The term incision originates from the Latin (in + cidere → incisio). An incision can be longitudinal, oblique or transverse. The most important types are demonstrat- ed in association with abdominal operations; the prin- ciples are identical in the other body regions (extremi- ties, chest, neck, etc.).
1. Longitudinal incisions
1. Midline; 2. supraumbilical (upper midline); 3. in- fraumbilical (lower midline); 4. right paramedian; 5. McEvedy preperitoneal approach for inguinal and fem- oral hernia repair (McEvedy PG: Femoral hernia. Ann R Coll Surg Engl, 1950).
1.1. Characteristics of longitudinal
incisions
Median incision
This was the commonest abdominal intervention be-
fore the era of minimally invasive surgery. The umbi- licus and the falciform ligament above the umbilicus should not be incised. Meticulous, careful handling of bleeding is necessary in the superficial layers before the peritoneum is opened. The urinary bladder can be reached through the Retzius space (spatium retropu- bicum Retzii); if there has previously been an opera- tion in this field, a more caudal entry is necessary (the chance of scar formation and adhesions is less).
Advantages: There is excellent exposure to the abdo- men and pelvis, which can easily be extended, and also rapid entry into the abdominal cavity; the mid- line is the least hemorrhagic incision, and is easy to perform; the linea alba is the guide to the midline.
Disadvantages: The scar may be wide and not beau-
tiful, with a possible increase in hernias and dehis- cence with the midline.
Paramedian incision
The site is parallel to and ~ 3 cm from the midline.
The following structures are divided: skin – anteri- or rectus sheath (the m. rectus is retracted laterally) – posterior rectus sheath (above the arcuate line) – transversalis fascia – extraperitoneal fat – peritone- um. Closure is performed in layers.
Indication: If excellent exposure is needed to one side of the abdomen or pelvis.
Advantages: A lower incidence of incisional hernias. Disadvantages: It takes longer to make and close this
incision, there is an increased risk of infection, and intraoperative bleeding, and a risk of nerve damage; if sited beside the midline, and it can compromise the blood supply in the middle.
2. Oblique incisions
(1). Kocher incision for cholecystectomy (sec. Theodor Kocher (1841–1917), Nobel Prize for medicine and physiology in 1909, mainly for thyroid surgery); (2). McBurney incision for appendectomy (after Charles McBurney (1845–1913), who performed his first op- eration for appendicitis in 1897); (3). left inguinal; (4). thoraco-abdominal
2.1. The basic type of oblique
incisions
Indications for McBurney muscle-splitting incision
(see later): Appendicitis, pelvic abscess and extra- peritoneal drainage. 2 4 3 1. medián 2. fels� medián 3. alsó medián 4. j.o. paramedián 5. McEvedy 1 5 2 4 1. Kocher 2. McBurney 3. b.o. inguinalis 4. thoraco-abdominalis 1 3
II. INCISIONS
3. Transverse incisions
1. Gable incision, 2. transverse muscle splitting, 3. Lanz incision, 4. Maylard incision, 5. Pfannenstiel incision, 6. Cherney incision
3.1. Basic characteristics of
transverse incisions
Advantages: These incisions give the best cosmetic results, they give a much stronger scar than midline incisions and less painful than longitudinal inci- sions, and there is less interference with respiration. There is no difference in dehiscence rate.
Disadvantages: They are more time-consuming, and
more hemorrhagic; nerves are sometimes divided, spaces are opened and there is a potential for hema- tomas; upper abdominal access is limited.
Main types:
Pfannenstiel incision: For gynecological indica-
tions. Advantages: Most wound security (in pelvic incisions), least exposure, usually 10-15 cm long. Disadvantages: Separates the perforating nerves and small vessels from the ant. rectus, and this
may weaken the strength of the wound healing. If extended past the m. rectus, it can damage the ih and ii nerves.
Maylard incision: This gives excellent exposure to the lower pelvis; it is used for radical pelvic sur- gery; it is a true transverse muscle-cutting inci- sion, 3–8 cm above the symphysis.
Cherney incision: This is like a Pfannenstiel inci- sion, but divides the m. rectus at the tendinous in- sertion to the symphysis. It gives excellent access to the space of Retzius. During closure, re-attach- ment of muscle tendons to the rectus sheath, and not the symphysis, should be performed in order to avoid osteomyelitis.
Rockey Davis (Elliot) incision: This alternative to the McBurney incision, extends to the lateral bor- der of the rectus (it was described first by JW El- liot in 1896, then by AE Rockey in 1905, and fi- nally by GG Davis in 1906).
Lanz incision: This is a special incision at the right fossa iliaca. As compared with the McBur- ney incision, it is transverse, more medial toward the rectus, and closer to the iliac crest (spina ili- aca anterior superior), and gives better cosmet- ic results. Due to its transverse direction, the ih and ii nerves can be damaged, and the incidence of hernia is higher. The main indication is expo- sure of the appendix and cecum; the mirror im- age (left iliac fossa) can be used for the left colon (not for the rectum).
4. Special extraperitoneal
incisions for staging
J-shaped incision: 3 cm medial to the iliac crest; this
allows the extraperitoneal removal of para-aortic nodes; it can also be left-sided; but the right is easier.
“Sunrise” incision: 6 cm above the umbilicus, per- mitting the extraperitoneal removal of para-aortic nodes, and allowing immediate irradiation.
2 1. Gable 2. haránt rácsmetszés 3. Lanz 4. Maylard 5. Pfannenstiel 6. Cherney 1 3 4 5 6