Obstet Gynecol. This video demonstrates how to use an automated external defibrillator (AED) in the context of cardiopulmonary resuscitation (CPR). - 2500+ OSCE Flashcards: https://geekymedics.com/osce-flashcards/ Regardless of the type of incision selected, the skin should be incised with a single, clean stroke of a sharp scalpel. Retroperitoneal and extraperitoneal approaches can be used for operations on the kidney, ureter, adrenal gland, bladder, splenic artery and vein, vena cava, lumbar sympathetic chain, abdominal aorta, and iliac vessels, and on groin hernias. L- or J-shaped incisions were first described by Masatoshi Makuuchi and have gained considerable popularity for upper abdominal surgery and liver resection in particular.14 These incisions, which extend from xiphoid to the umbilicus and across the right or left hemirectus in transverse fashion, have several theoretical and real advantages. TikTok: https://www.tiktok.com/@geekymedics Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Incisions, Closures, and Management of the Abdominal Wound, Gastrointestinal Surgery: A Historical Perspective. 00:00 Introduction A right thoracoabdominal incision can be used to expose the right hemidiaphragm, esophagus, liver, portal triad, inferior vena cava, right kidney, right adrenal gland, and proximal pancreas. provides better access to lateral structures than a midline approach, seperate incision in posterior rectus allows buttressing of wound and this reduces chance of herniation through incision site what are the disadvantages of paramedian incisions? The interrupted sutures are tied prior to skin closure and reinforce the running closure. In reality, the incision is a second surgical procedure, which interferesat least temporarilywith normal abdominal wall function. When its done, its because its the safest way to deliver your baby. A. Your obstetrician uses a local anesthetic (typically injected into the area) to numb your perineal area so you don't feel pain. Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health. A self-retaining rib retractor is inserted, and the intercostal space is gently spread. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). The incision should be considered as a second surgical procedure, which temporarily interferes with normal abdominal wall function. More wound infections were seen with transverse incisions.3, Controversy also persists regarding the relative advantages of midline versus paramedian incisions. Access is most often obtained at a site just above or below the umbilicusthe thinnest portion of the abdominal wall and a central location from which all quadrants of the abdominal cavity can be visualized. This content does not have an English version. Upper paramedian incision: surface markings. If you are a Mayo Clinic patient, this could Classically, it was thought that longitudinal incisions were at greater risk of dehiscence than transverse incisions.6 However, it is difficult to make legitimate comparisons since longitudinal incisions are more likely to be performed in cases of hemorrhage, trauma, sepsis, multiorgan disease, previous surgery, previous radiation therapy, and malignancyall of which increase the likelihood of postoperative complications. Transverse and oblique incisions can be placed in any of the 4 quadrants of the abdomen depending on the site of pathology. But sometimes the baby needs to be delivered before the vaginal tissues can stretch on their own. adv: less painful better cosmetic result no denervation of the rectus abdomens reduced chance of herniation when compared to midline incisors disadv: less exposure slower access can obstruct the most appropriate site for stoma formation what is a subcostal incision? (Reproduced with permission from Baker RJ, Fischer JE: Mastery of Surgery, 4th ed. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. 10-13). The perineal area will be sore and painful for a few weeks after an episiotomy. The midline incision allows rapid access to and adequate exposure of almost every region of the abdominal cavity and retroperitoneum. 10-10A). Use an ice pack or perineal cold pack (an ice pack and absorbent pad in one) to reduce swelling and ease soreness. While episiotomies are uncommon, there are still instances when your healthcare provider feels it's the safest option. You might take prescription medications or use a nonprescription pain reliever or stool softener. While the vertical midline incision remains most popular and is, perhaps, the most versatile, a variety of other incisions may have distinct advantages in specific settings. - 2500+ OSCE Flashcards: https://geekymedics.com/osce-flashcards/ Healthcare providers once thought making a surgical incision would help the vagina stretch and prevent severe tears. Transverse incisions are said to cause less pulmonary and systemic complications, but the claimed advantages may be because most transverse incisions are extraperitoneal, whereas midline incisions are intraperitoneal. Incisions, Closures, and Management of the Abdominal Wound If we combine this information with your protected The abdominal part of the incision may consist of a midline or upper paramedian incision, which allows exploration of the abdomen. Both of these conditions may result in lengths of bowel becoming trapped within the hernial sac (incarcerated), and the hernia may be sufficiently large or the defect through which it protrudes may be sufficiently tight to occlude intraluminal passage of bowel content (obstruction), venous outflow and later arterial supply (strangulation). The rectus sheath may be considered as having three distinct sections: 1. Insufflation tubing is then attached to the cannula and the obturator is withdrawn. The superior and inferior leaflets of the divided sheath are dissected from the underlying rectus muscles superiorly to the umbilicus and inferiorly to the pubic symphysis. Another technique to reduce tearing is to apply a warm compress to your perineum during the second stage of labor. You may opt-out of email communications at any time by clicking on 00:29 Demonstration A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. The skin incision is oriented obliquely and extends from approximately 2 cm above the anterosuperior iliac spine to a point just lateral to the pubic symphysis (Fig. All rights reserved. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. - 700+ OSCE Stations: https://geekymedics.com/osce-stations/ This incision is oriented obliquely. There is no posterior sheath above the level of the costal margin, as the recti remain covered anteriorly by the external oblique aponeurosis and insert directly onto the underlying costal cartilages. information and will only use or disclose that information as set forth in our notice of You might also be interested in our awesome bank of 700+ OSCE Stations. Carbon dioxide (CO2) is insufflated into the abdomen to a pressure of 12 to 15 mm Hg. (Reproduced with permission from Baker RJ, Fischer JE: Mastery of Surgery, 4th ed. Other recovery and complication rates are similar although the transverse incision may look better. Surface markings. G. Closure midline and inferior rectus. Cruse PJE, Ford R. The epidemiology of wound infection: a 10-year prospective study of 62,939 wounds. The vena cava is exposed on the right, and the aorta is exposed on the left. A midline episiotomy puts you at risk of fourth-degree vaginal tearing. Some people line their sanitary pads with witch hazel pads for extra relief. Disadvantages include patients experiencing more pain than they would from a transverse incision, particularly during deep breathing postoperatively, and the incision is perpendicular to the Langer's skin tension lines resulting in poorer cosmesis. The sheath is bounded laterally by the linea semilunaris, which is the longitudinal margin at which the internal oblique aponeuroses bifurcate to form anterior and posterior leaves. Part I: Influence on healing. In some cases, there will be anastomotic branches of the superior and inferior epigastric vessels crossing from either side, but the incision generally avoids major neurovascular bundles. A gridiron incision involves an arcing incision through the skin, subcutaneous fat and fascia, external and internal obliques, transversus abdominis and transversalis fascia. Use the arc, rather than direct contact, to prevent excessive devitalization of tissue. Alternatively, an oblique upper abdominal incision can be used and extended directly into the thoracic portion of the incision. A collection of data interpretation guides to help you learn how to interpret various laboratory and radiology investigations. The incision extends from the lateral margin of the rectus sheath at the level of the umbilicus toward the twelfth rib for approximately 12 to 14 cm (Fig. It'll take time for the baby to stretch the vaginal tissues to allow delivery. The incision can also be extended superiorly as far as the costal margin if necessary. The suspected position of the appendix and the thickness of the abdominal wall influence the placement of the incision as well as its length. How to Perform Chest Compressions | CPR Technique | OSCE Guide, Abdominal Surgical Incisions and the Rectus Sheath. Witch hazel helps to soothe the area and relieve irritation. The McBurney incision has largely been supplanted by the Rockey-Davis incision, which is oriented transversely as opposed to obliquely, allowing for better cosmesis (Fig. Join the Geeky Medics community: They evaluate the degree of the tear and check for complications. Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. Technique for Classical CS - Obstetrical Surgical Skills If the peritoneum is inadvertently entered, it is closed immediately. Division of the rectus and medial portions of the lateral abdominal muscles. The paired rectus abdominis muscles originate from the anterior bony pubic bones toward the midline and run cephalad to insert onto the xiphisternum and costal cartilages of ribs 5-7. Abdominal Incision: Vertical Midline. This article will review the techniques for, as well as the rationale and disadvantages of, common incisionsboth longitudinal and transverseto help the gynecologic surgeon minimize morbidity and maximize outcomes. 1977;112:1188.-, 9. Hendrix SL, Schimp V, Martin J. The choice of abdominal surgical incision is determined largely by access. A. Examination of the anesthetized patients abdomen will often reveal a mass, guiding placement of the incision directly over the appendix. - Medical Finals Question Pack: https://geekymedics.com/medical-student-finals-questions/ Patterns include vertical (midline and paramedian) incisions and transverse incisions (Pfannenstiel-Kerr, Joel-Cohen, Misgav Ladach, and Modified Misgav Ladach). B. Incision of the rectus sheath. Am J Surg. Surg Clin North Am. Mayo Clinic, Rochester, Minn. Sept. 7, 2018. Appropriate alignment of the closure is facilitated by initial placement of interrupted sutures at the edge of the rectus muscle, junction of the transverse and vertical portions of the incision, and superior aspect of the vertical incision. These advantages and disadvantages are summarized in Table 84.1 (for low transverse incisions) and Table 84.2 (for high transverse incisions). If the patient is obese or if extension of the incision is anticipated, the incision should be placed obliquely, allowing ready lateral extension. Incision location is particularly important. Within the abdomen lie the majority of the digestive tract and associated structures such as the liver, biliary tree, pancreas, kidneys and ureters, and the occasional pair of surgeons hands. However, the procedure is still used in certain cases. Advertising on our site helps support our mission. Facebook: http://www.facebook.com/geekymedics Generic early complications declare themselves in the hours and days following the operation and may include atelectasis, postoperative pneumonia, urinary tract infection, oliguria, bedsores and deep vein thromboses. DO NOT perform any examination or procedure on patients based purely on the content of these videos. This type of tearing extends through the anal sphincter and into the mucous membrane that lines the rectum. As the recti have a segmental nerve supply, it can be cut transversely without weakening a denervated . Such hand-assisted laparoscopic approaches are frequently associated with shorter operative times than are purely laparoscopic approaches and may have particular advantages for operations in which a larger incision is necessary to remove the surgical specimen (eg, laparoscopic colectomy) and more complex procedures.15 The initial step of any laparoscopic procedure is the establishment of pneumoperitoneum. kidneys Separate incision in posterior rectus allows buttressing of wound 2. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. Disadvantages Big Scar Very painful post-op Higher risk of wound breakdown Uses Emergency lapartotomy Almost all abdominal operations where full access is required Paramedian incision Uses Access to specific half of abdomen Advantages Access to lateral structures E.g. E. Lateral retractors are placed for exposure. Still, the procedure is sometimes needed. Use of this Web site is subject to the medical disclaimer. Pericostal sutures are placed to reapproximate the ribs. E. Peritoneum opened. However, when it comes to dissecting the underlying subcutaneous tissues, the debate continues over whether a scalpel or electrosurgery is best. A. The corkscrew position, with the thorax in the lateral position and the abdomen at 45 degrees from the horizontal plane. Sometimes the incision is more extensive than a natural tear would have been. Check out our NEW quiz platform at app.geekymedics.com, To be the first to know about our latest videos subscribe to our YouTube channel . PDF Ventral Midline Celiotomy in Horses Advantages and Disadvantages It is commonly used for open cholecystectomy. The theoretical advantage of a paramedian over a midline incision is a diminished risk of wound dehiscence and incisional hernia owing to the presence of rectus muscle interposed between layers of divided fascia. Alternatively, vertical incisions may be placed in a paramedian position, an approach that was previously more popular than it is today but continues to have its proponents. B. MidlineTechnique. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.). 6. There are two types of episiotomy incisions: Episiotomy recovery is uncomfortable. Some also believed it could prevent complications like urinary incontinence and pelvic floor dysfunction. Box 2. The incision is then carried down to the linea alba using either electrocautery or a scalpel; the decussation of fascial fibers in the upper abdomen serves as an important landmark for the midline. Nothing should compromise this, and a larger incision or even, on occasion, a second incision, should be created without hesitation if exposure is inadequate.