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Presented by:
Dr Ghulam Akbar Khaskheli

The treatment of injuries or
disorders of the body by
incision or manipulation,
especially with instruments.

Operative Procedure

An act of performing surgerymay

be called a surgical procedure,
operation, or simply surgery

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

Types of Surgery

Minimally-invasive surgery
involves smaller outer incision(s) to insert
miniaturized instruments within a body cavity or

A cut produced surgically by a sharp instrument that
creates an opening into an organ or space in the


choosing an incision these three

should be achieved

Classification of incisions

Vertical incision
Midline incisions
Paramedian incisions

Transverse and oblique incisions

Kocher's subcostal Incision

Chevron (roof top Modification )

Mercedes Benz Modification
Mc Burneys grid iron or muscle splitting incision.
Pfannenstiel incision
Maylard Transverse Muscle cutting Incision
Transverse Muscle dividing incision
Oblique Muscle cutting incision

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
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

Lower Midline Incision

From the umbilicus superiorly to
the pubic symphysis inferiorly.
Allow access to pelvic organs.
The peritoneum should be
opened in the uppermost area to
avoid possible injury to the

Full Midline Incision

From xiphoid to pubic symphysis
Great exposure is needed.

Midline incision


Adequate exposure of most of all abdominal viscera

It is almost bloodless.
No muscle fibers are divided.
No nerves are injured.
It is very quick to make as well as to close.


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

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

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

Transverse And Oblique


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

Special attention is needed for control of the

branches of the superior epigastric vessels
which lie posterior to and under the lateral
portion of the rectus muscle
The small eighth thoracic nerve will almost
invariably be divided
The large ninth nerve must be seen and
preserved to prevent weakening of the
abdominal musculature
Have two modification:
Chevron (Roof Top) Modification.
The Mercedes Benz Modification.

Chevron (Roof Top) Modification

The incision may be continued across the midline
into a double Kocher incision or roof top approach
which provide excellent access to the upper
abdomen particularly in those with a broad costal

Used for:

Total Gastrectomy.
Total oesophagectomy.
Extensive hepatic resections.
Bilateral adrenalectomy

The Mercedes Benz Modification

Consists of bilateral low
Kochers incision with an
upper midline incision up to
the xiphisternum.
Excellent access to the
upper abdominal viscera.
(mainly the diaphragmatic

McBurney Grid Iron



first described in 1894 by Charles McBurney

Is the incision of choice For most Appendectomies.
Made at the junction of the middle third and outer thirds
of a line running from the umbilicus to the anterior
superior iliac spine. (The McBurney Point)
The level and the length of the incision vary according to:
The thickness of the abdominal wall.
The suspected position of the appendix.
If palpation reveals a mass, the incision can be placed
directly over the mass.

Oblique VS Transverse over the skin creases.


May be used in the left lower quadrant to deal with certain

lesions of the sigmoid colon. (such as .drainage of a diverticular

The Ilioinguinal and Iliohypogastric nerves cross the

incision & any accidental injury can predispose the patient
to Inguinal hernia.

Good healing.
Negligible risk of herniation.

Pfannenstiel incision

(smile incision)

Used frequently by gynecologists and urologists

for access to the pelvis organs, bladder, prostate
and for caesarean section.
Usually 12 cm long and made in a skin fold
approximately 5 cm above symphysis pubis.
skin fascia anterior rectus sheath rectus
muscle transversalis fascia extraperitoneal
fat perineum.


A convex incision which minimizing muscle parasthesia

and paralysis post-operatively. It also follows the
cleavage linesin the skin resulting in less scarring
The incision offers Excellent cosmetic results because the
scar is almost always hidden by the pubic hair

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
Upper (midline, paramedian or oblique incision)
can be easily extended into either the right or left
chest for better exposure.

Principles of


Pre-operative planning - important!
for optimal cosmetic and functional result
healing process wound contraction and scarring - may
compromise function and appearance

to re-establish functional soft tissue structural support
to give the most natural aesthetic appearance with minimal


Principles of Wound Incision

First priority - maintain a sterile and aseptic
technique to prevent infection.
afford sufficient operating space and optimum
the direction of wound naturally heal is from side-to-side,
not end-to-end
the arrangement of tissue fibers in the area to be dissected
will vary with tissue type
the best cosmetic results when incision made to the
direction of tissue fibers


Principles of Wound Incision

Relaxed Skin Tension Lines
(Langers line)
Is the skin lines oriented perpendicular to
the direction of the underlying muscle
determined by examination of patients
natural skin creases at rest
orientation of the final scar parallel to or
within a natural skin crease gives a superior
cosmetic result.


Principles of Wound Incision

Dissection technique
clean incision should be made with one
stroke or evenly applied pressure on the
preserve integrity of as many of
underlying structures as possible

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.

Principles of Wound Incision

Dog ears
areas of redundant skin and subcutaneous tissue resulting
from a wound margin being longer on one side than the other
dealt with either by

incremental oblique placement of sutures to

redistribute the tension across the wound
fusiform excision of the dog ear with lengthens the
scar considerably


Principles of Wound Incision

removal of a dog ear
skin defect is sutured until the dog ear
becomes apparent
the dog ear is defined with a skin hook
and is incised round the base
excess skin is removed and the skin is


Principles of Wound Incision

Tissue handling
minimum tissue trauma promotes faster healing
surgeon must handle all tissues very gently - and as little as
retractors should be placed with care to avoid excessive
pressure, since tension can cause serious complications


Principles of Wound Incision

HAEMOSTASIS - allows surgeon to work in as clear a
field as possible with greater accuracy. Without adequate
control, bleeding may interfere with the surgeons view
of underlying structures.
also to prevent formation of postoperative hematomas
collection of blood (hematomas) or fluid (seromas) can
prevent direct apposition of tissue
these collections provide an ideal culture medium for
microbial growth serious infection


Principles of Wound Incision

avoid excessive tissue damage while clamping of ligating a
vessel of tissue. Mass ligation necrosis, tissue death and
prolonged healing time

Maintaining moisture in tissues

during long procedures irrigate wound with normal saline,
or cover exposed surfaces with saline-moistened gauze to
prevent tissue from drying out

Removal of necrotic tissue and foreign

adequate debridement of all devitalized tissue and removal
foreign materials
presence of foreign materials - increases possibility of

Thank you