2. 8 cm) to the lateral epicondyle and then to the posterior border of the ulna (ca. - Character 02:14 In a subsequent systematic review assessing the efficacy of closure techniques, which included 23 randomized controlled trials (nine involving the use of prophylactic mesh), the authors noted that in elective midline closure, the use of a slowly absorbable suture material for continuous closure with the small-bite technique resulted in significantly less incisional hernias than a large-bite technique did. Probably because of this he had less problems with postoperative tetany. Maingot's Abdominal Operations. Make a gently curved skin incision directly over the middle of the lateral condyle, initially 6-8 cm, extending proximally or distally if needed. Mkel JT, Kiviniemi H, Juvonen T, Laitinen S. Factors influencing wound dehiscence after midline laparotomy. A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ The lower abdominal muscle splitting approach is often chosen in case of open appendectomy or for specimen retrieval during laparoscopic surgery. Only one prospective randomized controlled trial has been conducted to determine the value of this practice, and the authors found no significant differences in complications between closure and nonclosure. The incision is centred over McBurneys point two-thirds of the distance between the umbilicus and the right anterior superior iliac spine (ASIS), where the base of the appendix is most likely to be found. Suture material is chosen. The subcostal incision is also used for access to the liver for wedge resections; for the adrenal gland on either side; and the spleen if on the left side. 2 (6083):351-2. Trends in open abdominal surgery in the United States-Observations from 9,950,759 discharges using the 2009-2013 National Inpatient Sample (NIS) datasets. It is used for radial head excision, removal of loose bodies, and repair of lateral ligaments, to fix condylar and Monteggia fractures, to release the joint capsule, and to remove osteophytes. Ann Surg. 284 (6320):931-3. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTk2MTc4OS10ZWNobmlxdWU=, Those with increased tension on the incision, Early planned reexploration of the peritoneal cavity, Unacceptable abdominal wall tension with conventional closure, Intraoperative instability necessitating a rapid temporary closure. The Joel-Cohen incision is widely used by obstetricians. However, the . [Full Text]. Exposure of the fascia is often enhanced with the use of S-shaped retractors. It is appropriate for certain operations on the liver, gallbladder and biliary tract. 167-92. Previous abdominal operation. 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. 8:89-94. The falciform ligament of the liver is commonly encountered if the incision is made to the right of the midline, and the tendinous intersections must be divided on the chosen side in order to access the peritoneum. By visiting this site you agree to the foregoing terms and conditions. In general surgery, the routinely usedincisions include the Lanz incision and midline incision. Chapters: 1 The intent of this chapter is to detail the surgical approaches that are useful for total knee arthroplasty. New York: McGraw-Hill; 2019. 15th ed. Do not place retractors around the radial neck. It can be difficult to identify precise intervals proximally because of confluence of fibers in the common extensor origin. Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Kao LS, et al, eds. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoscopic and Robotic SurgeonsDisclosure: Nothing to disclose. The inferior aspect of the fascial incision was grasped with Kocher clamps, elevated, and the underlying rectus muscles were . Wound dehiscence more commonly occurs in the first 1-2 weeks following definitive fascial closure of the abdominal wall, during the early stages of tissue healing. The initial incision used by Kocher was lateral along the anterior border of the sternomastoid muscle or vertical . The Kocher incision is not to be confused with the Kocher Maneuver, which describes the mobilization of the second and third portion of the duodenum and the pancreatic head. Indian J Med Sci. Point defects in the aponeurotic intersections of the linea alba may facilitate the development of epigastric hernias, which often simply contain preperitoneal fat but are often disproportionately painful for their size owing to their high tendency to strangulate. [QxMD MEDLINE Link]. A Kocher incision is made parallel to the subcostal margin to access the underlying liver and biliary tree. The primary advantage of this method is that multiple suture strands exist, so that if a suture breaks, the incision is held intact by the remaining sutures. Pronation of the forearm will move the nerve further from the plane of dissection. Kocher's incision - An oblique incision made in the right upper quadrant of the abdomen, classically used for open cholecystectomy. This allows us to get in touch for more details if required. Share cases and questions with Physicians on Medscape consult. Further advantages include the ease with which the incision may be extended either cephalad or caudally in order to improve access. Subcostal Also called upper oblique, Kocher's incision Gallbladder and biliary tract surgery Paramedian Upper R side (biliary tract, gallbladder) Upper L side (splenectomy, gastrectomy) Lower R side (small bowel resection) Lower L side (sigmoid colon resection) Midline Upper and lower abdominal incision Abdominal surgeries . The Maylard incision is placed higher than the Pfannenstiel incision, resulting in the possibility of extending it into a larger incision and gaining more exposure. In continuous fascial closure, two Kocher clamps are clamped to the fascial layer midway through the incision and then retracted by the assistant. Impaired Wound Healing. A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. . Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ 2001 Mar. - PSA Question Pack: https://geekymedics.com/psa-question-bank/ Agrawal CS, Tiwari P, Mishra S, Rao A, Hadke NS, Adhikari S, et al. Kocher's studies on one of his patients, who was operated on in 1874, led to an early discovery. 249 (4):576-82. The paramedian incision (no. Philadelphia: Elsevier; 2015. Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. Instagram: https://instagram.com/geekymedics 1987 Aug. 74 (8):738-41. Kocher incision: subcostal incision made parallel to the costal margin, starting below the xiphoid and extending laterally; used to access the gall bladder; these subcoastal incisions provide good abdominal viscera exposure and good healing. [16] and in a controlled clinical randomized trial. [QxMD MEDLINE Link]. [39] with abdominal wound dehiscence (burst abdomen) and incisional hernia as the primary outcomes. 2016 Jul. 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). This information is intended for medical education, and does not create any doctor-patient relationship, and should not be used as a substitute for professional diagnosis and treatment. This incision is also commonly utilised by vascular surgeons for elective and emergency repair of abdominal aortic aneurysms. The effect of damage control laparotomy on major abdominal complications: A matched analysis. Duttaroy DD, Jitendra J, Duttaroy B, Bansal U, Dhameja P, Patel G, et al. Guidelines for the prophylactic use of retention sutures are imprecise at best. Vol 2: 1549-66. 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. Of these, transverse incisions follow Langer lines of skin tension. Abdominal Wall Incision - Kocher - How to approach the abdominal cavity using a Kocher incision 2,005 views Oct 18, 2021 55 Dislike Incision 6.82K subscribers Notice You're signed out of. Perioperative Antirheumatic Drug Guideline Contains Caveats, 8-Week TB Treatment Strategy Shows Potential, Physicians of the Year 2022: Best and Worst, Clinical Approach to Chronic Wound Management in Older Adults. [40] They also noted that using interrupted sutures for closure of laparotomy incisions in this setting reduced the risk of abdominal wound dehiscence to less than 33%. Management strategy for dirty abdominal incisions: primary or delayed primary closure? The aponeurotic components of the sheath interdigitate in a thickened fibrous midline raphe between the two recti known helpfully as the linea alba (white line). The cookie is used to store the user consent for the cookies in the category "Performance". New York: McGraw-Hill; 2016. Patients should be cautioned to avoid lifting, pushing, or pulling anything heavier than 10 lb (~4.5 kg) and generally to avoid any type of straining (increased abdominal pressure) as much as possible for 4-6 weeks after surgery. Incisional hernia did not occur in either group. Unlike the midline incision, it is not an avascular plane. An oblique incision made in the right lower quadrant of the abdomen, classically used for. Lanz incision A variation of the traditional Mc Burney's incision, which was made at, McBurney incision / gridiron incision Described in 1894 by McBurney, used for appendectomy. Kizy S, Ikramuddin S. Abdominal wall, omentum, mesentery, and retroperitoneum. and the abdominal wall is closed in layers, except atthe lower angle of the incision, a small . They should be educated on signs and symptoms of incisional hernia and should be encouraged to contact the surgeon postoperatively in the presence of any of the following (any of which may portend postoperative complications): Short-term complications include wound infection and dehiscence. Advise the patient should be advised to seek advice if any signs of infection or wound dehiscence. Chevron incision This incision is a cut made on the abdomen below the rib cage. Zwart HJ, de Ruiter P. Subcuticular, continuous and mechanical skin closure: cosmetic results of a prospective randomized trial. The Lanz and Gridiron incisions are two incisions that can be used to access the appendix, predominantly for appendicetomy. 32-9. In liver surgery, the Kocher subcostal incision, i.e., the right subcostal oblique incision, is often used, which has the advantages of hepatic mobilization and vascular control. Tenderness at McBurney's point; Muscle guard and rebound tenderness over the appendix; Appendicectomy is usually performed through a muscle-splitting incision in the right iliac fossa. generic complications of surgery vs those specific to the operation, and presenting as immediate, early or late complications. Kocher elevator Kocher approach Kocher artery forceps Kocher biliary tract incision Kocher bladder retractor Robin-Lersundi A, Vega Ruiz V, Lpez-Moncls J, Cruz Cidoncha A, Abella Alvarez A, Melero Montes D, et al. The rectus abdominis muscle is supplied by the superior Access to the radiohumeral articulation has been . Surgical incisions are planned based on the expected extent of exposure needed for the specific operation planned. The intent of this chapter is to provide an overview of body tissues, surgical incisions, and surgical site closure. You can check out our guide to using SOCRATES here: https://geekymedics.com/the-socrates-acronym-in-history-taking/ Revisions: 25. Risk factors that could influence the choice of abdominal cavity approach are risk of incisional hernia, pain, bleeding, and infection. [1] ; however, a few consensus techniques are generally used. Join the Geeky Medics community: 1990 Jan. 77 (1):107. [Full Text]. [QxMD MEDLINE Link]. 4th ed. Laparoscopic method. 10 (2):129-36. Often, having the assistant cross the. Zinner MJ, Ashley SW, Hines OJ, eds. Evidence-based recommendations have been developed for the use of negative-pressure wound therapy (NPWT) in the setting of the open abdomen. Wound infection. [42] The aim of the study was to assess the incidence of wound infection and wound dehiscence. Use the information in this article to help you with the answers. Current practice of abdominal wall closure in elective surgery - Is there any consensus?. 4-1 ). Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. Neth J Surg. Alternatively, an upper midline incision can be used when other concomitant operations are planned and a wider exposure is needed. [46], Regardless of the method used for temporary abdominal closure, the primary aims must be to protect the abdominal viscera and to maintain sterility. Kocher's Subcostal Incision Frequently, a right subcostal incision is used for open operations in the gallbladder, liver, and biliary system, particularly in obese or muscular individuals with wide costal angles ( Figs. The small-bite technique (in which the distance between the suture and the wound edge is reduced to 5-8 mm and the distance from stitchto stitch is reduced to 5 mm from the fascial edge) has been assessed in an experimental study DONT FORGET these 3 key components of the cardiovascular exam for your upcoming OSCEs Save this video to watch later and dont forget to follow Geeky Medics! right subcostal/kocher cholecystectomy paramedial incision; heals stronger sigmoid surgery median incision over linea alba, more likely to herniate trauma--quicker thoracoabdominal esophagoduodenostomy McBurney incision appendectomy Fill in the Blank Exercise 14.02 . Although in theory this may stand, a paucity of data exists regarding the significance of closing the subcutaneous fat. [QxMD MEDLINE Link]. Typically, the midline incision remains above the umbilicus, still . Williams Z, Hope WW. Kocher himself, however, recognized the logic behind utilizing as small an incision as possible and is quoted as saying thyroidectomy incisions should be "as small as possible, as big as necessary," therefore perhaps qualifying him as the first minimally invasive surgeon. - Associated symptoms 03:04 The Kocher incision is a subcostal incision on the right side of the abdomen used for open exposure of the gallbladder and biliary tree. The. The incision runs 2-5cm lateral to the midline, cutting through the skin, subcutaneous tissue, and the anterior rectus sheath. This method uses 3 to 4 very small incisions. 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. A surgical incision is an aperture into the body to permit the work of the operation to proceed. The cookie is used to store the user consent for the cookies in the category "Other. Incisions through the anterolateral wall will, therefore, breach the following structures: As the fibres of the lateral abdominal wall muscles progress medially they give rise to fibrous sheets of tissue known as aponeuroses, allowing a far wider area of insertion than would be achievable with the typically round tendons seen on muscles of the appendicular skeleton. [Full Text]. 216 (1):56-59. Due to its continuation with Langers lines, the Lanz incision produces much more aesthetically pleasing results with reduced scarring. 1996 Feb. 162 (2):125-9. [Full Text]. A collection of anatomy notes covering the key anatomy concepts that medical students need to learn. There are still occasions where an open approach is required for speed, ease of access to relevant structures or in situations where laparoscopic equipment is unavailable. Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure: a meta-analysis. We use cookies to improve your experience on our site and to show you relevant advertising. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. 1977 Oct. 64 (10):733-6. The goal is approximation of tissue edges to allow scar formation. 1992 Nov. 79 (11):1172-3. 136 (3):272-5. layers of the abdominal wall inside out: peritoneum transversalis fascia transversus abdominus muscle internal oblique muscle external oblique muscle scarpa's fascia subcutaneous fat skin (camper's fascia, dermis, epidermis) time out has been completed and the incision is made with visual oozing of blood noted, what would you pass Surg Infect (Larchmt). However, a few studies have reported surgical treatment for TAMH, and the optimal surgical procedure remains controversial. 97), 1735-1756. Andrew Howard, Theddy Slongo, Peter Schmittenbecher. When rectus muscle is incorporated, using absorbable suture and a loose closure in order to decrease postoperative pain and tissue necrosis is important. We also use third-party cookies that help us analyze and understand how you use this website. Often, having the assistant cross the Kochers allows for better visualization for the surgeon. Occasionally, circumstances may dictate that permanent closure of the abdomen is contraindicated. The open approach involves the creation of a small incision, generally 1.5 cm, through which the abdominal fascia is grasped with straight clamps and elevated toward the wound. The skin incision is placed approximately 3 cm below and parallel to the costal margin. The elbow is an unforgiving articulation with significant bony congruity and a . You also have the option to opt-out of these cookies. Avoid dissection distal to the annular ligament or strenuous retraction because the posterior interosseous nerve, lying within the supinator muscle, is at risk. ) is a subcostal incision used to gain access for the gall bladder the biliary tree. The needle is then passed through the loop locking the stitch in order to anchor the knot or tied if it is not a looped suture. The cookie is used to store the user consent for the cookies in the category "Analytics". Closure of the uterine incision is done in 3 layers. 2003 Feb. 109 (2):130-7. Luis G Fernndez, MD, KHS, KCOEG, FACS, FASAS, FCCP, FCCM, FICS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Legal Medicine, American College of Surgeons, American Society of Abdominal Surgeons, American Society of General Surgeons, American Society of Law, Medicine & Ethics, American Trauma Society, Association for Surgical Education, Association of Military Surgeons of the US, Chicago Medical Society, Illinois State Medical Society, International College of Surgeons, New York Academy of Sciences, Pan-American Trauma Society, Society of Critical Care Medicine, Society of Laparoscopic and Robotic Surgeons, Southeastern Surgical Congress, Texas Medical Association, Undersea and Hyperbaric Medical SocietyDisclosure: Received honoraria from KCI for speaking and teaching; Received honoraria from PACIRA for speaking and teaching; Speaker / teaching honoraria for URGO -Stedmed North America. [Full Text]. They derive their blood supply from the superior and inferior epigastric arteries from the internal thoracic and external iliac arteries respectively, and their innervation from the anterior rami of spinal nerve roots T7-T12. Kocher's incision II: Tranverse incision over the thyroid for glandular removal Br J Surg. 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. This field is for validation purposes and should be left unchanged. Chap 36. The Lanz incision was designed to be more cosmetically subtle than the gridiron, with the benefit that it may be hidden beneath the bikini line but the disadvantage of commonly severing the ilioinguinal and iliohypogastric nerves. Am J Surg. Millbourn D, Cengiz Y, Israelsson LA. Roughly one-third to halfway between the umbilicus and the pubic symphysis lies the arcuate line (of Douglas), which is the point at which the posterior elements of the sheath perforate to join the anterior sheath and leave the thickened transversalis fascia in direct contact with the rectus muscles. Some common incision sites are discussed below. A review of the current literature addressing the techniques used in emergency laparotomy fascial closure appears to suggest that the interrupted suture method may offer some benefit in decreasing the incidence of early postoperative wound dehiscence. Divide the annular ligament, if intact, in line with the muscle interval. Using SOCRATES in History Taking | OSCE | Communication Skills, Abdominal Surgical Incisions and the Rectus Sheath. Am J Surg. Ann Surg. [19] Subcutaneous closure may be accomplished with absorbable suture in an interrupted or continuous fashion. 1. Kocher/Subcostal Incision The Kocher incision is a subcostal incision on the right side of the abdomen used for open exposure of the gallbladder and biliary tree. This can be accomplished as either a layered or a mass closure (see the image below). It is an optimal way for emergencies, as opening the abdomen should not take longer than 40-60 seconds. The rectus muscle was then pulled medially. It is also used by general and urological surgeons for some pelvic procedures such as radical open prostatectomy or cystectomy. Indian J Surg. The median length of the midline incision was slightly longer (12 vs. 10 cm, p < 0.05). To repair the lateral thigh dermal tissue area, a local skin flap was obtained, and a blade thick skin graft was used. [QxMD MEDLINE Link]. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. This approach is commonly used for procedures requiring emergency laparotomy, such as in faecal peritonitis secondary to malignant intestinal perforation or in cases of ischaemic bowel. Abdomen layers & surgical incisions Dr.Abhishek Reddy K 2k views SURGICAL INCISIONS ON ABDOMINAL WALL bhabajyoti 548 views skin incisions Kutty Saravanan 12.5k views Abdominal incisions sarwatmisbah 30.8k views Surgical incisions RiyaBaghele 221 views Surgeries human system training Deepak Mudgil 2.9k views [Full Text]. . It does not store any personal data. The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. Wound dehiscence following midline laparotomy is a particularly distressing event for the patient, whereby classically a serosanguinous discharge is noted from the wound 7-10 days postoperatively, and a day or so later the whole wound may burst open and spill the patients intestines into their lap. Temporary abdominal closure with polytetrafluoroethylene prosthetic mesh in critically ill non-trauma patients. Advertisement cookies are used to provide visitors with relevant ads and marketing campaigns. The effect is to alleviate the tension on the primary suture line. The average length of the incision is approximately 24 to 30 inches. An elastic defect in this raphe may allow the fascia to stretch and abdominal contents to bulge forward through the resulting divarication of the recti. . In a 2008 meta-analysis (23 studies; N = 10,900) Gupta et al compared continuous and interrupted techniques in abdominal wound repair, A Kocher incision (no. Theyinvolve passing through all of the abdominal muscles, transversalis fascia, and then the peritoneum, before entering the abdominal cavity. In a study comparing scar cosmesis at 6 months, no difference in appearance existed in patients with suture versus staple skin closure. [41] The authors concluded that interrupted closure of abdominal-wall fascia was better than continuous closure in the setting of emergency laparotomy. . (Kocher approach) to access to the radial head and the disrupted LCL. . [4] Continuous absorbable suture may be used. It is commonly used for open cholecystectomy. The port sites will vary depending on the surgery being performed, yet the umbilicus is nearly always utilised as a port site to allow the camera to pass through. The Pfannenstiel incision is a firm favourite of obstetricians for accessing the gravid uterus for which a curvilinear incision is made through the skin and subcutaneous fat, then a longitudinal incision made in the linea alba. A collection of data interpretation guides to help you learn how to interpret various laboratory and radiology investigations. Kocher Manoeuvre A wide Kocher maneuver is next performed with leftward reflection of the duodenum and head of the pancreas which allows near complete exposure of the portal vein and associated structures. [QxMD MEDLINE Link]. Treasure Island, FL: StatPearls; 2021. Excessive tension leads to tissue necrosis and eventual failure of the closure. This crosses the posterior radius, from anteriorly, three patient finger breadths distal to the radial head. [QxMD MEDLINE Link]. Nobel Laureate in Medicine 1909 "for his work on the physiology, pathology and surgery of the thyroid gland" (Courtesy of Nobelprize.org) Full size image. It provides good exposure for biliary and bariatric surgery and can be extended bilaterally if needed. The key principles of making surgical incisions are: Once the operation is over, surgical excisions can be closedby sutures, staples, steri-strips, tissue glue, or a combination of these agents. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. 2014 Aug. 76 (4):270-6. 1231 patients were treated with the classical Kocher's incision, whereas in 125 cases the minimal cer vical access was. [30] ; more recently reported figures have been in the range of 1-3%. The skin is the largest and heaviest organ of the body. 2009 Apr. Image courtesy of Wikimedia Commons. Named after Emil Theodor Kocher. S ummary of Layers to be Incised: . Bruhin A, Ferreira F, Chariker M, Smith J, Runkel N. Systematic review and evidence based recommendations for the use of negative pressure wound therapy in the open abdomen. most common type of incision associated with wound dehiscence followed by Kocher's incision (18%) and Mcburney's incision (10%). Am J Surg. A prospective randomised study. [29], In the past, abdominal midline surgical wound dehiscence rates as high as 10% were reported BackgroundIn focal congenital hyperinsulinism (CHI), surgery is the gold standard of treatment, even for lesions localized in the head of the pancreas. [QxMD MEDLINE Link]. Kocher's Incision: It is oblique in nature, extending from the abdominal upper right quadrant and is generally used for performing an open cholecystectomy. Am J Surg. ) is used for a wide array of abdominal surgery, as it allows the majority of the abdominal viscera to be accessed. This is most often due to a failure of proper wound healing. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. Interrupted or continuous slowly absorbable sutures for closure of primary elective midline abdominal incisions: a multicenter randomized trial (INSECT: ISRCTN24023541). Ueber die Vortheile des suprasymphysren Fascienquerschnitts fr die gynkologischen Koeliotomien. This cookie is set by GDPR Cookie Consent plugin. The posterior sheath is formed by the posterior leaf of the internal and the transversus abdominis aponeuroses and bears the superior and inferior epigastric arteries and their anastomotic network. Membranes are ruptured by toothed or Kocher's forceps. Bansiwal RK, Mittal T, Sharma R, Gupta S, Singh S, Abhishek K, et al. This cookie is set by GDPR Cookie Consent plugin. Corman ML, Veidenheimer MC, Coller JA. See the full course for free here: https://www.incision.care/free-trialSURGICAL OBJECTIVESThe surgical objective of any abdominal cavity approach is optimal exposure of the abdominal cavity for the indicated operation with minimal risk of complications. Surgical Incision is a cut made through the skin to facilitate an operation or precedure. The recti are interrupted by three paired tendinous intersections anchoring them to the anterior sheath, broadly found close to the xiphisternum, at the level of the umbilicus and then halfway between the two. J Surg Res. [Full Text]. Outcomes of primary fascial closure after open abdomen for nontrauma emergency general surgery patients. New York: McGraw-Hill; 2019. The sheath overlying the rectus muscles at the symphysis pubis is released, 4cm transversely, and the incision angled up to the lateral borders of the rectus muscles. Risk factors for wound dehiscence can be: Late complications include the development of an incisional hernia, where the underlying peritoneum and associated contents protrude through residual defects in the abdominal wall, and the formation of dense fibrotic intra-abdominal band adhesions. Br J Surg. Surgical Incisions Their Anatomical Basis Section: Thoracic Incisions: H. J. Pfannenstiel. 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