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INCISIONS

The planning, execution, and closure of an incision have an enormous impact on the outcome of an abdominal operation. The high combined incidence of surgical site infection, wound dehiscence, and hernia formation suggests a dominant contribution of wound complications to surgical morbidity. Moreover, the quality of exposure provided by an incision influences outcome in ways that defy easy quantification. An incision must provide access to the site of abdominal pathology and allow ready extension if greater exposure is required. Indeed, the adequacy of an incision is determined above all else by the safety with which an operation can be undertaken. Nothing should compromise this, and a larger incision or even, on occasion, a second incision, should be created without hesitation if exposure is inadequate. Notwithstanding this, the incision should be executed in a fashion that anticipates a secure wound closure and interferes as little as possible with the function and cosmesis of the abdominal wall. While the vertical midline incision remains most popular and is, perhaps, the most versatile, a variety of other incisions may have distinct advantages in specific settings.

Choice of Incision

Abdominal incisions can be vertically, transversely, or obliquely oriented. The avascular linea alba affords the vertical midline its superior flexibility. Indeed, when optimal exposure of the entire abdominal cavity is necessary (eg, exploration for abdominal trauma), the vertical midline incision is preferred and can be extended superiorly to the xiphoid process and inferiorly to the symphysis pubis. Resection of the xiphoid may afford even better superior exposure when needed. Alternatively, vertical incisions may be placed in a paramedian position, an approach that was previously more popular than it is today but continues to have its proponents. Transverse and oblique incisions can be placed in any of the 4 quadrants of the abdomen depending on the site of pathology. Common examples include the Kocher subcostal incision for biliary surgery, the Pfannenstiel infraumbilical incision for gynecologic surgery, and the McBurney and Rocky-Davis incisions for appendectomy. A bilateral subcostal incision affords excellent exposure of the upper abdomen. Alternatively, when superior exposure of upper abdominal organs (eg, the esophagogastric junction) is required, thoracoabdominal incisions may be used. Retroperitoneal and extraperitoneal structures (eg, the kidney, adrenal gland, and aorta) may be readily exposed through abdominal wall incisions; often obliquely oriented or curvilinear flank incisions are used. Recently, J- or L-shaped incisions have gained popularity for exposure of the upper quadrants of the abdomen and for hepatic resection in particular.

The relative merits and disadvantages of vertical versus transverse incisions remain subjects of active debate. Proponents of transverse incisions argue that they anticipate a more secure closure than with vertical incisions—a hypothesis supported by anatomic and surgical principle. The fascial fibers of the anterior abdominal wall are oriented transversely or obliquely. Transverse incisions, therefore, parallel this orientation and allow for ready reapproximation with sutures placed perpendicular to the fibers. In contrast, vertical incisions disrupt ...

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