INCISIONS
FLANK INCISION
FLANK INCISION HIGH YIELD FACTS
Remember vessels/nerves are underneath each rib.
The 12th rib medially will point to the position of the renal hilum.
You cut through latissimus and possibly serratus anterior over rib.
Summary of Layers to be Incised:
• Skin
• Adipose tissue
• Scarpa’s fascia
• Adipose tissue
• External oblique muscle
• Internal oblique muscle
• Transversalis abdominis muscle
• Transversalis fascia
The 12th rib medially will point to the position of the renal hilum.
You cut through latissimus and possibly serratus anterior over rib.
Summary of Layers to be Incised:
• Skin
• Adipose tissue
• Scarpa’s fascia
• Adipose tissue
• External oblique muscle
• Internal oblique muscle
• Transversalis abdominis muscle
• Transversalis fascia
FLANK INCISION STEPS
The 12th rib medially will point to the position of the renal hilum.1
11th vs. 12th rib approach depends on habitus and tumor/kidney location
11th vs. 12th rib approach depends on habitus and tumor/kidney location
- Incise skin, adipose, scarpa's along the length, 11th rib incision goes from rib to lateral border of rectus mm.
- (if excising 11th rib, incise mm fibers on top down to bone, use periosteal elevator momving medial to lateral, use costal elevator to free rib posteriorly, clamp with Kocher and rib cutter, can use bone wax to smoothen surface.
- Deepen the lateral aspect down to the rib through latissimus and serratus anterior (if present) and external oblique on medial aspect of rib
- Divide medial portion incision moving lateral toward medial on abdominal wall mm
- Divide intercostal tissue, remember vessels/nerves are underneath each rib.
- Divide internal oblique mm, then tranversus abdominis mm, then transversalis fascia & enter retroperitoneal.
- Push peritneum anterior and medial with spongestick. If you open the peritneum can run 3-0 chromic.
- Place retractor
FLANK INCISION CLOSURE
4 layers
1-Transversus abdominis with internal oblique muscle along with their fascias. Start laterally and work medially b/c mm separation easier to see laterally. Resorpable 0
2- External oblique mm/fascia. Lateral to medial. If some ext. oblique closed in 1st layer, do not have to extend fully medially. Resorpable 0
3 - Subcutaneous interupted 2-0
4. Skin closure
1-Transversus abdominis with internal oblique muscle along with their fascias. Start laterally and work medially b/c mm separation easier to see laterally. Resorpable 0
2- External oblique mm/fascia. Lateral to medial. If some ext. oblique closed in 1st layer, do not have to extend fully medially. Resorpable 0
3 - Subcutaneous interupted 2-0
4. Skin closure
FLANK INCISION COMPLICATIONS
Pneumothorax, especially if 11th rib incision too posteriorly.
Place chest tube or bubble out air and close defect: place 12fr, purse string, place foley in bowl of saline, place in trendelenburg, hold in max inspiration and repeat until bubbling stops, remove catheter while simultaneously tying purse string suture. f/u x-ray
Place chest tube or bubble out air and close defect: place 12fr, purse string, place foley in bowl of saline, place in trendelenburg, hold in max inspiration and repeat until bubbling stops, remove catheter while simultaneously tying purse string suture. f/u x-ray
- AUA CORE CURRICULUM Incisions. Accessed 9/24/18
SUBCOSTAL INCISION
SUBCOSTAL INCISION HIGH YIELD FACTS
Preferred when vena cava access is necessary (ie thrombus or need for early clamping of hilum-bleeding, medial tumors, fear of intravascular spread).
Epigastric runs posterior to rectus mm-suture ligate this
The 12th rib medially will point to the position of the renal hilum.
Summary of Layers to be Incised:
Epigastric runs posterior to rectus mm-suture ligate this
The 12th rib medially will point to the position of the renal hilum.
Summary of Layers to be Incised:
- Skin
- Adipose tissue
- Scarpa’s fascia
- Adipose tissue
- External oblique muscle
- Internal oblique muscle
- Transversalis abdominis muscle
- Transversalis fascia
- Peritoneum
SUBCOSTAL INCISION STEPS
1. Incise from tip of the 11th rib medially towards the xiphoid process 2-3 fingerbreadths below the ribcage and following its outline. Medial border of the incision is the lateral aspect of the ipsilateral rectus muscle but it can be extended medially by dividing the rectus muscle. Can span both body halves (Chevron incision) for maximum exposure.
2.Incise through skin and dissect the subcutaneous fat
3. Divide the external oblique muscle followed by the internal oblique muscle and then the transversus abdominis from lateral to medial.
4. Can divide ipsilateral rectus muscle (& anterior/posterior rectus sheaths), partially or completely if necessary, although this adds to significant post-operative pain. Elevate the rectus muscle with an Army-Navy inserted underneath to help dissection and avoiding bowel injury. The superior epigastric vessels runs underneath the rectus--suture ligate this.
5. Push peritoneum posteriorly with a finger or spongestick.
6. Incise peritoneum in the center of the incision by elevating it with two forceps cutting with scissors in between them. Insert finger underneath the peritoneum and continue opening with cautery.
7. Place self retaining retractor and begin surgery
2.Incise through skin and dissect the subcutaneous fat
3. Divide the external oblique muscle followed by the internal oblique muscle and then the transversus abdominis from lateral to medial.
4. Can divide ipsilateral rectus muscle (& anterior/posterior rectus sheaths), partially or completely if necessary, although this adds to significant post-operative pain. Elevate the rectus muscle with an Army-Navy inserted underneath to help dissection and avoiding bowel injury. The superior epigastric vessels runs underneath the rectus--suture ligate this.
5. Push peritoneum posteriorly with a finger or spongestick.
6. Incise peritoneum in the center of the incision by elevating it with two forceps cutting with scissors in between them. Insert finger underneath the peritoneum and continue opening with cautery.
7. Place self retaining retractor and begin surgery
SUBCOSTAL INCISION CLOSURE
Typically don't close peritoneum, but can use absorbable suture can be used (e.g. 2-0 chromic).
1st layer is the fascia of the posterior rectus sheath and the fascia of the transversus abdominis and internal oblique muscle can be closed with a thick absorbable suture (ie. 0-loop Maxon) in running fashion.
2nd layer is closure containing the anterior rectus sheath and the external oblique fascia (ie. 0-loop Maxon).
3rd layer is interrupted subcutaneous sutures (ie 2-0 Vicryl).
4th layer is skin, subcuticular running suture or staples.
1st layer is the fascia of the posterior rectus sheath and the fascia of the transversus abdominis and internal oblique muscle can be closed with a thick absorbable suture (ie. 0-loop Maxon) in running fashion.
2nd layer is closure containing the anterior rectus sheath and the external oblique fascia (ie. 0-loop Maxon).
3rd layer is interrupted subcutaneous sutures (ie 2-0 Vicryl).
4th layer is skin, subcuticular running suture or staples.
SUBCOSTAL INCISION COMPLICATIONS
Bowel injury, spleen/liver injury, vena cava or aorta or other vascular injury
- AUA CORE CURRICULUM Incisions. Accessed 10/21/18
THORACOABDOMINAL INCISIONS
THORACOABDOMINAL INCISION HIGH YIELD FACTS
THORACOABDOMINAL INCISION STEPS
THORACOABDOMINAL INCISION CLOSURE
THORACOABDOMINAL INCISION CLOSURE
THE FOLLOWING IS COPY PASTED FROM ABOVE SECTIONS TO BE INCLUDED WHEN USING "COMMAND + F" TO SEARCH THIS PAGE
FLANK INCISION
HIGH YIELD FACTS
Remember vessels/nerves are underneath each rib.
The 12th rib medially will point to the position of the renal hilum.
You cut through latissimus and possibly serratus anterior over rib
Summary of Layers to be Incised:
• Skin
• Adipose tissue
• Scarpa’s fascia
• Adipose tissue
• External oblique muscle
• Internal oblique muscle
• Transversalis abdominis muscle
• Transversalis fascia
INCISION STEPS
The 12th rib medially will point to the position of the renal hilum.1
11th vs. 12th rib approach depends on habitus and tumor/kidney location
CLOSURE
4 layers
1-Transversus abdominis with internal oblique muscle along with their fascias. Start laterally and work medially b/c mm separation easier to see laterally. Resorpable 0
2- External oblique mm/fascia. Lateral to medial. If some ext. oblique closed in 1st layer, do not have to extend fully medially. Resorpable 0
3 - Subcutaneous interupted 2-0
4. Skin closure
COMPLICATIONS
Pneumothorax, especially if 11th rib incision too posteriorly.
Place chest tube or bubble out air and close defect: place 12fr, purse string, place foley in bowl of saline, place in trendelenburg, hold in max inspiration and repeat until bubbling stops, remove catheter while simultaneously tying purse string suture. f/u x-ray
HIGH YIELD FACTS
Remember vessels/nerves are underneath each rib.
The 12th rib medially will point to the position of the renal hilum.
You cut through latissimus and possibly serratus anterior over rib
Summary of Layers to be Incised:
• Skin
• Adipose tissue
• Scarpa’s fascia
• Adipose tissue
• External oblique muscle
• Internal oblique muscle
• Transversalis abdominis muscle
• Transversalis fascia
INCISION STEPS
The 12th rib medially will point to the position of the renal hilum.1
11th vs. 12th rib approach depends on habitus and tumor/kidney location
- Incise skin, adipose, scarpa's along the length, 11th rib incision goes from rib to lateral border of rectus mm.
- (if excising 11th rib, incise mm fibers on top down to bone, use periosteal elevator momving medial to lateral, use costal elevator to free rib posteriorly, clamp with Kocher and rib cutter, can use bone wax to smoothen surface.
- Deepen the lateral aspect down to the rib through latissimus and serratus anterior (if present) and external oblique on medial aspect of rib
- Divide medial portion incision moving lateral toward medial on abdominal wall mm
- Divide intercostal tissue, remember vessels/nerves are underneath each rib.
- Divide internal oblique mm, then tranversus abdominis mm, then transversalis fascia & enter retroperitoneal.
- Push peritneum anterior and medial with spongestick. If you open the peritneum can run 3-0 chromic.
- Place retractor
CLOSURE
4 layers
1-Transversus abdominis with internal oblique muscle along with their fascias. Start laterally and work medially b/c mm separation easier to see laterally. Resorpable 0
2- External oblique mm/fascia. Lateral to medial. If some ext. oblique closed in 1st layer, do not have to extend fully medially. Resorpable 0
3 - Subcutaneous interupted 2-0
4. Skin closure
COMPLICATIONS
Pneumothorax, especially if 11th rib incision too posteriorly.
Place chest tube or bubble out air and close defect: place 12fr, purse string, place foley in bowl of saline, place in trendelenburg, hold in max inspiration and repeat until bubbling stops, remove catheter while simultaneously tying purse string suture. f/u x-ray
SUBCOSTAL INCISION
High Yield Facts:
Preferred when vena cava access is necessary (ie thrombus or need for early clamping of hilum-bleeding, medial tumors, fear of intravascular spread).
Epigastric runs posterior to rectus mm-suture ligate this
The 12th rib medially will point to the position of the renal hilum.
Summary of Layers to be Incised:
Incision
1. Incise from tip of the 11th rib medially towards the xiphoid process 2-3 fingerbreadths below the ribcage and following its outline. Medial border of the incision is the lateral aspect of the ipsilateral rectus muscle but it can be extended medially by dividing the rectus muscle. Can span both body halves (Chevron incision) for maximum exposure.
2.Incise through skin and dissect the subcutaneous fat
3. Divide the external oblique muscle followed by the internal oblique muscle and then the transversus abdominis from lateral to medial.
4. Can divide ipsilateral rectus muscle (& anterior/posterior rectus sheaths), partially or completely if necessary, although this adds to significant post-operative pain. Elevate the rectus muscle with an Army-Navy inserted underneath to help dissection and avoiding bowel injury. The superior epigastric vessels runs underneath the rectus--suture ligate this.
5. Push peritoneum posteriorly with a finger or spongestick.
6. Incise peritoneum in the center of the incision by elevating it with two forceps cutting with scissors in between them. Insert finger underneath the peritoneum and continue opening with cautery.
7. Place self retaining retractor and begin surgery
Closure
Typically don't close peritoneum, but can use absorbable suture can be used (e.g. 2-0 chromic).
1st layer is the fascia of the posterior rectus sheath and the fascia of the transversus abdominis and internal oblique muscle can be closed with a thick absorbable suture (ie. 0-loop Maxon) in running fashion.
2nd layer is closure containing the anterior rectus sheath and the external oblique fascia (ie. 0-loop Maxon)
3rd layer is interrupted subcutaneous sutures (ie 2-0 Vicryl)
4th layer is skin, subcuticular running suture or staples.
High Yield Facts:
Preferred when vena cava access is necessary (ie thrombus or need for early clamping of hilum-bleeding, medial tumors, fear of intravascular spread).
Epigastric runs posterior to rectus mm-suture ligate this
The 12th rib medially will point to the position of the renal hilum.
Summary of Layers to be Incised:
- Skin
- Adipose tissue
- Scarpa’s fascia
- Adipose tissue
- External oblique muscle
- Internal oblique muscle
- Transversalis abdominis muscle
- Transversalis fascia
- Peritoneum
Incision
1. Incise from tip of the 11th rib medially towards the xiphoid process 2-3 fingerbreadths below the ribcage and following its outline. Medial border of the incision is the lateral aspect of the ipsilateral rectus muscle but it can be extended medially by dividing the rectus muscle. Can span both body halves (Chevron incision) for maximum exposure.
2.Incise through skin and dissect the subcutaneous fat
3. Divide the external oblique muscle followed by the internal oblique muscle and then the transversus abdominis from lateral to medial.
4. Can divide ipsilateral rectus muscle (& anterior/posterior rectus sheaths), partially or completely if necessary, although this adds to significant post-operative pain. Elevate the rectus muscle with an Army-Navy inserted underneath to help dissection and avoiding bowel injury. The superior epigastric vessels runs underneath the rectus--suture ligate this.
5. Push peritoneum posteriorly with a finger or spongestick.
6. Incise peritoneum in the center of the incision by elevating it with two forceps cutting with scissors in between them. Insert finger underneath the peritoneum and continue opening with cautery.
7. Place self retaining retractor and begin surgery
Closure
Typically don't close peritoneum, but can use absorbable suture can be used (e.g. 2-0 chromic).
1st layer is the fascia of the posterior rectus sheath and the fascia of the transversus abdominis and internal oblique muscle can be closed with a thick absorbable suture (ie. 0-loop Maxon) in running fashion.
2nd layer is closure containing the anterior rectus sheath and the external oblique fascia (ie. 0-loop Maxon)
3rd layer is interrupted subcutaneous sutures (ie 2-0 Vicryl)
4th layer is skin, subcuticular running suture or staples.