11/13/24, 7\:16 PM Guide | Abdominal surgical incisions and abdominal scars

Abdominal surgical incisions and abdominal scars

Table of contents

Introduction

This article discussed abdominal surgical incisions and the common abdominal scars you may encounter in an OSCE
scenario. You may also be interested in our guide to the anatomy of the abdominal wall.

Common abdominal incisions

Many surgical procedures may now be performed laparoscopically, with generally better results in terms of cosmesis,
postoperative pain, recovery time, and thus reduced length of stay and quicker return to function compared with traditional
open techniques.
However, there are still occasions where an open approach is required for speed, ease of access to relevant structures, or
situations where laparoscopic equipment is unavailable.
Patients with abdominal scars frequently appear in OSCEs, and you may be expected to identify the scar and discuss its
clinical relevance.
Abdominal incisions

Midline incision

A midline incision may be used to access most intra-abdominal structures, including those of the retroperitoneum. It utilises
the relatively avascular nature of the linea alba to access the abdominal contents without cutting or splitting muscle
the process, with the exception of the small pyramidalis muscle at the pubic crest.
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In some cases, anastomotic branches of the superior and inferior epigastric vessels will cross from either side, but the incision
generally avoids major neurovascular bundles.
Further advantages include the ease with which the incision may be extended either cephalad or caudally in order to improve
access.
Disadvantages include patients experiencing more pain than they would from a transverse incision, particularly during deep
breathing postoperatively, and the incision is perpendicular to the Langer’s skin tension lines resulting in poorer cosmesis.
This approach is commonly used for procedures requiring emergency laparotomy, such as in faecal peritonitis secondary to
malignant intestinal perforation or in cases of ischaemic bowel. Limited midline incisions are also employed to assist
laparoscopic cases such as bowel resections, where the dissection and mobilisation of the specimen to be excised are
performed laparoscopically but then a larger port is required for retrieval.
A midline incision will thus encounter the following layers of tissue\:
Skin
Subcutaneous fatty layer (Camper’s fascia)
Membranous fascia (Scarpa’s)
Linea alba
Transversalis fascia
Preperitoneal fat
Parietal peritoneum

Paramedian incision

The scar of a paramedian incision may be seen running parallel to the midline in a limited number of patients but has fallen
from common practice in favour of the midline incision due to its complexity and poor cosmesis.
If the incision is made to the right of the midline, the falciform ligament of the liver is commonly encountered. The tendinous
intersections must be divided on the chosen side to access the peritoneum.

Pararectal incision

Like the paramedian approach, the pararectal incision has now largely been abandoned. Disadvantages include disruption of
the innervation to the rectus lying medially.

Gridiron incision

A gridiron incision involves an arcing incision through the skin, subcutaneous fat and fascia, external and internal obliques,
transversus abdominis and transversalis fascia. It is commonly used for open appendicectomies.
The incision is centred over McBurney’s point two-thirds of the distance between the umbilicus and the right anterior superior
iliac spine (ASIS), where the base of the appendix is most likely to be found. This classically corresponds to the area of maximal
tenderness on clinical examination when the appendix has become su
This incision may be modi
injury to the ilioinguinal and iliohypogastric nerves. The arc may be extended cephalad and laterally in order to facilitate access
to the ascending colon, which is known as the Rutherford-Morison incision.

Lanz incision

The Lanz incision was designed to be more cosmetically subtle than the gridiron, with the bene
beneath the bikini line but the disadvantage of commonly severing the ilioinguinal and iliohypogastric nerves.
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Pfannenstiel incision

The Pfannenstiel incision is a
through the skin and subcutaneous fat, followed by a longitudinal incision in the linea alba. General and urological surgeons
also use it for some pelvic procedures, such as radical open prostatectomy or cystectomy.

Transverse incision

A transverse incision is a useful laparotomy technique for paediatric patients who have not yet developed deep subphrenic or
pelvic recesses, and in whom the surgeon, therefore, does not need the ability to extend the incision longitudinally as a
by the midline incision.
This incision is also commonly utilised by vascular surgeons for elective and emergency repair of abdominal aortic aneurysms.

Kocher incision

A Kocher incision is made parallel to the subcostal margin to access the underlying liver and biliary tree. It is commonly used
for open cholecystectomy.
It may be mirrored on the contralateral side to provide access to the spleen or performed bilaterally as a Rooftop incision to
e
the risk of injuring the superior epigastric vessels, and lateral extension of the incision risks disrupting intercostal nerves.
Structures within the transpyloric plane\:
L1 vertebral body
Tip of the 9 th
costal cartilage
Fundus of the gallbladder
Duodeno-jejunal
Pylorus of the stomach
The neck of the pancreas
Renal hila
Conus of the spinal cord

Complications of abdominal incisions

Complications are best considered in terms of speci
to the operation, and presenting as immediate, early or late complications. The incidence and nature of complications will be
in

Immediate and early complications

Immediate complications of a midline laparotomy incision may include anaesthetic di
primary haemorrhage from cut vessels and iatrogenic injury to surrounding tissues and viscera.
Generic early complications declare themselves in the hours and days following the operation and may include atelectasis,
postoperative pneumonia, urinary tract infection, oliguria, bedsores and deep vein thromboses.
Speci
once the blood pressure normalises, intra-abdominal collection, postoperative ileus and wound infection. If nerves have been
severed during the operation, this is most likely to become apparent over the following few days as the e
wear o

Wound dehiscence

Wound dehiscence following midline laparotomy is a particularly distressing event for the patient, whereby classically, a
serosanguinous discharge is noted from the wound 7-10 days postoperatively, and a day or so later, the whole wound may
burst open and spill the patient’s intestines into their lap.
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Risk factors for wound dehiscence can be\:
Patient-speci
disease)
Procedure-speci

Late complications

Late complications include the development of an incisional hernia, where the underlying peritoneum and associated
contents protrude through residual defects in the abdominal wall, and the formation of dense
adhesions.
Both of these conditions may result in lengths of bowel becoming trapped within the hernial sac (incarcerated), and the hernia
may be su
bowel content (obstruction), venous out
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