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General Surgery
Incisions, Closures, and Management of the Abdominal Wound
Built from Maingot's Abdominal Operations
What’s inside
11 sections · 182 slides
Overview
- Topics covered
- Impact of the incision on surgical outcome
- Requirements of an adequate incision
Choosing the incision
Orientation, site, the evidence behind each choice, and preparing the skin
- Orientation of abdominal incisions
- Flexibility of the vertical midline incision
- Incisions matched to the site of disease
- Anatomical argument for transverse incisions
- Evidence on vertical versus transverse incisions
- Wound infection in the transverse incision trial
- Midline versus paramedian incisions
- Lateral paramedian incision
- Re-entering the abdomen through an old scar
- Preparation of the surgical site
- Choice of skin antiseptic
Vertical incisions
Midline, paramedian and the vertical muscle-splitting incision
- Exposure gained by the midline incision
- Surface marking of the upper midline incision
- Making the midline incision
- Layers divided in a midline incision
- Safe entry into the peritoneum
- Dividing the linea alba and peritoneum
- Protecting the viscera as the wound is opened
- Surface marking of the upper paramedian incision
- Making a paramedian incision
- Freeing the rectus muscle from the anterior sheath
- Hazards during the paramedian dissection
- Lower paramedian incision: skin to rectus muscle
- Lower paramedian incision: vessels and peritoneum
- Vertical muscle-splitting incision
Transverse and oblique incisions
Kocher, McBurney, Rockey-Davis and Pfannenstiel
- Principles of transverse and oblique incisions
- Nerve supply of the rectus muscle
- Indications for the Kocher subcostal incision
- Technique of the Kocher subcostal incision
- McBurney and Rockey-Davis incisions
- Surface markings for appendicectomy incisions
- Placing the appendicectomy incision
- Layers split in the muscle-splitting approach
- Why the muscles are split rather than cut
- Opening the oblique muscles for appendicectomy
- Opening the peritoneum and delivering the appendix
- Enlarging the appendicectomy wound
- Pfannenstiel incision
- Steps of the Pfannenstiel incision
- Advantages and limits of the Pfannenstiel incision
Chest and retroperitoneal approaches
Thoracoabdominal incisions and routes that stay behind the peritoneum
- Exposure gained by a thoracoabdominal incision
- Restrictions on the thoracoabdominal incision
- Corkscrew position and the line of the incision
- Corkscrew position and the abdominal part of the incision
- Entering the chest
- Opening the diaphragm
- Two ways of opening the diaphragm
- Closing a thoracoabdominal incision
- Advantages of retroperitoneal and extraperitoneal approaches
- Structures reached from behind the peritoneum
- Retroperitoneal approach to the lumbar area
- Left lumbar approach to the retroperitoneum
- Landmarks and closure in the lumbar approach
- Posterior approach to the kidney and adrenal gland
- Posterior approach to the kidney and adrenal gland
- Reaching Gerota's fascia
- Managing pleural injury in the posterior approach
- Retroperitoneal approach to the iliac fossa
- Extraperitoneal approach to the iliac vessels and ureter
Laparoscopic access
Getting into the abdomen through small incisions, safely
- Principles of laparoscopic access
- Hand-assisted laparoscopic surgery
- Site of first entry
- Open (Hasson) technique
- Securing the Hasson cannula
- Closed (Veress needle) technique
- Confirming Veress needle placement
- Signs of wrong Veress needle placement
- Radially expanding and optical access trocars
- Open versus closed entry
- Safety data for open versus closed entry
- Rules for placing additional ports
Closing the abdomen
Fascia, suture choice, skin, retention sutures and mesh
- Most common
- Factors that raise the risk of wound failure
- Mass closure versus layered closure
- Arguments over suture material
- Evidence on suture material
- Why braided permanent suture behaves worst
- Rate of resorption of different suture materials
- Suture materials that do not resorb
- Reading the suture resorption table
- Continuous versus interrupted closure
- Recommended approach to laparotomy closure
- Technique of mass closure
- Placing the mass closure bite
- The completed mass closure
- Bite size and tension in mass closure
- Suture length to wound length ratio
- Skin closure options
- Staples versus subcuticular suture
- Tissue glue for skin closure
- Skin closure in contaminated wounds
- Fascial dehiscence and its consequences
- Sources of raised intra-abdominal pressure
- Retention sutures: purpose and evidence
- Drawbacks of retention sutures
- Selecting patients for retention sutures
- Placing retention sutures
- Mesh underlay for the at-risk closure
- Biologic implants and complex reconstruction
- Closure of laparoscopic port sites
- Devices that help port-site closure
Temporary closure and the open abdomen
Damage control, dressings that hold the abdomen open, and later closure
- Origins of temporary abdominal closure
- The three phases of damage control
- Survival data behind damage control
- Patients who benefit from temporary closure
- Bogota bag and plastic drapes
- Absorbable mesh as a temporary cover
- Wittman patch
- Open abdomen technique
- Barrier placed over the abdominal contents
- Drains and dressing over the barrier
- Preventing loss of abdominal domain
- Abdominal vacuum-assisted closure
- Limits of the prolonged open abdomen
Managing the wound after operation
Dressings, and what the evidence says about leaving the wound alone
- Purpose of the postoperative dressing
- Evidence on removing the dressing
- Types of surgical dressing
- Vacuum-assisted closure dressing
Wound complications
Infection, necrotising infection, seroma, haematoma, dehiscence
- 7.3
- Bacterial load and the role of foreign material
- Risk factors for surgical site infection
- Further risk factors for infection
- Classification of surgical site infection by depth
- Reading the infection criteria table
- Criteria for defining surgical site infections
- Criteria for defining surgical site infections, continued
- Classifying wounds by contamination
- Classification of surgical wounds
- Classification of surgical wounds, continued
- Risk scoring systems: SENIC and NNIS
- Organisms responsible for infection
- Antibiotic prophylaxis: which drug
- Antibiotic prophylaxis: timing and dose
- Bowel preparation before colorectal surgery
- Reading the prevention recommendations
- Preoperative measures to prevent surgical site infections
- Team and theatre measures to prevent infection
- Asepsis, surgical technique and surveillance measures
- Wound closure, incision care and reporting of infection rates
- Treatment of incisional infection
- Treatment of deep space infection
- Necrotising wound infection: how it presents
- Signs that should raise suspicion
- Laboratory and imaging findings
- Treatment of necrotising infection
- Repeat inspection after debridement
- Gas gangrene
- Hyperbaric oxygen in clostridial infection
- Two types of necrotising fasciitis
- Type I necrotising fasciitis
- Type II necrotising fasciitis
- Antibiotics in necrotising fasciitis
- Seroma
- Wound haematoma
- When a haematoma needs the operating theatre
- Stitch abscess
- Suture material and stitch abscess
- 1-3%
- Recognising dehiscence
- Patient factors linked with dehiscence
- Managing dehiscence and evisceration
- Choices at reclosure
- Non-operative management of dehiscence
- Incisional hernia
Summary
The points worth carrying away
- Key points: choosing and making the incision
- Key points: closure
- Key points: wound complications
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- Maingot's Abdominal Operations, 12th Edition