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Prior to bringing the patient to the operating room, the surgical site is marked with the patient’s co-operation by the operating surgeon to ensure correct site surgery. The patient is carefully positioned on the operating table while taking into consideration the need for special equipment such as heating pads, electrocautery grounding plates, sequential compression stockings, and anesthesia monitoring devices. The arms may be positioned at the side or at right angles on arm boards, which allows the anesthesiologist better access to intravenous lines and other monitoring devices. It is important that the patient be positioned without pressure over the elbows, heels, or other bony prominences; neither should the shoulders be stretched in hyperabduction. The arms, upper chest, and legs are covered with a thermal blanket. Simple cloth loop restraints may be placed loosely about the wrists, whereas a safety belt is usually passed over the thighs and around the operating table. The entire abdomen is shaved with clippers, as is the lower chest when an upper abdominal procedure is planned. In hirsute individuals, the thigh may also require hair removal with clippers for effective application of an electrocautery grounding pad. The grounding pad should not be placed in the region of metal orthopedic implants or cardiac pacemakers. Loose hair may be picked up with adhesive tape, and the umbilicus may require cleaning out with a cotton-tipped applicator. The first assistant scrubs, puts on sterile gloves, and then places sterile towels well beyond the upper and lower limits of the operative field so as to wall off the unsterile areas. The assistant vigorously cleanses the abdominal field with gauze sponges saturated with antiseptic solution (see Chapter 1). Some prefer iodinated solution for skin preparation. Prophylactic antibiotics are administered intravenously within 1 hour of the incision.

After positioning, skin preparation, and draping, a TIME OUT is performed as described in Chapter 3, table 1.

The incision should be carefully planned before the anatomic landmarks are hidden by the sterile drapes. Although cosmetic considerations may dictate placing the incision in the lines of skin cleavage (Langer’s lines) in an effort to minimize subsequent scar, other factors are of greater importance. The incision should be varied to fit the anatomic contour of the patient. It must provide maximum exposure for the technical procedure and of the anticipated pathology, while creating minimal injury to the abdominal wall, especially in the presence of one or more scars from previous surgical procedures. The most commonly used incision is a midline one that goes between the two rectus abdominis muscles, around the umbilicus, and through the linea alba (figure 1). For procedures in the pelvis, the incision is extended to the pubis; whereas for upper abdominal operations, the incision may extend up and over the xiphoid. Following preparation, the abdomen is walled off with sterile towels placed transversely at the xiphoid and pubis and longitudinally about either rectus ...

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