditions.
• Disadvantages
– It is less vascular
– Poor healing process
– High chances of incisional hernia as Linea Alba is a fibrous structure with less vascularity.
(2) Infraumbelical midline incision
• Layers to be cut
– Skin
– Subcutaneous tissue
– Linea alba
– Transversalis fascia
– Peritoneum.
• Indications
– Cessarean section
– Hysterectomy
– Hysterotomy
– Surgeries of urinary bladder
– Prostectomy
– Surgery of ovary
– Ruptured ectopic gestation
– Sigmoid volvulus.
• Advantages
– Risk of incisional hernia is less..
(3) Paramedian incision
– Any incision on side of midumbelical line is Paramedian incision.
• Types
– Right and left upper paramedian incision
– Right and left mid Paramedian incision
– Right and left lower Paramedian incision.
• Layers to be cut
– Skin
– Subcutaneous tissue
– Anterior rectus sheath
– Rectus abdominis muscle
– Posterior rectus sheath
– Transversalis fascia
– Peritoneum.
• Advantages
– Less chance of incisional hernia
– wound is stronger.
• Disadvantages
– More time is taken to open various layers.
• Indications of right upper paramedian incision
– liver surgery
– Gall bladder surgeries
– surgeries of common bile duct
– Pancreatic surgery
– Gastric surgeries
– Perforated peptic ulcer
– Surgery to treat tumor of ascending and transverse colon
• Indication of left upper paramedian incision
– Gastrectomy
– Spleenectomy
– Surgeries for body and tail of pancreas.
• Indication of mid Paramedian incision.
– It is mainly used for explorative surgery
(4) Pfanlebsteil incision
– It is a skin crease incision
• Layers to cut
– Skin
– Subcutaneous tissue.
– Oblique muscle
– Rectus muscle
– Transversalis fascia
– Peritoneum.
• Indications
– Cesarean section
– Hysterectomy
– Ectopic gestation
– prostatectomy
• Advantages
– It heals well and fast
– Has good cosmetic result
– very less chance of incisional hernia
• Disadvantages
– Occasionally osteitis pubis may develop.
(5) Mcburney incision
– Muscle splitting incision.
• Layers to be cut
– Skin.
– Subcutaneous tissue
– External oblique muscle
– Internal oblique muscle
– Transversalis fascia
– Peritoneum.
(6) Rutherford Morrison’s incision
– Same as Mcburney incision but the muscle are cut instead of being split.
• Indications.
– Appendiectomy
– colostomy
– Cecostomy
• Advantages
– Easy to open
– Good cosmetic result.
– Only a small scar is produced.
(7) Subcostal incison
– Incision made horizontal or parallel to costal margin from xiphoid process to the tip of 9th costal margin.
• Indications
– Cholecystectomy
– Surgery of liver and gall bladder
– Bile duct operations
– Sub diaphragmatic abscess
– Diaphragmatic injuries
• Layers to be cut
– Skin
– Subcutaneous tissue
– Rectus muscles are divided.
– Peritoneum
• Advantages
– Easy visualization of gall bladder
• Disadvantages
– Limited exposure
– The incision cannot be extended.
(8) Thoracoabdominal incision.
• Indication
– Esophagogastrectomy
– Repair of hernia
– Ruptured diaphragm.
• Advantages
– Good exposure
• Disadvantages
– Intercostal to be should be put post-operatively.
(9) Battles pararectal incision
– It is a vertical and subumbelical incision about 5cm in length over lateral part of recti muscle
• Layers to be cut
– Skin
– Subcutaneous tissue
– Anterior recti is divided
– Rectus muscle us retracted
– Post rectus sheath
– Transversalis fascia
– Intercostal muscles are retracted
– Peritoneum.
• Indications
– Appendiectomy
– Gynecological operations
(10) Incision for inguinal hernia
– About 2 fingers abouve and parallel to the medial 2/3 rd of inguinal ligament.
• Indications
– simple herniotomy
• Preoperative assessment and physiotherapy management
(1) Subjective assessment
✓ patient profile
– Name
– Age
– Sex
– Occupation
– Address
– Date of admission
– Date of Operation
– chief complaint
✓ Provisional diagnosis
– Name of surgery
– Type of surgery
✓ History
– Present medical history ( onset, duration )
– Past medical history / surgical history
– Any surgery or treatment done earlier
– Personal /family history.
(2) Objective assessment
(A) On observation
– Built of patient
– Level of consciousness
– Eyes ( pale / yellow )
– Respiratory assesment : Chest movements, accessory muscles work,
Pattern of breathing , cough effort , chest deformities, dyspnea, sputum .
– Extremities : edema, cyanosis, clubbing.
– General posture and gait pattern
(B) On palpation
– Edema : pitting or non-pitting
– Trigger point tenderness
– Movement of chest : symmetrical and asymmetrical.
– Tracheal or mediastinal shift
– ROM examination
– Vocal fremitus
(C ) On percussion :
– Resonance : hyper/hypo
(D) On auscultation :
– Heart sounds
– Breath sounds
– Any added sounds.
(3) Investigation
– Case sheet reading
(4) Vital signs
• Aims of treatment
– To gain patients confidence
– Reassurance
– removal of secretions
– movement of upper and lower extremities
– To teach bed mobility exercises
– Body and postural alignment
– To teach splinting over the incision.
• Means of treatment
(1) Gain patients confidence
– Introduction with the patient is necessary
– Make him /her understand the importance of the surgery and various preoperative exercise
– Expalin the effects of treatment
– Remove patient fear and anxiety by reassurance and listening to the patient’s problems .
(2) To optimize relaxation
– Teach Diaphragmatic breathing exercises
– Various relaxation postures and yoga
(3) Mucociliary transport /removal of secretions
– Deep breathing exercises are taught
– Postural drainage with percussion, vibration and shaking techniques
– Coughing and huffing is taught
– Patients should be encouraged to stop smoking immediately
– Manual airway clearence techniques like ACBT , autogenic drainage is taught, PEP and incentive spirometry.
– Viscous and thick secretions can be removed by nebulizer or suctioning , humidification .
(4) Encourage movements of upper and lower extremity
– Ankle / toe movements
– Knee flexion / extension exercise
– Shoulder girdle exercise
– Butterfly techniques .
(5) Bed mobility exercises
– Turning from side to side
– Getting up without pulling the drainage tubes is also taught , bridging exercises.
– Toileting , eating, dressing can also be taught.
(6) Body and postural alignment
– Proper positioning of body with pillow support
– Postural awareness training by use of mirror for feedback
– Sideward, upward, backward streching of trunk is taught.
– Medicine ball exercises and core stabilizing exercise are also taught.
• Common abdominal Surgeries
(1) Exploratory laprotomy
– It is a mid Paramedian incision where surgery is performed where the exact location of diagnosis and pathology is not known.
– Thus, a small mid Paramedian incison can be done which is extended upwards or downwards depending on site of pathology.
– It is commanly performed during Spleenectomy.
(2) Gastrectomy ( removal of part or all of stomach )
– Partial gastrectomy is done for carcinoma of stomach or peptic ulcer
– Total gastrectomy is done for carcinoma of stomach , high gastric ulcers in the lower end of stomach.
• Incision
– Right upper paramedian incision
– Left upper paramedian Incision
– Supraumbilical incision.
(3) Cholecystectomy
– chronic cholecystitis
– Gallstones
• Incision
– Right upper paramedian Incision
– Kocher’s subcostal incison
(4) Appendectomy
– Removal of vermiform appendix in case of appendicitis with or without perforation.
• Incision
– Mcburney’s incision
– Lan’z incision
– Battle’s pararectal incison.
•Clinical of acute appendicitis
– Pain near umbilicus
– Vomiting
– Fever
– Hematuria
(5) Vagotomy
– Here, the branches of vagal nerve are denervated.
– It is done for duodenal ulcers and denervated
– Incision is left upper paramedian Incision
(6) Spleenectomy
– Removal of spleen
• Indications
– Rupture of spleen
– Hemolytic anemia
– Thalassemia
– Cysts of spleen
– hyperspleenism
– Tumors of spleen
• Incision
– left upper paramedian Incision
– Abdomniothoracic incision