Different types of incision in gynecological surgeries can be vertical, transverse or oblique. The choice of decision depends upon the pathology prompting the surgery, presence or abscence of upper abdominal disease, suspicion of malignancy and co morbid state of the patient.
Vertical midline incision is the most easily mastered incision. It affords rapid entry and provide excellent exposure. Moreover, it is easy to extend it if more exposure is required.This is useful in surgeries for mailgnancies,large abdominal masses and if severe adhesions are expected such as in severe endometriosis.Also it is least haemorrhagic and there is minimal nerve damage.In cases of life threatening secondary haemorrahge it is preferred due to above properties.
Still there are certain negative points which restricts the use of this incision , most important being weakness in its strength. There is risk of hernia formation and dreaded complication of burst abdomen. Therefore mass closure technique must be used which minimises these complications. Other disadvantages are cosmetically bad looking scar which is visible also, increased post op pain and interference with repiration.If there had been previous abdominal surgery or adhesions are expected, peritoneum should be opened more cephaladly taking care not to injure adhered bladder or bowels.
Paramedian incision is opening the abdomen 1cm. lateral to the midline. It was advocated due to its alleged greater strength but various studies have failed to confirm this. It takes more time than midline incision. If there was previous midline incision there is risk of loss of blood supply between two scars, gives bad scars.There is risk of injury to blood vessels running below the rectus muscle while seperating them and risk of injury to nerves. So, practically this incision confers no advantage over midline incision.
Pfannenstiel is the transverse incision.Classically it is slightly curved and is at various levels above the symphisis pubis. Usually a modification is used where it is low transverse in cision not necessarily curved. This incision is many times stronger than the vertical incisions, conferring minimal risk of hernia formation.It is cosmetically superior, scar being along the natural skin lines and usually in the bikni area so not visible.It is associated with less post op. pain and less interference with the respiration in post op. period.It is the preferred incision in most of the benign gynecological conditions.
Disadvantage of pfannenstiel is: it takes more time and exposure will be limited as extension of incision is difficult. Extending the incision more laterally has the risk of involvement of ilio hypogastric and ilio inguinal nerves. Upward extension will give bad inverted T or J shaped scar.Also, there is risk of wound hematoma especially in obese patients and those on anticoagulants.Therefore , in these cases drains should be considered.
Cherney and Maylard incisions are other transverse incisions where rectus muscle is cut from its tendinous insertion at pubic symphisis.These are useful when access is required to Space of Reitz in urinary incontinence surgeries.
Other small suprapubic or oblique incisions are used in laproscopic surgeries.They have no use in other surgeries. Rectus sheath in these cases should be closed properly as Reichter hernia may develop.
McBurney\"s oblique incision which is classically described for appendicectomy may be used for draining pelvic abscess.But it gives bad scars and is therefore not preferred over low transverse incisions.
Thus,choice of incision need to be highly individualised.
Posted by uma M.
Critically evaluate the different types of abdominal incisions used in gynaecological surgery.
Various abdominal incisions have been developed in order to preserve function as well as possible and which heals rapidly with good strength.
Before deciding on type of incision to be given it is essential that nature of disease,type of surgery required have to be taken into consideration. It is essential that proposed incision is discussed with the patient during pre op councelling .
Basic understanding of anatomy of anterieo abdominal wall is essential .
Broadly incisions can be vertical or transverse.Vertical incisions were used more often in the past. Midline incision is commonly employed. This incision avoids cutting all major vessels,nerves,vessels in ant abdominal wall.It divides rectus sheath and not cuts.It gives good acess to the whole of the abdomen . If extension is required it can be made easily superiorly to gain acess to sub diaphragmatic area.It is easiest,quickest incision that can be made. Main draw back with this is it heals slowly,higher incidence fo wound dehiscence,and incisional hernia at a later date. This should be closed by mass clouser technique, (rectus sheath and poritoneum closed with 1 cm deep bites 1cm apart).Absorbable manofilament gives best result with less post po pain, less wound dehiscence.Paramedian incision ,1 cm lateral to midline ,is another type of vertical incision, not used these days, as it provides no improved acess to either side of abdomen.Midline incision is indicated for cases of carcinoma ovary ,endometrium,LARGE fibroid.
Transverse incisions are being increasinly used for gynaecological surgeries.All transeverse incisions heal rapidly than vertical . Cosmetic result is superior.Good acess to pelvis can be obtained.Ocassional difficulties are encountered ta acess pelvic brim. These incisions are difficult to extend if improved abdominal exposure is needed. Less wound dehiscence, less
post op pulmonary complications ,less pain than vertical incision, permit early mobility. All simple gynaecological surgeries simple hysterectomy,colposuspension can be completed with these incisions.Various transverse incisions discribed include Pfennensteil incision, Maylard incision, cherney incision, Ruther ford morrisom incision.Pfannensteil incision is commonly used incision,involves dividing each layer of abdominal wall seperately in differant darections, a low transeverse incision given 2 cm above pubic symphysis,slightly curved upwards.Extending the incision more laterally has the risk of involvement of ilio hypogastric and ilio inguinal nerves. extension will need bad inverted T or J shaped scar.It is more time consuming than vertical . Maylard incision involves dividing all layers in line with skin incisionand also divides the inferior epigastric vessels.Rectus sheath is not seperated from muscle, and closure is in layers,muscle is not closed allowing it to be drawn with the sheath . This incision provides improved acess to side walls of pelvis than pfrnnensteil and so is use full for oncology surgeries like wertheimes hysterectomy, for lymphadenectomies.Cherney incision is similar to pfannesteil , but involves dividing of rectus muscle 1 cm from their insertion into symphis pubis. Muscle is closed with continous suture in the membranous portion. This is use ful for oncology surgeries and urology surgeries.Ruther ford morrison incision is usefull for approaching ovarian masses in pregnancy,esp in II half.Involves division of all layers in line with incision.McBurney\"s oblique incision comonly used for appendicectomy may be used for draining pelvic abscess.But it gives bad scar.
Incision most appropriate to individual patient in chosen depending on patient charecteristics like presence of obesity, nature of disease requiring surgery, extent of surgery required , and patient\'s wishes, surgeon\'s comfort.In extremely obese women it would be preferable to give midline incision than operating below panniculus, where ther will be nidus for infection .
Posted by Nitin P.
The type of abdominal incision used depends on the indication for the surgery. A basic surgical principle of an adequate incision is followed. The other determining factors regards abdominal incision are immediate postoperative complications such as haematoma, infection, pain and burst abdomen. Late postoperative complications include cosmesis, keloid and hernia. Adhesions will form after nearly all surgeries, but the extent to which they form is determined by the injury to the peritoneum. Hence they will tend to be more after a long vertical incision and less after a short transverse incision.
Patient characteristics such as previous surgeries on the abdomen, obesity, respiratory compromise will also determine the type of incision.
Patient acceptability and documentation in consent are important aspects of which incision is used.
Transverse incision, commonly the suprapubic Pfannenstiel incision offers good access to the pelvis for most benign surgeries. It also has advantages of cosmesis, reduced pain and lower incidence of burst abdomen as compared to vertical incisions. However, the entry into the abdomen is delayed as compared to a vertical incision and hence is not preferred in situations where immediate entry is desired.
There are limitations to how much a transverse incision can be extended. This is a drawback in the event of unexpected pathology or complications. There are also more incidences of haematoma as compared to vertical incisions.
In case of large tumours, access is limited. It is not suitable for ovarian malignancy as staging is significantly limited.
Vertical incisions offer rapid entry into the abdomen in case of an acute emergency. They are ideally suited for large tumours, where the diagnosis is in doubt and in cases of malignancy. Upper abdominal assessment is better with vertical incisions. They can be median or paramedian. There is no evidence that the paramedian incisions offer any advantage over midline incisions. The risk of burst abdomen and hernia is reduced by the use of mass closure techniques.
They are also suited for entry into the abdomen when adhesions are expected towards the pelvis or the bladder is suspected to be adherent to the anterior abdominal wall.
The vertical incisions are more likely to cause respiratory compromise because of difficult abdominal breathing and pain.
Groin incisions and ileal fossa incisions are used for groin node dissection and pelvic wall lymph node dissection. They are not suitable for most other gynae surgery.
Laparoscopy requires 5 to 10 mm incisions and these may be in the iliac fossae or suprapubic. They are highly cosmetic. They are not suitable for any other surgery. Wound healing, bruising can be a problem Also, hernia can be a late complication.
They may need to be extended to remove from the abdomen a specimen which has already been disconnected laparoscopically.
