ABDOMINAL INCISION

 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

 

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