Issues of Concern
Abdominal Incisions
Midline
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The midline abdominal incision, frequently used for exploratory laparotomy, including trauma surgery, involves a longitudinal cut through the avascular plane of the linea alba, providing relatively bloodless access to the abdominopelvic cavity. This incision is particularly advantageous in emergency surgeries, offering extensive exposure from the xiphoid process to the pubis, making it a preferred choice for wide access.[8][9]
Periumbilical
Supra- and infraumbilical incisions navigate the tissues around the umbilicus, avoiding the umbilical stalk. Infraumbilical incisions are often incorporated into vertical midline incisions within the linea alba, or they may be transverse or semilunar, commonly used in open umbilical herniorrhaphy or immediate postpartum bilateral tubal ligation. Supraumbilical incisions are sometimes favored for open umbilical herniorrhaphy in patients with prior infraumbilical surgeries. During umbilical herniorrhaphy, a flap that includes the umbilicus is usually created to preserve the umbilical stalk and the overlying skin. Additionally, the periumbilical area is a common access point for laparoscopy.[10]
Pararectus
The pararectus incision is made along the semilunar line, lateral to the rectus abdominis muscle, where the lateral aponeuroses meet the rectus sheath. This approach is utilized to repair certain abdominal wall hernias, pelvic orthopedic surgeries, or when creating a stoma. In stoma creation, the rectus abdominis muscle is either retracted or split, and the peritoneum is divided to allow passage through the abdominal wall.[11][12]
Paramedian
The paramedian incision, typically placed lateral and parallel to the linea alba, offers access to lateral viscera. This incision can be positioned just lateral to the linea alba, penetrating the rectus muscle or near the lateral border of the rectus sheath, about 3 cm lateral to the midline. Above the arcuate line, the anterior rectus sheath and rectus muscle are retracted laterally, exposing the posterior rectus sheath. Ligation of peripheral branches of the inferior epigastric artery may be necessary. This approach is associated with a lower incidence of incisional hernia than the midline incision.[13]
Kocher or Subcostal
The Kocher incision, a subcostal incision made inferior and parallel to the costal margin, primarily provides access to the gallbladder, biliary tree, pancreas, duodenum, and vena cava. Bilateral Kocher incisions, known as Chevron incisions, are sometimes extended superiorly at the midline in a Mercedes Benz modification for liver transplants or epigastric pathology requiring greater exposure.[14] Although the Chevron incision may disrupt the bilateral superior epigastric arteries, collateral circulation from perforating branches of the oblique muscles and the inferior epigastric artery generally maintains blood supply to the abdominal wall. However, ligation of the inferior epigastric artery could jeopardize this vascular supply.[15]
Unlike the midline incision, the subcostal approach is not avascular and requires ligation of the superior epigastric artery branches within the rectus muscle. The incision extends through multiple layers, including the rectus fascia, muscle, and peritoneum. Other vessels encountered during this incision include the perforating intercostal and external oblique arteries.[15]
The plane between the peritoneum and the transversus abdominus muscle is well-defined lateral to the semilunar line, whereas, medially, the peritoneum may be affixed to the posterior rectus sheath. Intercostal nerves run between the internal oblique and transversus abdominus muscles, and excessive dissection in that plane risks denervation of muscles and subsequent hernia formation.[16]
When creating a subcostal incision, staying a few centimeters below the costal margin is important to ensure enough fascia for closure. Meticulous hemostasis and preservation of nerves will reduce complication risk. Postoperative pain may be increased with division of the rectus muscle. The incision is closed in a layered fashion by approximating muscle and fascial layers.[16][17]
Gridiron, McBurney, and Lanz
The gridiron or McBurney incision is made in the lower abdomen and can be performed on either side. When done on the right, it has traditionally been used for open appendectomies for acute appendicitis, while the left-sided version is used for conditions like sigmoid diverticulitis. The incision is perpendicular to a point one-third of the distance from the anterior superior iliac spine to the umbilicus, and dissection proceeds through multiple layers, including the external oblique, internal oblique, transversus abdominus, transversalis fascia, and peritoneum. The superficial epigastric artery and perforating branches of the inferior epigastric artery may require ligation.
The Lanz incision, a transverse cut made at the same location as the right-sided gridiron or McBurney incision, follows Langer lines while using the same anatomical landmarks. This incision serves as an alternative approach for open appendectomy and is often preferred because it tends to result in less scarring compared to the gridiron incision.[18][19]
Thoracoabdominal
A thoracoabdominal incision provides exposure to the lower thoracic cavity, the upper abdomen, and the retroperitoneum. Beginning at the seventh intercostal space, the incision runs obliquely to the costal margin before continuing longitudinally along the abdomen to the umbilicus.[20] This incision provides excellent exposure to the pleural space, distal esophagus, lateral abdominal organs, great vessels, kidneys, and adrenal glands. Right-sided thoracoabdominal incisions expose the hepatic region, and left-sided incisions provide access to the stomach and distal esophagus.[21][22] The thoracoabdominal incision is thought to be particularly well suited to address large retroperitoneal masses.[22]
Positioning during a thoracoabdominal incision is tailored to the surgical focus, with variations in patient positioning depending on the target anatomy. For example, for operations on the distal esophagus, the patient is placed in a right lateral decubitus position for a left thoracoabdominal incision. In contrast, the upper esophagus is accessed via a right thoracoabdominal incision with the patient placed in a left lateral decubitus position. Access to the perirenal aorta requires a left chest bump and pelvic rotation.[20]
The incision typically starts 1 to 2 cm below the tip of the scapula, with the latissimus and serratus anterior muscles divided down to the chest wall, and the chest entered by cutting through the intercostal muscles over the eighth rib. Following pleural incision and lung packing, the diaphragm and costal margin cartilage are divided, and the abdomen is entered through lateral retraction of the rectus muscles and division of the posterior sheath. Thoracoabdominal incisions are contraindicated in patients with significant lung pathology.[23][24]
Thoracic Incisions
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Thoracotomy
A thoracotomy incision allows surgeons to access various structures within the thoracic cavity, with the specific placement of the incision depending on the intended procedure. The anterolateral approach, commonly utilized in lung transplantation and other upper thoracic surgeries, provides excellent exposure to the upper lobe, right middle lobe, and anterior hilum. This approach can be performed bilaterally without the need for a sternotomy in the case of bilateral lung transplantation. A left anterolateral thoracotomy is typically employed in cases of penetrating thoracic trauma, aortic arch repair, or cross-clamping of the thoracic aorta. On the other hand, a right-sided anterolateral thoracotomy is often used for certain cardiac repairs and initial or reoperative cardiac valve surgeries.
During an anterolateral thoracotomy, the patient is positioned supine. The incision begins at the fourth or fifth intercostal space, extending along the submammary crease from the lateral border of the sternum to the anterior axillary line. The pectoral muscles, serratus anterior, and intercostal muscles are divided. In some cases, additional incisions or extensions may be required to gain further access, such as a left supraclavicular incision for controlling an injury to the left subclavian artery.[25]
The clamshell incision, an extension of the anterolateral thoracotomy to the opposite side with a transverse division of the sternum, offers additional exposure when necessary. The clamshell incision is often used in penetrating trauma, particularly with suspicion of multiple injuries, when the location of an injury is uncertain, or at the hands of a clinician unaccustomed to navigating the thorax. The clamshell provides rapid access to a quickly deteriorating trauma patient.[25]
Posterolateral thoracotomy is another approach to accessing pulmonary structures, including the hilum, middle and posterior mediastinum, pulmonary vessels, thoracic trachea, and esophagus.[26][27][28] The patient is placed in a lateral decubitus position, and the incision is made at the anterior axillary line in the fifth or sixth intercostal space, extending around the scapula posteriorly and along the rib line anteriorly. The latissimus dorsi muscle is divided perpendicular to its fibers for functional closure, while the serratus anterior is retracted. Although this incision provides excellent exposure, it is known to be quite painful and can impair respiratory mechanics due to the division of respiratory muscles.[29][30][31]
There are many variations in approaches with which to access the thoracic cavity. One example is the vertical right axillary minithoracotomy that begins high in the axilla along the anterior border of the latissimus and divides the serratus anterior, exposing the third or fourth rib. With this incision, the patient is often extubated in the operating room instead of perhaps days later in the intensive care unit. Associated benefits include early feeding and mobilization, early adoption of nonnarcotic pain control, shortened hospital stay, and fewer activity restrictions. Additionally, the wound infection rate is significantly lower than sternal wound infections.[32]
Median Sternotomy
The median sternotomy is a vertical incision dividing the sternum, providing wide access to the mediastinum and pleural cavity. This incision also allows surgical access to the aorta, superior vena cava and branches, carotid arterial branches to the head, upper extremities, and epigastric region while also providing access to the lower trachea and main stem bronchi and is used for resection of anterior mediastinal tumors. This incision is the most commonly used incision for open-heart surgery and is also utilized for the resection of anterior mediastinal tumors.[33]
The median sternotomy remains the preferred incision for most cardiac surgeries because it offers excellent visibility and access to the heart and associated structures. The incision is made along the midline of the sternum, extending from the sternal notch to the xiphoid process. The pectoral fascia is divided between the pectoralis muscles following the skin incision. The transverse venous arch of the jugular vein is clipped, and ligaments at the clavicle and sternum are carefully divided to allow for unimpeded division of the sternum.[33]
In some cases, the sternotomy incision may be extended into the abdomen or supraclavicular space for additional exposure. This extension is useful for accessing structures such as the origin of the right subclavian artery, in managing wide-scope trauma, or, for example, gaining proximal and distal control of a blood vessel.[33] While the median sternotomy provides excellent access, it has some disadvantages, including poor cosmetic outcomes, a relatively high incidence of deep wound infections, delayed healing, and potential nonunion. Additionally, the incision may negatively impact respiratory mechanics.[34]
Many innovations and modifications of the traditional median sternotomy have been implemented in the modern surgical era. In those with an amenable body habitus, a smaller skin incision still permits full division of the sternum. Hybrid approaches are becoming more common, including collaboration between interventionists using percutaneous routes and surgeons using small open or videoscopic surgical techniques. Examples include an approach for a hypoplastic left heart, pulmonary valve replacement in the setting of a dysfunctional right ventricular outflow tract, and intraoperative pulmonary stenting.[35]
Trapdoor
The trapdoor incision is a complex combination of a supraclavicular, sternal, and thoracotomy incision, encircling the pectoral area. This incision starts in the supraclavicular position, extends down the sternum, and continues across the inframammary crease, opening a “door” to the pleural space, the mediastinum, the cervical vasculature, and the heart.[36][37][38] This incision has largely been dismissed as too morbid but is occasionally required to control bleeding from penetrating trauma and may be used for aortic arch aneurysms. This degree of exposure may be necessary in persons with a larger body habitus.
Infraclavicular
The infraclavicular incision is primarily used to gain access to the subclavian vessels. The incision is made transversely through the skin and subcutaneous tissues, parallel to and just below the clavicle. In cases where access to the distal subclavian artery is also needed, a supraclavicular incision may be added. The infraclavicular approach offers good exposure to the first rib, making it useful for operations addressing thoracic outlet syndrome. The incision is made approximately 2 fingerbreadths below the clavicle, and the pectoralis major muscle is split, while the attachment of the pectoralis minor is divided to expose the axillary fat pad, subclavian vein and artery, and brachial plexus.[39][40]
Supraclavicular
The supraclavicular incision provides access to the distal subclavian vessels, either in the setting of trauma or elective surgery, and is also used as an approach to thoracic outlet syndrome, providing good access to the anterior scalene muscle. This incision can be connected with others, such as a sternotomy or cervical incision, to provide greater cervical or thoracic anatomy exposure.[41][42]
The incision begins superior to the clavicle at the distal attachment of the sternocleidomastoid muscle, extending laterally and posteriorly for several centimeters to the medial border of the trapezius muscle. Care is taken along the medial aspect of the incision to avoid the internal and external jugular veins. The platysma muscle is incised, and platysmal flaps are developed, allowing access to the anterior scalene muscle, the jugular vein, and the subclavian artery. This procedure requires special attention to handle the phrenic nerve and brachial plexus.[1][41][42][43]
Neck Incisions
The choice of neck incision depends on the clinical context. The neck is a small area dense with critical vessels, nerves, and muscles, and the mandible and base of the skull may restrict access. The neck is classically divided into anatomic zones, particularly in trauma settings, but advancements in imaging and the availability of endovascular interventions have led to a shift in how these zones are approached.[44][45]
A collar incision is typically used for procedures involving midneck structures, such as the thyroid. This incision is placed within a skin crease about 2 finger breadths above the sternal notch, and a platysmal flap is carefully created to avoid the external jugular vein. This approach offers good exposure and a cosmetically favorable outcome, though some surgeons prefer a lateral incision for unilateral procedures. Transaxillary endoscopic lobectomy is gaining popularity in thyroid surgery due to its lower risk of injury to the recurrent laryngeal nerve and improved cosmetic results.[46][47][48][49]
When exploring the neck for traumatic injuries, an incision is made along the anterior border of the sternocleidomastoid muscle, extending through the subcutaneous tissue and platysma. The sternocleidomastoid muscle is retracted laterally to expose the carotid sheath, with the facial vein serving as a useful landmark as it crosses the carotid artery bifurcation. For proximal vessel access, the incision may be extended into a sternotomy or continued to the angle of the mandible for distal access. Where feasible, endovascular intervention is also considered.[50] Open tracheostomies are performed through a vertical or horizontal incision superior to the thyroid over the second or third tracheal rings. A percutaneous tracheostomy can often be performed instead, requiring a smaller skin incision, usually done at the bedside.[51]
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Pelvic Incisions
Pfannenstiel
The Pfannenstiel incision is common for Cesarean section and other pelvic, urologic, and orthopedic surgeries. This transverse lower abdominal incision is made 2 finger breadths above the pubic symphysis, extending towards the anterior superior iliac spines. After dissecting the subcutaneous fat, the anterior rectus sheath is divided transversely. The rectus muscle is then separated vertically along the midline, preserving the muscle fibers, and the peritoneum is entered vertically.[52]
The risk for a postoperative subcutaneous hematoma following a Pfannensteil incision is associated with poor hemostasis of the inferior epigastric vessels. One study’s results cited a 6% incidence of postoperative hematoma from either the inferior or superficial epigastric artery. While this incision offers limited surgical exposure confined to the pelvis, it has a low hernia rate and favorable cosmetic outcomes. Additionally, study resul suggest that the incidence of chronic incisional pain is lower with this incision compared to a vertical midline incision.[52][53][54]
Maylard and Cherney
The Maylard incision, positioned parallel and superior to the Pfannenstiel incision about 6 to 8 cm above the pubic tubercle, is used for accessing pelvic structures in procedures like hysterectomies or lymph node dissections. This incision is made transversely, cutting through the bilateral rectus abdominis, the linea alba, and the internal and external oblique muscles, extending laterally to the edge of the rectus or medial oblique muscles. The inferior epigastric vessels are identified and ligated.[55] Compared to a vertical midline incision, the Maylard incision is associated with a lower incidence of hernias, particularly in obese individuals, and provides better exposure to pelvic structures. The Cherney incision, a variant of the Maylard, involves transecting the rectus muscle transversely from its pubic attachments and retracting it superiorly to gain access to the lower pelvis and retroperitoneum.[53]
Inguinal
The inguinal incision is the standard approach for open inguinal hernia repair. The incision is made approximately 1 cm above and parallel to the inguinal ligament, cutting through the subcutaneous fat and superficial fascia layers to reach the external oblique muscle. The external oblique aponeurosis is then opened, extending laterally for several centimeters from the external ring of the inguinal canal. The superficial epigastric vein is often encountered and ligated during this procedure. This incision is also used in urologic surgeries such as cryptorchidism and varicocele repairs.[56]
McEvedy
The McEvedy incision, now largely obsolete, was traditionally used for femoral hernia repair. This vertical incision is made along the lateral edge of the rectus muscle down to the level of the femoral canal. During the repair, the rectus muscle is retracted medially, providing access to the preperitoneal space and, if necessary, the peritoneum. Given the proximity of the femoral nerve, artery, and vein, careful dissection is required in this area. The McEvedy incision fell out of favor due to its high rate of incisional hernias.[57][58]
Gibson
The Gibson incision begins 3 cm above and parallel to the inguinal ligament, medial to the anterior superior iliac spine, and extends in an arc to the lateral border of the rectus sheath. This incision is used to access the retroperitoneum, exposing the iliac vessels, ureter, and the psoas muscle. This incision is most commonly employed in kidney transplantation.[59][60][61]
Laparoscopic Incisions
Minimally invasive surgery has transformed surgical practice by significantly reducing recovery times, morbidity, and postoperative pain by providing an effective reoperation approach, as it allows access to tissue planes free of scars and adhesions from prior surgeries. Various laparoscopic entry techniques include the Veress needle, optical port, and Hasson trocar. These methods have been extensively studied for their success rates and risk of injury. A comprehensive review of 57 randomized controlled trials found no significant differences in safety or efficacy among these techniques.[62]
The most common entry point for laparoscopic surgery is the umbilicus, but when access here is not feasible, the left upper abdomen is often chosen as an alternative site. An optical port allows laparoscope insertion through a bladed trocar, providing direct visualization during abdominal entry after an initial skin incision. The Veress needle method estimates the thickness of the abdominal wall and confirms its position with a saline test once the needle is presumed to be in the peritoneal cavity. The Hasson trocar technique involves dissecting through the abdominal wall and placing the trocar under direct visual and tactile guidance. Once the pneumoperitoneum is established and the laparoscope is inserted, additional trocars are placed under direct visualization. Decompression of the stomach and bladder is recommended before any initial trochar insertion.[63]
Recent advancements in laparoscopic surgery include single-incision ports, where all instruments are introduced through a single 12 mm incision. Variations of this technique include using fascial bridges to prevent carbon dioxide leakage or specialized port devices with multiple entry points that maintain a seal while allowing separate instrument access. However, single-port laparoscopic surgery has been linked to a higher incidence of incisional hernias compared to traditional laparoscopic methods.[64][65][66][67]
Minimally invasive techniques have also been increasingly adopted in thoracic surgery, where they are used to optimize patient outcomes by reducing hospital stays and surgical morbidity. These techniques, which minimize muscle division, have been shown to produce comparable surgical results to more invasive approaches while promoting faster recovery, better cosmetic outcomes, and overall improved quality of life. For instance, the right axillary minithoracotomy, commonly used in pediatric congenital heart defect repairs, has proven safe, with low complication and reoperation rates and excellent cosmetic results. This technique has become the standard approach in some medical institutions due to its effectiveness in accelerating patient recovery.[32]
Incisions for Robotic Surgery
Over the past 2 decades, robotic surgery has become increasingly available and versatile, allowing for the robotic management of many complex conditions, such as tracheobronchomalacia, thoracic outlet syndrome, paraesophageal hernia, esophagectomy, and even lung transplantation. Robotic surgery offers the benefits of faster recovery and reduced postoperative pain. With proper training, surgeons can achieve greater precision and outcomes comparable to or better than traditional open surgery.[68][69]
The first robotic mitral valve repair was performed in 1998 by Alain Carpentier using a Da Vinci system, which has subsequently been used for bypass grafting, valve repair, and congenital defects, in addition to more complex procedures such as a 2-patch repair of a right partial anomalous pulmonary venous connection and repair of a sinus venosus atrial septal defect. Robotic-assisted thoracic surgery has shown potential advantages, including more effective lymph node dissection in oncological procedures.[70][71] Transoral robotic surgery, first reported in 2005, has become a standard approach for treating tumors of the tongue base, oropharynx, hypopharynx, parapharyngeal space, and supraglottic larynx and addressing obstructive sleep apnea. The Da Vinci system is primarily used for these procedures, offering precise and minimally invasive access to difficult-to-reach areas.[72][73]
Natural Orifice Surgery
Natural orifice surgery involves accessing the pelvis or peritoneal cavity through a natural body opening, such as the stomach or uterus, rather than creating an external incision. This technique aims to achieve scarless surgery, although its use remains limited and primarily experimental. One of the main challenges is ensuring optimal closure of the access site, which has prevented this approach from becoming standard practice and has largely confined it to the research domain.[74]
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