ASPIRAS, MELANY BEJARIN BSN 4

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 Burneys Grid iron or muscle splitting incision (iv) Oblique Muscle cutting incision (v) Pfannenstiel incision (vi) Maylard Transverse Muscle cutting Incision (C) Abdominothoracic incisions A. Vertical incisions: Vertical incisions include the midline incision, paramedian incision, and the MayoRobson extension of the paramedian incision. (i) Midline Incision: Almost all operations in the abdomen and retroperitoneum can be performed through 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 upper abdominal viscera, (e) It is very quick to make as well as to close; it is unsurpassed when speed is essential (Clarke, 1989) (f) a midline epigastric incision also can be extended the full length of the abdomen curving around the umbilical scar. .

Midline or transverse incision

(ii) Paramedian Incision (white arrow)The skin incision is placed 2 to 5 cm lateral to the midline over the medial aspect of the bulging transverse convexity of the rectus muscle. Extra access can be obtained by sloping the upper extremity of the incision upwards to the xiphoid (Didolkar et al, 1995). Skin and subcutaneous fat are divided along the length of the wound. The anterior rectus sheath is exposed and incised, and its medial edge is grasped and lifted up with haemostats. The medial portion of the rectus sheath then is dissected from the rectus muscle, to which the anterior sheath adheres. Segmental blood vessels encountered during the dissection should be coagulated. Disadvantages : 1. It tends to weaken and strip off the muscles from its lateral vascular and nerve supply resulting in atrophy of the muscle medial to the incision. 2. The incision is laborious and difficult to extend superiorly as is limited by costal margin. 3. It doesnt give good access to contralateral structures. The Mayo-Robson extension of the paramedian incision is accomplished by curving the skin incision towards the xiphoid process. Incision o fthe fascial planes is continued in the same direction to obtain a larger fascial opening (Pollock, 1981). (B) Transverse Incisions Transverse incisions include the Kocher subcostal incision, transverse muscle dividing, McBurney, Pfannenstiel, and Maylard incisions.

 Kocher subcostal incision Theodore Kocher originally described the sub

costal incision; it affords excellent exposure tothe gall bladder and biliary tract and can be made on the left side to afford access to the spleen(Kocher, 1903). It is of particular value in obese andmuscular patients and has considerable merit if diagnosis is known and surgery. Transverse Muscle-dividing incision : The operative technique used to make such anincision is similar to that for the Kocher incision. In newborns and infants, this incision is preferred,because more abdominal exposure is gained per length of the incision than with vertical exposure because the infants abdomen has a longer transverse than vertical girth (Gauderer, 1981). This is also true of short, obese adults, in whom transverse incision often affords a better exposure. McBurney Grid iron or Muscle-split incision The McBurney incision, first described in 1894 by Charles McBurney is the incision of choice for most appendicectomies McBurney, 1894). The level and the length of the incision will vary according to the thickness of the abdominal wall and the suspected position of the appendix (Jelenko &Davis 1973; Watts & Perrone, 1997). Good healing and cosmetic appearance are virtually always achieved with a negligible risk of wound disruption or herniation. Oblique Muscle-cutting incision This incision bears the eponym of theRutherford-Morrison incision (Talwar et al, 1997).This is extension of the McBurney incision by division of the oblique fossa and can be used for a right or left sided colonic resection, caecostomy or sigmoid colostomy. Pfannenstiel incision The Pfannenstiel incision is used frequently by gynaecologists and urologists for access to thepelvis organs, bladder, prostate and for caesarean section (Ayers & Morley, 1987; Mendez et al, 1999;Hendrix et al, 2000). The skin incision is usually 12cm long and is made in a skin fold approximately 5cm above symphysis pubis. The incision is deepened through fat and superficial fascia to expose both anterior rectus sheaths, which are divided along the entire length of the incision. The sheath is then separated widely, above and below from the underlying rectus muscle. Additional picture.

Pfannenstiel Incision The Pfannenstiel incision has become popular in the past decade for cosmetic

reasons. This is particularly true in younger women having surgery for benign gynecologic and pelvic problems. If properly placed, it is generally concealed by regrowth of pubic hair. The purpose of the technique is to provide a cosmetic incision for pelvic surgery. Physiologic Changes. The Pfannenstiel incision transects neurovascular pathways in the skin of the abdominal wall and frequently requires partial or compete transection of the rectus abominis muscle. It is rarely associated with incisional hernia, has a low incidence of wound dehiscence, and heals without significant scarring. The latter fact may be due to the copious blood supply in the mons pubis. Points of Caution. A Pfannenstiel incision should never be used in oncologic surgery. It does not give exposure to the upper abdomen and provides only limited exposure to aortic and lymph nodes for their analysis and dissection. Care must be taken to avoid incidental laceration of the inferior epigastric artery and vein on the lateral margin of the rectus muscles. If the muscles are to be transected, the epigastric artery and vein should be identified, clamped, and ligated prior to transection of the muscle. Hemostasis is particularly important during this incision. The vascularity of the mons pubis increases the risk of hemorrhage, formation of hematoma, and infection. The surgeon should ensure that the incision is dry before closure of the wound. If there is any question, a small suction drain should be left in the incision for 24-48 hours. Technique

Maylard incision In an effort to improve surgical exposure to the lateral pelvic sidewall with a transverse incision, Maylard proposed a transverse muscle-splitting incision. This incision usually refers to a subumbilical transverse incision. For gynecologic surgery, the incision is made 3-8 cm superior to the pubis symphysis. The anterior rectus sheath is cut transversely. The inferior epigastric vessels are

identified under the lateral edge of each rectus muscle and then are ligated.

Cherney incision Cherney described a transverse incision that allows excellent surgical exposure to the space of Retzius and the pelvic sidewall. The skin and fascia are cut in a manner similar to a Maylard incision. The rectus muscles are separated to the pubis symphysis and separated from the pyramidalis muscles. A plane is developed between the fibrous tendons of the rectus muscle and the underlying transversalis fascia. Using electrocautery, the rectus tendons are cut from the pubic bone. The rectus muscles are retracted and the peritoneum opened. Modified Gibson incision Some gynecologic oncologists perform an extraperitoneal lymph node dissection using a modification of the Gibson incision. This incision can be made on each side of the midline, but often, the skin is cut only on the left. The incision is started 3 cm superior and parallel to the inguinal ligament. Extension is made vertically 3 cm medial to the anterior superior iliac spine to the level of the umbilicus. The fascia is cut and the peritoneum bluntly dissected, as described above. The round ligament and the inferior epigastric vessels are ligated to facilitate surgical exposure. Care is needed when exposing the lymph nodes using only a left-sided incision. Too much traction on the peritoneum can result in avulsion of the inferior mesenteric vessels.

MILAGROS E. WAMINAL BSN - 4 TYPES OF SURGERY

Surgery is a medical technology consisting of a physical intervention on tissues. As a general rule, a procedure is considered surgical when it involves cutting of a patients tissues or closure of a previously sustained wound. Other procedures that do not necessarily fall under this rubric, such as angioplasty or endoscopy, may be considered surgery if they involve common surgical procedure or settings, such as use of a sterile environment, anesthesia, antiseptic conditions, typical surgical instruments, and suturing or stapling. All forms of surgery are considered invasive procedures; socalled noninvasive surgery usually refers to an excision that does not penetrate the structure being excised (i.e. laser ablation of the cornea) or to a radiosurgical procedure (i.e. irradiation of a tumor). Surgery is a unique experience of a planned physical alteration encompassing three phases: PREOPERATIVE, INTRAOPERATIVE AND POSTOPERATIVE. These 3 phases are together referred to as the PERIOPERATIVE PERIOD. Surgical procedures are commonly grouped according to: A. Purpose Diagnostic Palliative Ablative Constructive Transplant Confirms or establishes a diagnosis; Example biopsy of a mass in a breast. Relieves or reduces pain or symptoms of a disease; it does not cure; Example - resection of nerve roots. Removes a diseased body part; Example (cholecystectomy) removal of a gallbladder

Restores function or appearance that has been lost or reduced; Example breast implant Replaces malfunctioning structures; Example hip replacement

B. Degree of Urgency Emergency Surgery Elective Surgery Is performed immediately to preserve function or the life of the client. Example surgeries to control internal hemorrhage Is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening (but may ultimately threaten life or well being) or to improve the clients life. Example cholecystectomy for chronicgallbladder disease, plastic surgery procedures such as breast reduction surgery

C. Degree of Risk Major Surgery It involves a high degree of risk, for a variety of reasons: It may be complicated or prolonged, large losses of blood may occur, vital organs may be involved, or postoperative complications may be likely. Example organ transplant, open heart surgery, removal of kidney

Minor Surgery

It involves little risk, produces few complications, and is often performed in a day surgery. Example breast biopsy, removal of tonsils, knee surgery.

The degree of risk involved in a surgical procedure is affected by the clients age, general health, nutritional status, use of medications, and mental status. Age Very young and elder clients are greater surgical risks than children and adults. The physiologic response of an infant to surgery is substantially different from an adults. The blood volume in an infant is small, and its fluid reserves limited. The older adult often has fewer physiologic reserves to meet the extra demands caused by surgery. The older adult may be poorly nourished, which can impair healing. Surgery is least risky when the clients general health is good. Common health problems that increase surgical risk and may lead to the decision to postpone or cancel surgery are malnutrition, cardiac conditions, blood coagulation disorders, renal diseases, diabetes mellitus, liver diseases, etc. Adequate nutrition is required for normal tissue repair. Obesity contributes to postoperative complications such as pneumonia, wound infection and wound separation. Obese and underweight client are vulnerable to pressure ulcer formation due to positioning required for surgery. A malnourished client is at risk for delayed wound healing, wound infection and fluid and electrolyte alterations. The following medication can increase surgical risk: Anticoagulants increase blood coagulation time. Tranquilizers may interact with anesthetics, increasing the risk of respiratory depression. Corticosteroids may interfere with wound healing and increase the risk of infection. Diuretics may affect fluid and electrolyte balance. Clients with dementia may have difficulty understanding proposed surgical procedures and may respond unpredictably to anesthetics. Extreme anxiety also increases surgical risk and interferes with the clients ability to process information and respond appropriately to instructions.

General Health

Nutritional Status

Medications

Mental Status

Anesthesia involves the use of medicines to block pain sensations (analgesia) during surgery and other medical procedures. Anesthesia also reduces many of your body's normal stress reactions to surgery. The type of anesthesia used for your surgery depends on:

our medical history, including other surgeries you have had and any conditions you have (such as diabetes). You will also be asked whether you have had any allergic reactions to any anesthetics or medicines or whether any family members have had reactions to anesthetics. The results of your physical exam. A physical exam will be done to evaluate your current health and identify any potential risks or complications that may affect your anesthesia care. Tests such as blood tests or an electrocardiogram (EKG, ECG), if needed. The type of surgery that you are having. o You need to be able to lie still and remain calm during surgery done with local or regional anesthesia. o Young children usually cannot stay still during surgery and need general anesthesia. o Adults who are extremely anxious, in pain, or have muscle disorders also may have difficulty remaining relaxed and cooperative. o Some surgical procedures require specific positions that may be uncomfortable for long periods if you are awake. o Some procedures require the use of medicines that cause muscle relaxation and affect your ability to breathe on your own. In such cases, your breathing can best be supported if general anesthesia is used.

Based on your medical condition, your anesthesia specialist may prefer one type of anesthesia over another for your surgery. When the risks and benefits of different

anesthesia options are equal, your anesthesia specialist may let you choose the type of anesthesia.

Anesthesia methods
There are several ways that anesthesia can be given.

Local anesthesia involves injection of a local anesthetic (numbing agent) directly into the surgical area to block pain sensations. It is used only for minor procedures on a limited part of the body. You may remain awake, though you will likely receive medicine to help you relax or sleep during the surgery. Regional anesthesia involves injection of a local anesthetic (numbing agent) around major nerves or the spinal cord to block pain from a larger but still limited part of the body. You will likely receive medicine to help you relax or sleep during surgery. Major types of regional anesthesia include: o Peripheral nerve blocks. A local anesthetic is injected near a specific nerve or group of nerves to block pain from the area of the body supplied by the nerve. Nerve blocks are most commonly used for procedures on the hands, arms, feet, legs, or face. o Epidural and spinal anesthesia. A local anesthetic is injected near the spinal cord and nerves that connect to the spinal cord to block pain from an entire region of the body, such as the belly, hips, or legs. General anesthesia is given into a vein (intravenously) or is inhaled. It affects the brain as well as the entire body. You are completely unaware and do not feel pain during the surgery. Also, general anesthesia often causes forgetfulness (amnesia) right after surgery (postoperative period).

For some minor procedures, a qualified health professional who is not an anesthesia specialist may give some limited types of anesthesia, such as procedural sedation. Procedural sedation combines the use of local anesthesia with small doses of sedative or analgesic agents (painkillers) to relax you. Medicines used for anesthesia A wide variety of medicines are used to provide anesthesia. Their effects can be complex. And they can interact with other medicines to cause different effects than when they are used alone. Anyone receiving anesthesia-even procedural sedationmust be monitored continuously to protect and maintain vital body functions. The complex task of managing the delivery of anesthesia medicines as well as monitoring your vital functions is done by anesthesia specialists. Medicines used for anesthesia help you relax, help relieve pain, induce sleepiness or forgetfulness, or make you unconscious. Anesthesia medicines include:

Local anesthetics, such as bupivacaine or lidocaine, that are injected directly into the body area involved in the surgery. Intravenous (IV) anesthetics, such as fentanyl, propofol, or sodium thiopental, that are given through a vein.

Inhalation anesthetics, such as isoflurane and nitrous oxide, that you breathe through a mask.

Other medicines that are often used during anesthesia include:

Muscle relaxants, which block transmission of nerve impulses to the muscles. They are used during anesthesia to temporarily relax muscle tone as needed. Reversal agents, which are given to counteract or reverse the effects of other medicines such as muscle relaxants or sedatives given during anesthesia. Reversal agents may be used to reduce the time it takes to recover from anesthesia.