TYPE OF INCISIONSUpper Midline The upper midline incision provides access to the esophagus, hiatus, stomach and duodenum,

pancreas,and hepatobiliary system. If extended, it allows major hepatic resection, adrenalectomy, and splenectomy.Midline incisions are the most versatile incisions because easy extension superiorly or inferiorly allows access to all parts of the abdominal and retroperitoneal space without difficulty.Upper midline incisions are very painful and restrict pulmonary function, particularly vital capacity, by about 50 percent. Pulmonary problems, especially in patients with a history of lung disease, prior pneumonia, emphysema,etc. are common after an upper midline incision, so the subcostal incision is preferred by many surgeons. Subcostal (Kocher) The subcostal, or Kocher incision is used for open biliary surgery ,such as cholecystectomy. TheKocher incision is not to be confused with the Kocher Maneuver, which describes the mobilization of the secondand third portion of the duodenum and the pancreatic head. The subcostal incision is also used for access to theliver for wedge resections; for the adrenal gland on either side; and the spleen if on the left side. When extendedlaterally on the right with the patient in a rotated position, the incision is used for portacaval shunts. The incisionmay be extended medially as an alternative to the upper midline incision. Bilateral subcostal incisions are used to access to liver for transplant and liver resections. The exposure is oftenhelped with a vertical extension to the xyphoid. Specialized retractors such as the Olivier and some blades for theupper hand have been developed for this incision. Procedure : The standard subcostal incision is made 1 to 2 finger breadths below the costal margin, to facilitateclosure so that the incision line is not on or over the costal margin. The exposure requirements will determine theincision length. The incision should be sized at the smallest length possible while safely permitting an adequate procedure. The incision is closed in two or three layers; usually the inner two layers are closed with a runningabsorbable suture, and the outer layer (external oblique and anterior rectus fascia) with either running or absorbablesuture.The major advantage of the subcostal incision over the upper midline incision is greater lateral exposure andless pain. Upper midline incisions are very painful and restrict pulmonary function, particularly vital capacity, byabout 50 percent. Pulmonary problems, especially in patients with a history of lung disease, prior pneumonia,emphysema, etc. are common after an upper midline incision, thus the subcostal incision is preferred by manysurgeons. The disadvantage of the subcostal incision is that the operation takes longer, because there are morelayers to close.Generally, the subcostal incision heals well. Transverse The transverse incision is made just above the umbilicus and divides one or both sides of the rectusmuscle as necessary. Transverse incisions are most commonly used for access to the right colon (when placed onthe right), duodenum, and access to the pancreas where the incision is carried across the midline. They provideexcellent exposure to the subhepatic space and upper gastrointestinal tract , reportedly with less pain than amidline incision. However, in the current era, many surgeons have entirely replaced transverse incisions withmidline incisions extended as necessary to gain lateral access to the abdominal and retroperitoneal viscera. Lower Midline Lower midline incisions are used for complex appendicitis, sigmoid colonic, rectal, urological, andgynecological procedures. The muscles at the midline often overlap obscuring the linea alba and making divisionof the muscle necessary in lower midline incisions.In general, these incisions are well tolerated by patients but are often painful. The weight of the abdominal contentsand an obese abdominal wall may put additional strain on such incisions, increasing the risk of hernia formation.For very obese patients, stretching of the abdominal wall can occur. Access to the pelvis is best achieved through anupper abdominal or periumbilical incision in these cases. The principle advantage of the lower midline incision is that the incision can be extended superiorly for processesor operations that involve the upper abdominal viscera or require extra exposure. Similarly, the best exposure of the pelvis is gained by a lower midline incision to the pubis. McBurney When the diagnosis of appendicitis is clear, the McBurney incision is one of two incisions used for appendectomy

. The McBurney's Point is located one third of the distance from the anterior superior iliac crest tothe umbilicus. This is the classic location of the appendix. Since the appendix is a mobile part of the body, it may be found in various places in the right lower quadrant. For best exposure, incision should be adapted after physicalexamination at the maximum point of tenderness. This incision is usually made parallel with the course of the fibersof the external oblique fascia, one or two inches cephalad to the anterior superior spine of the ilium. The Rocky-Davis incision provides another option. Unlike the McBurney incision, it is a straight transverse at theskin and splits the muscle. Again, either incision is made as long as necessary to achieve adequate exposure. Thin people require a smaller incision than obese patients. Those patients with an anterior appendix are usually easier tomanage through a small incision, as opposed to retrocecal appendices which require an extended incision. Extending the right lower quadrant incision for greater exposure usually requires either medial extensionopening the rectus fascia and displacing the rectus muscle medially, or a second midline incision. The second midline incision may be considered in patients with pathology that extends beyond the right lower quadrant. Paramedian Paramedian incisions are rarely used. This incision provides little additional exposure beyond a midlineincision. The blood and nerve supply to the abdominal wall enters from either side and may cross the midline poorly. For this reason paramedian incisions have an increased risk of rendering part of the abdominal wallanesthetic and ischemic. The result is poor wound healing and increased risk of hernias. Groin incision Groin incisions may be oblique or within the skin lines and nearly transverse. Generally, they endmedially at the level of the external ring, usually 1 to 2 finger breadths above the external ring. Laterally, theseincisions usually extend for 10-12 cm, depending on the size of the patient, the size of the hernia, and prior surgery.Staying out of the inguinal crease reduces the risk of infection. Such incisions are closed in layers.The obliqueinguinal incision may be on the right or left side and is used for hernia repair . The superficial epigastric vein isusually encountered in the subcutaneous tissue. It is ligated and divided. Pfannenstiel, or "bikini incision" Pfannenstiel incisions are horizontal at the skin but divide the fascia and muscle of the abdominal wallvertically in the midline. They are principally used for urological and gynecological procedures because theyminimize scarring. However, large skin flaps are developed under such incisions and with contamination, they may be more prone to infectious complications. Since the size of the incision is necessarily restricted by the lateralextent of the skin incision, exposure to deep pelvic structures may be less than optimal.These incisions should be avoided in patients who are obese, those requiring extensive deep pelvic dissection, andthose with prior lower abdominal midline incisions where the scar is already present.

MILAGROS E, WAMINAL RLE 9BSN 4 1-14-11 DIFFERENT INCISION SITES Classification of incisions:The incisions used for exploring the abdominal cavity can be classified as:(A) Vertical incision: These may be(i) Midline incision(ii) Paramedian incisions(B) Transverse and oblique incisions:(i) Kocher's subcostal Incision(a) Chevron (Roof top Modification )(b) Mercedes Benz Modification(ii) Transverse Muscle dividing incision(iii) Mc Burneyds Grid iron or muscle splitting incision(iv) Oblique Muscle cutting incision(v) Pfannenstiel incision(vi) Maylard Transverse Muscle cutting Incision(C) Abdominothoracic incisionsA. Vertical incisions:Vertical incisions include the midline incision, paramedian incision, and the Mayo Robson extension of the paramedian incision.(i) Midline Incision: Almost all operations in the abdomen andretroperitoneum can be performed thr ough this universally acceptable incision(Guillou et al, 1980). Advantages:(a) It is almost bloodless(b) No muscle fibers are divided,(c) No nerves are injured; (d) it affords goods access to the upperabdominal viscera,(e) It is very quick to make as well as to close; it is unsurpassed whenspeed is essential (Clarke, 1989) (f) a midline epigastric incision alsocan be extended the full length of the abdomen curving around theumbilical scar.

Information About Sutures in the Operating Room

When asking for a suture generally three peices of information are included; suture size, suture type and suture needle. For the suture pictured above, a surgeon would say, "Give me a 4-0 Vicryl on a PS-2". 4-0 (pronounced 4-oh) refers to the size of the suture fiber. Vicryl is the type of suture. And finally a PS-2 is the type of needle the suture is attached to.

Suture Size

Smallest 10-0 Typically used in the most delicate surgeries. Common in both Ophthalmic (eye) 9-0 surgery and for repairing small damaged nerves often due to lacerations in the 8-0 hand. 7-0 Used for repairing small vessels and arteries or for delicate facial plastic surgery. 6-0 Common for use in vascular graft sewing such a carotid endarterectomy. 5-0 Used for larger vessel repair such as an Abdominal Aortic Aneurysm or 4-0 skin closure. 3-0 Skin closure when there is a lot of tension on the tissue, closure of muscle layers 2-0 or repair of bowel in general surgery. 0 For closing of the fascia layer in abdominal surgery, the joint capsule in knee and 1 hip surgery or deep layers in back surgery. 2 For repair of tendons or other high tension structures in large orthopedic 5 surgeries. Largest

Suture Type
There are many different types of suture, the two most important properties are... Absorbable Vs Non-Absorbable and Braided Vs Non-Braided The Vicryl suture pictured above is an example of a braided absorbable suture.

Absorbable Suture
Absorbable suture breaks down over time in the body. Examples of absorbable suture include Monocryl, Vicryl, Chromic, and PDS. The amount of time it takes a suture to break down in the body depends on a few factors such as suture type, size and the location it is placed. The list to follow includes the most common absorbable sutures in most operating rooms listed from shortest to longest break down time. *Complete breakdown of strength times of various Ethicon Sutures: Vicryl Rapide 2 weeks Undyed Monocryl 3 weeks Dyed Monocryl 4 weeks Coated Vicryl 4 weeks

PDS 9 weeks Panacryl 70 weeks Note Suture absorption rates can increase in patients with fever, infection or protein deficiency. Also, the strength to a suture will decrease significantly prior to its complete breakdown time. Therefore a suture with higher tissue tension will have a greater chance of failure prior to the amount of time listed above

Non-Absorbable Suture
Nylon (Ethilon), Gortex, Silk, Fiberwire, Ethibond, Prolene and Steel are all example of non absorbable suture. When used on the skin, these sutures will be removed however when used in the body they will be retained inside the tissue. Common uses for non absorbable suture: Interrupted skin suturing when sutures will be removed later, 4-0 Nylon Securing drains to skin, 2-0 Silk Repair stitches for blood vessels, 6-0 Prolene Vessel graft stitches for AAA, Fem-Pop or Carotid Artery grafts 5-0, 6-0 prolene or gortex Bowel repair stitch, 3-0 silk Achilles Tendon Repair, #5 Ethibond or Fiberwire

Braided or Non-Braided Suture

Braided suture have a number of strands woven together like a string. Examples of braided suture are; Silk, Vicryl and Ethibond. Non-Braided or Monofilament Sutures have a single strand such as Monocryl, PDS,and Ethilon Nylon. Often times it will be surgeon preference when choosing a braided or non-braided suture. 4-0 vicryl and 4-0 monocryl are by far the most common sutures used from sewing the skin. Both are absorbable however vicryl is braided and monocryl is non-braided. It is thought that non-braided sutures cause less reactivity in the body and are not as prone to becoming infected because they lack the grooves and rough surface for things to adhere. However non-braided sutures can have a greater tendency to loosen at the surgical knot with the lack of grip.

Suture Needles
Along with selecting the correct suture it is important as well to select an appropriate needle. The two factors in selecting a needle are size and if a cutting or tapered needle is needed. While there are exceptions, much of the time you will find tapered needles are used inside the body such as on bowel, fascia, or muscle where the tissue is more easily pierced. Cutting needles are used for skin and very tough tissue such as bone and tendon.

Beyond choosing a cutting or tapered needle one only needs to select an appropriate size. There are hundreds of sizes and types of needles. Listed below are some of the most common used in most typical surgical procedures.

Tapered Suture Needles

TP or CTX Used for closing fascia during abdominal surgery. CT or CT1- For closing the joint space in knee and hip surgery or deep tissue layers after closing the fascia in general surgery. CT2 - Often used on the uterus in OB Gyn procedures. SH Used to stitch the bowel or close layers of tissue in breast surgery. CV or BV Used for vessels and nerve repair, very small and delicate and often used with a Castro Viejo needle holder.

Cutting Suture Needles

FSLX - Large skin closure when a lot of tension is present common for retention sutures or large orthopedic use. FSL Often used for sewing in drains or skin closure needing higher tension closure. FS2 or PS2 - For common skin closure. P3 Used for skin closure of small incisions such as hand surgery or facial plastic surgery.