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Presented by:
Dr Ghulam Akbar Khaskheli
SURGERY
The treatment of injuries or
disorders of the body by
incision or manipulation,
especially with instruments.
Operative Procedure
Types of Surgery
Elective surgery
correct a non-life-threatening condition, and is
carried out at the patient's request,
Semi elective surgery
must be done to avoid permanent disability or death,
but can be postponed for a short time.
Emergency surgery
must be done promptly to save life, limb, or functional
capacity.
Types of Surgery
Minimally-invasive surgery
involves smaller outer incision(s) to insert
miniaturized instruments within a body cavity or
structure,
Incision
Definition
A cut produced surgically by a sharp instrument that
creates an opening into an organ or space in the
body.
When
Classification of incisions
Vertical incision
Midline incisions
Paramedian incisions
Thoracoabdominal incisions.
Midline incision
the most common incision
Have three types:
Upper Midline Incision
From xiphoid to above umbilicus.
Skin superficial and deep fascia
linea alba extraperitoneal fat
peritonium.
Division of the peritoneum is best
performed at the lower end of the
incision, just above the umbilicus so that
falciform ligament can be seen and
avoided.
.
Midline incision
Advantages:
Disadvantages:
Extensive is difficult
More painful.
Chest complications.
Wound infection,. Ugly scar, Incisional hernia, etc.
Paramedian incision
2 to 5 cm lateral to the midline.
Over the medial aspect of the
bulging transverse convexity of the
rectus muscle.
skin fascia anterior rectus
sheath The anterior rectus muscle
is freed from the anterior sheath and
retracted laterally The posterior
rectus sheath (if above the
arcuateline) or transversalis fascia
(if below the arcuate line)
extraperitoneal fat. andperitoneum
Advantages
Provide an access to the lateral structure such as the spleen or the kidney
The closure is theoretically more secure because the rectus muscle can act
as a support between the reapproximated posterior and anterior fascial
planes so lower risk of dehiscence and hernia as compared to midline
incision
Disadvantages
Takes longer to make and close
Incision needs to be closed in layers
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
The incision is laborious and difficult to extend superiorly as is limited by
costal margin.
It does not give good access to contralateral structure
Risk of epigastric vessels injury
Kochers incision
Incision parallel to the right
costal margin. started at the
midline, 2 to 5 cm below the
xiphoid and extends
downwards, outwards and
parallel to and about 2.5 cm
below the costal margin
It shows excellent exposure to
the gallbladder and biliary tract
and can be made on the left
side to show access to the
spleen.
.
Used for:
Total Gastrectomy.
Total oesophagectomy.
Extensive hepatic resections.
Bilateral adrenalectomy
(muscle-split
incision)
Advantages
Good healing.
Negligible risk of herniation.
Pfannenstiel incision
(smile incision)
Advantages:
Disadvantages:
Limited exposure of the abdominal organs. Use of incision is
therefore restricted to the pelvic organs
High risk of injury to the bladder
Extension of the incision is difficult laterally
Thoracoabdominal Incision
Converts the pleural and peritoneal cavities into
one common cavity excellent exposure.
Left incision Resection of the lower end of the
esophagus and proximal portion of the stomach.
Right incision elective and emergency hepatic
resections.
Upper (midline, paramedian or oblique incision)
can be easily extended into either the right or left
chest for better exposure.
Principles of
Incision
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Introduction
Pre-operative planning - important!
for optimal cosmetic and functional result
healing process wound contraction and scarring - may
compromise function and appearance
Goals
to re-establish functional soft tissue structural support
to give the most natural aesthetic appearance with minimal
distortion
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Fusiform excision
performed with longitudinal axis running
parallel to RSTL
the length should be 4 times with the
width of the defect to produce an
accurate coaptation of skin edges
without dog ear formation.
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Thank you