The incision is made to run parallel to the costal margin, starting below the xiphoid and extending laterally. Closure of laparotomy wounds: skin staples versus sutures. [5, 22] with the possibility of delayed primary closure, depending on the state of the wound bed as it progresses. Zwart HJ, de Ruiter P. Subcuticular, continuous and mechanical skin closure: cosmetic results of a prospective randomized trial. Thus, excellent cosmesis can usually be achieved with the Pfannenstiel, Maylard . - Character 02:14 The average length of the incision is approximately 24 to 30 inches. Br J Surg. Am J Surg. ) is used for a wide array of abdominal surgery, as it allows the majority of the abdominal viscera to be accessed. The median length of the midline incision was slightly longer (12 vs. 10 cm, p < 0.05). Using SOCRATES in History Taking | OSCE | Communication Skills, Abdominal Surgical Incisions and the Rectus Sheath. Chevron incision This incision is a cut made on the abdomen below the rib cage. 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. Ellison EC, Zollinger RM Jr. Laparotomy. Avoid dissection distal to the annular ligament or strenuous retraction because the posterior interosseous nerve, lying within the supinator muscle, is at risk. New York: McGraw-Hill; 2020. surgical technique, site and orientation of incision, intra-operative contamination, lengthy procedure). Listen. . Crosen M, Sandhu R. Fascial Dehiscence. [QxMD MEDLINE Link]. Front Surg. However, this may impair wound healing as well.Upper abdominal cavity approaches:Upper abdominal cavity approaches like the Kocher, Chevron, and mini transverse incision can be used for abdominal surgery of the liver, gallbladder, pancreas, and stomach. Abdominal incisions: techniques and postoperative complications 317 over,exposureoftheabdomenisexcellent.Exten-sions,whenrequired,caneasilybemadesuperiorly Kizy S, Ikramuddin S. Abdominal wall, omentum, mesentery, and retroperitoneum. Necessary cookies are absolutely essential for the website to function properly. Probably because of this he had less problems with postoperative tetany. The subcostal or Kocher incision is an oblique incision that follows the profile of the costal margin and is directed in a medio-proximal direction. The great advantage of the midline incision is the limited risk of bleeding as the incision is made along the avascular linea alba. 3. 2012 Farlex, Inc. All rights reserved. Abdominal wound closure: current perspectives. Some common incision sites are discussed below. [19] Subcutaneous closure may be accomplished with absorbable suture in an interrupted or continuous fashion. right subcostal/kocher cholecystectomy paramedial incision; heals stronger sigmoid surgery median incision over linea alba, more likely to herniate trauma--quicker thoracoabdominal esophagoduodenostomy McBurney incision appendectomy Fill in the Blank Exercise 14.02 . A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. [QxMD MEDLINE Link]. Abdominal Wall Incision - Kocher - How to approach the abdominal cavity using a Kocher incision 2,005 views Oct 18, 2021 55 Dislike Incision 6.82K subscribers Notice You're signed out of. 11th ed. This produces a distinct ridge in the midline on increasing intra-abdominal pressure that is often mistaken for an epigastric hernia. The fascia and then peritoneum are divided under direct vision. The assistant following the continuous closure should apply sufficient tension to approximate the tissue without strangulating it. YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LjMxakdNallNcng0, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LkJPVjVZMzBKczY4, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LkxEM2VkQzB2NTBr, Start typing to see results or hit ESC to close, Deep Vein Thrombosis (DVT) Examination OSCE Guide, Pre-hospital Advanced Life Support (ALS) OSCE Guide, Adult Choking (Basic Life Support) OSCE Guide, Paediatric Intravenous Cannulation OSCE Guide, Intrauterine System (Mirena) Counselling OSCE guide, Geeky Medics OSCE Book | Clinical Examination, Complications of abdominal surgical incisions, Paediatric Gastro-oesophageal Reflux Disease, A Career as a GP with Special Interest with Dr Fiona Mosgrove, Subcutaneous fatty layer (Campers fascia), Patient-specific (i.e. 10th ed. [QxMD MEDLINE Link]. Medical Dictionary for the Health Professions and Nursing Farlex 2012 Kocher, E. Theodor, Swiss surgeon and Nobel laureate, 1841-1917. 2000 Mar. The Kocher incision is not to be confused with the Kocher Maneuver, which describes the mobilization of the second and third portion of the duodenum and the pancreatic head. In a subsequent systematic review assessing the efficacy of closure techniques, which included 23 randomized controlled trials (nine involving the use of prophylactic mesh), the authors noted that in elective midline closure, the use of a slowly absorbable suture material for continuous closure with the small-bite technique resulted in significantly less incisional hernias than a large-bite technique did. Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. Segen's Medical Dictionary. 1. Standring S, ed. Disadvantages include the risk of injuring the superior epigastric vessels, and lateral extension of the incision risks disruption of intercostal nerves. Epidermis, dermis, and subcutis, showing hair follicle, sweat gland, and sebaceous gland. 8 cm) Full size image It is crucial to protect the terminal branches of the posterior CN of the forearm, which run through the subcutaneous tissue. Effect of damage control laparotomy on major abdominal complications and lengths of stay: A propensity score matching and Bayesian analysis. After transverse . Maingot's Abdominal Operations. Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ [1, 15, 47] Long-term monitoring after the postoperative period is not considered necessary. Indian J Med Sci. [Full Text]. You are being redirected to
[QxMD MEDLINE Link]. It may be mirrored on the contralateral side to provide access to the spleen or performed bilaterally as a Rooftop incision to provide efficient access to organs such as the pancreas and biliary tree within the transpyloric plane (see below). Interrupted abdominal closure prevents burst: randomized controlled trial comparing interrupted-x and conventional continuous closures in surgical and gynecological patients. [Full Text]. The suture is subsequently run in a continuous fashion, with each bite including tissue from the linea alba, the rectus sheath, and muscle itself if necessary to get an adequate bite. 5:34. The operation was performed (Figure 2 and Figure 3) The benefits of mass closure include decreased cost and decreased operating time. Incisional hernia did not occur in either group. A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. adjacent to her previous Kocher incision on physical exam. [QxMD MEDLINE Link]. The lower abdominal muscle splitting approach is often chosen in case of open appendectomy or for specimen retrieval during laparoscopic surgery. [Full Text]. Abdominal incisions. The cookie is used to store the user consent for the cookies in the category "Other. 2015 Dec 4. Cengiz Y, Blomquist P, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. If nerves have been severed during the operation, this is most likely to become apparent over the following few days as the effects of anaesthesia wear off and the patient notices the deficit (or neuropathic pain). Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. The primary advantage of this method is that multiple suture strands exist, so that if a suture breaks, the incision is held intact by the remaining sutures. A collection of communication skills guides, for common OSCE scenarios, including history taking and information giving. [4] The purpose of subcutaneous closure is to close any potential space, reducing the area for seroma accumulation. Layer's to Open:- Skin Subcutaneous fat External Oblique apponeurosis External Oblique muscle Internal oblique muscle Transverse addominis The incision will take a long time and is often technically difficult, however it does prevent any division of the rectus muscle and provides access to lateral structures. 1996 Feb. 162 (2):125-9. Stock photos, 360 images, vectors and videos Gray's Anatomy: The Anatomical Basis of Clinical Practice. [1] ; for this reason, the ensuing discussion of abdominal closure focuses on this incision. Care is taken to control and ligate any branches of the superficial epigastric vessels. (C) Continuous suture. Doherty GM, ed. (if excising 11th rib, incise mm fibers on top down to bone, use periosteal elevator momving medial to lateral, use costal elevator to free rib posteriorly, clamp with Kocher and rib cutter, can . 2020. Int Surg J. In continuous fascial closure, two Kocher clamps are clamped to the fascial layer midway through the incision and then retracted by the assistant. Theodor Kocher (1841-1917), Professor of Surgery in Berne, Switzerland. Robin-Lersundi A, Vega Ruiz V, Lpez-Moncls J, Cruz Cidoncha A, Abella Alvarez A, Melero Montes D, et al. From: Rich's Vascular Trauma (Fourth Edition), 2022 View all Topics Download as PDF About this page Vagotomy and Pyloroplasty - 700+ OSCE Stations: https://geekymedics.com/osce-stations/ Starting at the superior or inferior aspect of the incision, the looped PDS is passed through the vertex of the fascia (see the image below). . Diagnosis was made of a 6.2 cm 5 cm bowel-contain-ing RUQ posterior rectus sheath hernia with intact rectus muscle. Arch Surg. Complications: prevention and management. Close the capsule with resorbable sutures (3/0). Previous abdominal operation. This classically corresponds to the area of maximal tenderness on clinical examination when the appendix has become sufficiently inflamed to cause localised peritonitis. [QxMD MEDLINE Link]. Post-operative antibioticsmay be warranted depending on the degree of contamination. Non-absorbable sutures or staples must be removed; the time when they are removed may vary depending on the site and indicationof the closure. Wernick B, Nahirniak P, Stawicki SP. Gallbladder, biliary tract and certain liver operations can be suited for a Kocher's incision. Either a posterior skin incision with a lateral skin flap or a lateral skin incision can be used. The Pfannenstiel incision is a transverse suprapubic incision, placed approximately 5 cm superior to the pubic symphysis (see the image below). 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 2003 Feb. 109 (2):130-7. The first is a continuous locking suture taking most of the myometrium but not passing through the decidua to guard against endometriosis and weakness of the scar. This cookie is set by GDPR Cookie Consent plugin. The internal oblique and transversalis muscles should be subsequently closed in a single layer with interrupted or running suture. Interrupted or continuous slowly absorbable sutures for closure of primary elective midline abdominal incisions: a multicenter randomized trial (INSECT: ISRCTN24023541). On examination, the patient may have a palpable lump close to the lateral border of the rectus sheath, commonly at the level of Douglas. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. Muscle herniation of the lower extremity, such as tibialis anterior muscle herniation (TAMH), is not a rare cause of leg pain in athletes. An elastic defect in this raphe may allow the fascia to stretch and abdominal contents to bulge forward through the resulting divarication of the recti. Adhesive tapes and synthetic glues can be used in addition to sutures and staples to reinforce closure. Laparoscopic surgery (keyhole surgery) requires small incisions to be made in the skin, which allow instruments to be passed into the abdominal cavity. Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure: a meta-analysis. [QxMD MEDLINE Link]. It uses a long, thin tube called a laparoscope. 1999 Oct. 165 (10):958-61. Negative side-effects of retention sutures for abdominal wound closure. 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. . Both of these conditions may result in lengths of bowel becoming trapped within the hernial sac (incarcerated), and the hernia may be sufficiently large or the defect through which it protrudes may be sufficiently tight to occlude intraluminal passage of bowel content (obstruction), venous outflow and later arterial supply (strangulation). The Maylard incision is placed higher than the Pfannenstiel incision, resulting in the possibility of extending it into a larger incision and gaining more exposure. However, this procedure would be associated with a risk of . This modification prevented the high incisional hernia rate. A collection of data interpretation guides to help you learn how to interpret various laboratory and radiology investigations. Disadvantages include disruption of the innervation to the rectus lying medially. Between 2009 and 2013, an estimated 2 million patients per year underwent an open surgical intervention in the United States. - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ Weiland DE, Bay RC, Del Sordi S. Choosing the best abdominal closure by meta-analysis. 1977 Oct. 64 (10):733-6. The needle is then passed through the loop locking the stitch in order to anchor the knot or tied if it is not a looped suture. Abdomen layers & surgical incisions Dr.Abhishek Reddy K 2k views SURGICAL INCISIONS ON ABDOMINAL WALL bhabajyoti 548 views skin incisions Kutty Saravanan 12.5k views Abdominal incisions sarwatmisbah 30.8k views Surgical incisions RiyaBaghele 221 views Surgeries human system training Deepak Mudgil 2.9k views Surgical Incisions. [42] The aim of the study was to assess the incidence of wound infection and wound dehiscence. A muscle-splitting abdominal incision, described in 1894 by McBurney, used for appendectomy; it parallels the external oblique, 2.5-5 cm from the right anterosuperior iliac spine, through the external oblique to the internal oblique and transversalis muscles. For most closures, the authors prefer to use looped 0 polydioxanone (PDS) suture. Am J Surg. Fortelny RH. The paramedian incision (no. The thickness of the skin and its layers is determined by its location. When the two ends are within 1 cm of each other, they are tied with six to 10 knots. Br J Surg. Kustners incision A transverse incision is made 5cm above the symphysis pubis but below the anterior iliac spine. The two primary methods of skin closure are with suture or staples. Incisions that are most useful for obstetric patients include the midline (vertical) incision and the Pfannenstiel, Maylard, Cherney, and supraumbilical (transverse) incisions ( Fig. 2. 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 Langers skin tension lines resulting in poorer cosmesis. Find the perfect kocher incision stock photo, image, vector, illustration or 360 image. The incision runs 2-5cm lateral to the midline, cutting through the skin, subcutaneous tissue, and the anterior rectus sheath. Am J Surg. Lower abdominal cavity approaches:Lower abdominal cavity approaches like the Maylard, Pfannenstiel, Joel-Cohen, or lower midline can be used for gynecological, obstetrical, or pelvic surgery or can be used as an extraction site for specimen removal during for example colorectal surgery. For most of the length of the paired recti, the anterior sheath is formed by the external oblique and anterior leaf of the internal oblique aponeuroses. Eur J Surg. Incisional burst strength also increased with the number of stitches used. Roughly one-third to halfway between the umbilicus and the pubic symphysis lies the arcuate line (of Douglas), which is the point at which the posterior elements of the sheath perforate to join the anterior sheath and leave the thickened transversalis fascia in direct contact with the rectus muscles. The rectus abdominis muscle is supplied by the superior See the full course for free here: https://www.incision.care/free-trialSURGICAL OBJECTIVESThe surgical objective of any abdominal cavity approach is optimal exposure of the abdominal cavity for the indicated operation with minimal risk of complications. Patients should be cautioned to avoid lifting, pushing, or pulling anything heavier than 10 lb (~4.5 kg) and generally to avoid any type of straining (increased abdominal pressure) as much as possible for 4-6 weeks after surgery. Also well-known to all thyroid surgeons is the "Kocher incision", a transverse, slightly curved incision about 2 cm above the sternoclavicular joints. We use cookies to improve your experience on our site and to show you relevant advertising. Br Med J (Clin Res Ed). A surgical incision is an aperture into the body to permit the work of the operation to proceed. A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. The Kocher's incision group had a significantly shorter hospital stay (median time 5 vs 8 days). Laparoscopic method. We also use third-party cookies that help us analyze and understand how you use this website. The anterior rectus sheath is separated and moved laterally, before the excision is continued through the posterior rectus sheath (if above the arcuate line) and the transversalis fascia, reaching the peritoneum and abdominal cavity. Subcoastal incision (or) Kocher's Incision. 1. The subcostal incision is also used for access to the liver for wedge resections; for the adrenal gland on either side; and the spleen if on the left side. Paramedian closure is similar in technique to midline closure; however, it is necessary to ensure reapproximation of the anterior and posterior rectus sheath when above the arcuate line (see the image below). Hernia. (Volkmann's) Sammlung klinischer Vortrge, Leipzig, 1900, n F. 268 (Gynk. 19 (2):329-37. The elbow is an unforgiving articulation with significant bony congruity and a . 2019 Mar. Kocher himself, however, recognized the logic behind utilizing as small an incision as possible and is quoted as saying thyroidectomy incisions should be "as small as possible, as big as necessary," therefore perhaps qualifying him as the first minimally invasive surgeon. It is also used by general and urological surgeons for some pelvic procedures such as radical open prostatectomy or cystectomy. Kocher elevator Kocher approach Kocher artery forceps Kocher biliary tract incision Kocher bladder retractor Eur J Surg. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. In a study comparing scar cosmesis at 6 months, no difference in appearance existed in patients with suture versus staple skin closure. A comprehensive collection of medical revision notes that cover a broad range of clinical topics. Medscape Education, Invasive Group A Streptococcus Outbreaks Associated With Home Healthcare, England, 20182019, encoded search term (Abdominal Closure) and Abdominal Closure, Pressure Injuries (Pressure Ulcers) and Wound Care. The skin incision is placed approximately 3 cm below and parallel to the costal margin. [QxMD MEDLINE Link]. Current Diagnosis & Treatment: Surgery. It can achieve the same standards of tumor resection and surgical field accessibility as the midline approach, while reducing postoperative recovery. Skin incision. Vol 2: 1549-66. Like the paramedian approach, the pararectal incision has now largely been abandoned. Instagram: https://instagram.com/geekymedics 41st ed. Zollinger's Atlas of Surgical Operations. (Kocher approach) to access to the radial head and the disrupted LCL. 1 and 6 ). [10] Some surgeons believe that closure of the peritoneum reduces adhesions between the abdominal contents and the suture line; however, at this time, there is only limited scientific evidence for this belief. This is an evolving field of study, and additional research will be required for further refinement of these initial recommendations. It is appropriate for certain operations on the liver, gallbladder and biliary tract. Reattach the muscles and fascia with resorbable sutures (2/0 or 3/0). Two modifications and extensions of the Kocher incision are possible: If you'd like to support us and get something great in return, check out our awesome products: You don't need to tell us which article this feedback relates to, as we automatically capture that information for you. A midline laparotomy can run anywhere from the xiphoid process to the pubic symphysis, passingaround the umbilicus. The lateral edges of the incisions remain medial to the internal oblique muscles. : a strong forceps for controlling bleeding in surgery having serrated blades with interlocking teeth at the tips. The skin is the largest and heaviest organ of the body. [QxMD MEDLINE Link]. [Full Text]. [5], The theoretical disadvantage of mass closure is that a single suture is responsible for maintaining the integrity of the closure. Immediate complications of a midline laparotomy incision may include anaesthetic difficulties, haemodynamic instability, primary haemorrhage from cut vessels and iatrogenic injury to surrounding tissues and viscera. [QxMD MEDLINE Link]. The sheath is bounded laterally by the linea semilunaris, which is the longitudinal margin at which the internal oblique aponeuroses bifurcate to form anterior and posterior leaves. This field is for validation purposes and should be left unchanged. Although in theory this may stand, a paucity of data exists regarding the significance of closing the subcutaneous fat. Fassiadis N, Roidl M, Hennig M, South LM, Andrews SM. Can Skin Care Aid Use of Diabetes Devices? To find out more, read our privacy policy. Seiler CM, Bruckner T, Diener MK, Papyan A, Golcher H, Seidlmayer C, et al. 2009 Nov. 144 (11):1056-9. The effect of damage control laparotomy on major abdominal complications: A matched analysis. Kocher's Incision: It is oblique in nature, extending from the abdominal upper right quadrant and is generally used for performing an open cholecystectomy. Abdominal Incisions PRIYA ANUSHA DSOUZA. A right subcostal (Kocher) incision is the most often used incision and allows excellent exposure of the gallbladder bed and cystic duct. Examples of such circumstances include the following: Various methods and materials are used to accomplish temporary closure (eg, sterile intravenous bag, fish-shaped viscera retainer, or abdominal vacuum pack). It provides good exposure for biliary and bariatric surgery and can be extended bilaterally if needed. When the center of the incision has been reached, the same method is used on the opposite end of the incision. The falciform ligament of the liver is commonly encountered if the incision is made to the right of the midline, and the tendinous intersections must be divided on the chosen side in order to access the peritoneum. It should be the aim of the surgeon to employ the type of incision considered to be the most suitable for that particular operation to be performed. Kocher's incision II: Tranverse incision over the thyroid for glandular removal They derive their blood supply from the superior and inferior epigastric arteries from the internal thoracic and external iliac arteries respectively, and their innervation from the anterior rami of spinal nerve roots T7-T12. #geekymedics #fyp #fypviral #studytok #medicalstudentuk #medtok #studytips #studytipsforstudents #medstudentuk #premed #medschoolfinals #shorts, Cardiovascular Exam Tips - DON'T FORGET these 3 things , Watch this video to find out the most COMMONLY FORGOTTEN components of the cardiovascular history! Save this video to help prepare for your upcoming OSCEs and dont forget to follow Geeky Medics! Within the abdomen lie the majority of the digestive tract and associated structures such as the liver, biliary tree, pancreas, kidneys and ureters, and the occasional pair of surgeons hands. 1998 Dec. 176 (6):666-70. - Examples 05:45 Chapters: Theyinvolve passing through all of the abdominal muscles, transversalis fascia, and then the peritoneum, before entering the abdominal cavity. There continues to be debate regarding the most effective strategy for abdominal-wall closure. [QxMD MEDLINE Link]. Franz MG. The cookie is used to store the user consent for the cookies in the category "Analytics". [33, 34, 35, 36] Damage-control surgery (trauma or emergency general surgery) is associated with fascial dehiscence rates of 13-50%. In pediatrics the most common use of this approach is open reduction of radial head/neck fractures. 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 more expedient return to function when compared with traditional open techniques. New York: McGraw-Hill; 2019. This can be accomplished as either a layered or a mass closure (see the image below). New York: McGraw-Hill; 2019. Wound infection. The open approach involves the creation of a small incision, generally 1.5 cm, through which the abdominal fascia is grasped with straight clamps and elevated toward the wound. Wound healing. Surgical Incisions Their Anatomical Basis Section: Thoracic Incisions: H. J. Pfannenstiel. Kocher's studies on one of his patients, who was operated on in 1874, led to an early discovery. A transverse incision traverses the anterior and posterior rectus sheath when above the arcuate line; thus, it is necessary to repair both, together or separately. Roses RE, Morris JB. 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. If you do not agree to the foregoing terms and conditions, you should not enter this site. There is no evidence that mass closure is associated with an increased incidence of hernia formation or wound dehiscence. Image courtesy of Wikimedia Commons. Point defects in the aponeurotic intersections of the linea alba may facilitate the development of epigastric hernias, which often simply contain preperitoneal fat but are often disproportionately painful for their size owing to their high tendency to strangulate. Controlled clinical trial of three suture materials for abdominal wall closure after bowl operations. The main difference between the Maylard incision and any other transverse lower abdominal incision, such as the Pfannenstiel incision, is that in the Maylard incision the rectus muscle is transected instead of split. Closure of subcutaneous fat: a prospective randomized trial. [41] The authors concluded that interrupted closure of abdominal-wall fascia was better than continuous closure in the setting of emergency laparotomy. sion ( k'kr in-sizh'n) An abdominal incision below and parallel to the costal margin. Chap 36. Typically, the midline incision remains above the umbilicus, still . (D) Two PDS ends meeting in middle of incision, tied together, and cut. 1231 patients were treated with the classical Kocher's incision, whereas in 125 cases the minimal cer vical access was. Subcostal Also called upper oblique, Kocher's incision Gallbladder and biliary tract surgery Paramedian Upper R side (biliary tract, gallbladder) Upper L side (splenectomy, gastrectomy) Lower R side (small bowel resection) Lower L side (sigmoid colon resection) Midline Upper and lower abdominal incision Abdominal surgeries . Defects in the integrity of the internal oblique may give rise to the formation of Spigellian hernias, allowing protrusion of the peritoneal sac into the rectus sheath. [30] ; more recently reported figures have been in the range of 1-3%. 2009 Apr. Wissing J, van Vroonhoven TJ, Schattenkerk ME, Veen HF, Ponsen RJ, Jeekel J. Fascia closure after midline laparotomy: results of a randomized trial. er's forceps k-krz-. The fascia was incised in the midline, and the incision was extended laterally with the Mayo scissors. Optimal exposure in pediatric abdominal surgery can be achieved by a transverse incision due to the abdominal proportions of the infant. Mass closure is continuous fascial closure with a single suture. Hussain SA. Either a posterior skin incision with a lateral skin flap or a lateral skin incision can be used.