Abdominal Incisions

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The abdominal portions of the alimentary tract lie within the abdominal cavity and are usually approached through incisions made in the abdominal wall.

A large variety of abdominal incisions have been devised for operations upon the abdominal portion of the alimentary tract. To discuss their relative merits and demerits, it is essential to describe the anatomy of the abdominal wall. ANATOMY

Layers of the Abdominal Wall

The abdominal wall consists of seven layers ( Fig. 21-1 ) of tissue, of which the fourth or middle layer, the muscle-bone layer, is the most important. These layers will be considered in the order in which they are encountered while progressing inward.

The skin is the outermost layer. The course of the connective bundles of the corium forms lines of tension (Langer's lines of cleavage) in the skin. Over the anterior abdomen, these lines of cleavage run in a more or less transverse direction ( Fig. 21-2 ). Skin incisions made parallel to these lines of cleavage result in much finer scars than do those that cut across the lines of cleavage. This factor is not of primary importance in selecting an abdominal incision, but it may be taken into consideration if other factors are equal and for patients in whom the cosmetic result is important.

2. Subcutaneous Tissue

This layer consists of fat, which is variable in amount, contained within fibrous compartments. The more superficial portion of the subcutaneous fat contains much less fibrous tissue than does the deeper portion. This is called Camper's fascia. It continues beneath the skin to envelop the body. The deeper portion of the subcutaneous tissue of the abdominal wall contains more fibrous elements and forms a membranous fascial layer (Scarpa's fascia), which is separated from the underlying deep fascia by areolar tissue. Scarpa's fascia extends a few centimeters below the inguinal ligament to fuse with the deep fascia (fascia lata) of the thigh. This more superficial fascia continues over the penis and the surface of the spermatic cord and eventually forms the dartos layer. In the midline, Scarpa's fascia fuses with the deep fascia to form the fundiform ligament of the penis.

These inferior attachments of Scarpa's fascia explain why urine extravasated from a ruptured urethra often extends upward toward the costal margin rather than downward over the thigh, and also why femoral hernias tend to progress up over the inguinal ligament rather than down toward the knee. Both Camper's and Scarpa's fasciae have relatively poor

Figure 21-1 Cross section of seven layers of abdominal wall. 1, Skin—first layer. 2, Superficial fascia—second layer. 3, Deep fascia—third layer. 4, External oblique, internal oblique, transversus abdominis muscles of the fourth or muscle-bone layer. Each muscle has fascial layer on superficial and deep aspects. 5, Transversalis fascia—fifth layer. 6, Extraperitoneal or subserous fat of sixth layer. 7, Peritoneum— seventh layer. 8, Fusion point of three layers of lumbodorsal fascia. 9, Middle layer of lumbodorsal fascia. 10, Posterior layer of lumbodorsal fascia. 11, Anterior layer of lumbodorsal fascia. 12, Right and left sympathetic trunks behind inferior vena cava and aorta, respectively. 13, Peritoneum reflected off posterior abdominal wall as mesentery of intestine. 14, Transversalis fascia—also lines abdominal cavity but is not reflected onto viscera. 15, Aponeurosis of transversus abdominis fusing to posterior rectus sheath. 16, Aponeurosis of external oblique fusing to anterior rectus sheath. 17, Aponeurosis of internal oblique splitting to form anterior and posterior rectus sheath. (From Lampe, E. W.: Surgical anatomy of the abdominal wall. Surg. Clin. North Am., 32:545, 1952, with permission.)

Peritoneum Fascia Skin

Figure 21-2 Lines of tension of the skin (Langer). The general course of the connective tissue bundles of the corium determines the direction of these linear clefts. Whenever possible, incisions should follow these lines, because there will then be little gaping of the wound, allowing a subsequent fine scar. Broader scars follow incisions across the lines.

Figure 21-3 The right rectus abdominis and the left pyramidalis. The greater part of the left rectus abdominis has been removed to show the superior and inferior epigastric vessels. (From Williams, P.L., and Warwick, R. [eds.]: Gray's Anatomy, 36th Br. ed. Philadelphia, W.B. Saunders, 1980, with permission.)

Figure 21-4 The deep muscles of the back. On the left side, the erector spinae and its upward continuations (with the exception of the longissimus cervicis, which has been displaced laterally) and the semispinalis capitis have been removed. (From Williams, P.L., and Warwick, R. [eds.]: Gray's Anatomy, 36th Br. ed. Philadelphia, W.B. Saunders, 1980, with permission.)

Anterior Displaced Rectum

Figure 21-5 Muscles of the trunk, anterior view. The left sternocleidomastoid, pectoralis major, external oblique, and a portion of the deltoid have been removed to show underlying muscles. A portion of the rectus abdominis has been cut away to expose the posterior part of its sheath. (From Borland's Illustrated Medical Dictionary, 29th ed. Philadelphia, W.B. Saunders, 2000, with permission.)

Sternohyoid

Sternocleidomastoid , Trapezius

Biceps

Short head / Long head

Latiasimtls dorei

Coraco-/ brachialiü

Pect oral is major

I cut insertion)

Sternohyoid

Biceps

Short head / Long head

Latiasimtls dorei

External oblique.

Serra tus anterior - Trans versus

Umbilicus Internal oblique Linea arcuata

Gluteus medium

Deep inguinal ring

Spermatic cord

Tensor faaciae latae

Sartorius

Figure 21-6 Boundaries of Petlt's triangle and the triangle of auscultation.

External oblique.

Inguinal ligament *

Superficial inguinal ring Femoral ring

Femoral vein -

Great saphtnuua vein '

Serra tus anterior - Trans versus

Umbilicus Internal oblique Linea arcuata

Gluteus medium

Deep inguinal ring

Spermatic cord

Tensor faaciae latae

Sartorius

Figure 21-6 Boundaries of Petlt's triangle and the triangle of auscultation.

sternal oblique, but Its dlgltatlons from the ribs have been preserved. The sheath of the rectus abdominis has been opened and Its anterior lamina removed. (From Warwick, R., and Williams, P.L.: Gray's Anatomy, 35th Br. ed. Philadelphia, W.B. Saunders, 1973, with permission.)

Picture Transverse Colon Behind Ribs

Figure 21-8 Transverse sections through the anterior abdominal wall. A, Immediately above the umbilicus. B, Below the arcuate line. Note the extent to which the external oblique aponeurosis remains as a separate entity, passing medially, ventral to rectus, before blending with the other aponeuroses; these have already fused, lateral to rectus. (From Warwick, R., and Williams, P.L.: Gray's Anatomy, 35th Br. ed. Philadelphia, W.B. Saunders, 1973, with permission.)

alba that vary with the level of the fibers on the abdominal wall.

alba that vary with the level of the fibers on the abdominal wall.

Figure 21-11 Abdominal plexus of the thoracic nerves. The nerves are exposed by removal of the external and internal oblique muscles and by reflection of the rectus muscle. The seventh through twelfth thoracic nerves and the first lumbar nerve are shown as they anastomose after emergence from the intercostal spaces. (From Bishop, W.E., Carr, B.W., Anson, B.J., et al.: Parietal intermuscular plexus of thoracic nerves. Q. Bull. Northwestern Univ. M. School, 17:209, 1943, with permission.)

nerves. Q. Bull. Northwestern Univ. M. School, 17:209, 1943, with permission.)

Figure 21-12 Schema of blood supply to the anterolateral abdominal wall.

epigastric artery Pyramidalis muscle

Figure 21-12 Schema of blood supply to the anterolateral abdominal wall.

Internal thoricic (mammary) arteries

Esophagus Hiatus

mgular segment has been cut from the cranial portion of the latissimus dorsi. The rhomboideus major (at 2), one of the three constituents of the second layer of flat muscles of the back, has been removed in its middle half to expose the column of long muscles.

Gland CloquetRelationship Stomach
Figure 21-15 Normal anatomic relationship between lower end of esophagus, cardiac end of stomach, and esophageal hiatus, showing the relationship of the diaphragmaticoesophageal membrane of these structures.
Gland Cloquet

Figure 21-16 Disposition of transversalis fascia. The lateral compartment of the femoral artery contains the femoral artery, the middle compartment contains the femoral vein, and the medial compartment forms the femoral canal, containing the gland of Cloquet. Femoral hernia extends into the canal. The femoral sheath is formed by femoral prolongation of the transversalis fascia. The peritoneum and transversalis fascia overlie the bladder. At the tendinous arch, the transversalis fascia splits to form the superior and inferior branches. Note the visceral fascia arising from the superior pelvic diaphragmatic fascia.

Sheath Rectus Abdominis
Figure 21-17 Transverse section through the abdominal wall.

Erector splfiif mu sc I«

Tendinous Sheath

Lumbar vertebra IV

Rectus aJieafh

Figure 21-18 Principal vertical abdominal incisions. These may be made on either side, depending on the site of the surgical lesion.

Erector splfiif mu sc I«

Quadratus I umbo ram muscle l_Ht¡35ÍmU5 doral

Lumbar vertebra IV

Peritoneum TransvensaHe fesoa

Aponeurosis, internai oblique and transversa abdominis Linea alba muscle«

Transversalls fascia

Semtlufiar line

Anterior layer of rectus sheath Posterior layer of rectus sheath abdominis muscle

Rectus aJieafh

Figure 21-18 Principal vertical abdominal incisions. These may be made on either side, depending on the site of the surgical lesion.

Abdominal Incision Images

Figure 21-19 Principal transverse abdominal incisions. These are usable on either side, depending on the site of the surgical lesion.

Transverse Abdominal Incision

Figure 21-19 Principal transverse abdominal incisions. These are usable on either side, depending on the site of the surgical lesion.

Upper ahrlnmliiiiL

Right upper quadrant

Transverse

Rockey-Da

Lower abdominal

Left upper quadrant

Transverse umbilical

Lftft lower quadrant

Inguinal PfannensUef

Figure 21-20 Midline vertical epigastric Incision. A, The line of the incision extends from the xiphisternum to the umbilicus. B, Method of opening the peritoneal cavity.

The method of suturing the linea alba with nonabsorbable suture may vary. In the average patient, when there is little or no tension, a row of simple, interrupted, over-and-over sutures placed through the linea alba at least 1 cm lateral to the cut edge on each side, and including a few underlying fibers of the rectus muscle in each side, is used. Each stitch is tied immediately. The tied long

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