Described abdominal and pelvic incision: (1) Kocher incision, (2) midline incision, (3) Mc Burney incision, (4) Battle incision, (5) Lanz incision, (6) paramedian incision, (7) transverse incision, (8) Rutherford Morrison incision, (9) Pfannenstiel incision
Kidneys, adrenals, prostate and bladder may be accessed by different approaches. A clear example is a kidney mass that may be resected partially while considering a flank incision (traditional way) or even a trans-abdominal sub-costal approach too. It depends also on surgeon’s preference, and patient’s anatomy.
The goal of this chapter is to review the standard and most commonly performed surgical incisions and highlight some tips while performing these open surgical approaches to the pelvis in urological surgery [1–4].
A midline abdominal incision can be used to access the abdominal cavity above or below the umbilicus. The incision is quick to perform and it results in minimal blood loss, owing to the avascular nature of the linea alba. The exposure of the abdomen as a whole is excellent. Extensions, when required, can easily be made superiorly or inferiorly, providing access to the whole abdominal cavity, including the retro-peritoneum. All these properties render the midline approach suitable for emergency and exploratory laparotomy of the abdominal cavity.
As illustrated in Fig. 31.2, a vertical incision is made through skin, subcutaneous fat and Scarpa’s fascia, linea alba, and peritoneum if needed. The exact location of the incision in the linea alba is based on the decussation of the fibers of the external oblique aponeurosis, thus serving as a surgical landmark. About one third of the distance from the umbilicus there is a demarcation line called the arcuate line. Above this line, the aponeurosis of the three flat muscles (external, internal and transversalis muscles) of the abdominal wall split into two lamina, one above and one below the rectus muscle (anterior and posterior sheaths, respectively). Below the arcuate line, the three aponeuroses pass above the rectus muscle, and only a thin transversalis fascia layer covers the rectus posteriorly. Consequently, when doing a extraperitoneal pelvic surgery, like retropubic prostatectomy or cystotomy, the transversalis fascia is incised below the arcuate line and swept up starting behind the symphysis pubis towards the umbilicus. Conversely, if a transperitoneal approach is utilized, like in a radical cystectomy, the posterior sheath is incised near the umbilicus giving early access to the peritoneal space. Exposure is obtained by separating the rectii using a self-retaining retractor.
The midline incision: (a) Patient is in supine position, Trendelenburg position may be utilized to gain better exposure to the deep pelvis. (b) In urologic surgery, infra-umbilical incision is made. The linea alba is appreciated by the decussation of external oblique fibers. If entry of peritoneum is desired, incision of arcuate line and ligation of urachus are done. (c) Tight closure is ensured by approximating the anterior rectus sheath. If desired, a drain may be exited from a separate stab incision across abdominal wall
The midline incision is generally preferred by all surgical specialties because of its ease, speed and excellent exposure. However, midline incisions can be associated with increased postoperative pain as compared to transverse or oblique incisions. Furthermore, it has a higher rate of incisional hernias as compared to lateral paramedian, oblique or transverse incisions.
Gibson incision is a crucial incision that gives an excellent exposure to the iliac fossa and the lower third of the ureter. It is mainly used in renal transplantation, in order to expose the iliac vessels, and is also ideal for any unilateral distal ureteral procedure when full exposure of the bladder is not needed.
Points of Technique
The patient is placed in supine position, with the lumbosacral junction flexed. The table is therefore gently flexed accordingly, to provide a better exposure. A curvilinear incision is initiated with a scalpel, 2 cm medial to the antero-superior iliac spine and aiming infero-medially one finger breadth above the inguinal ligament, to the lateral border of the rectus abdominis muscle. Some surgeons prefer to perform a “hockey stick” extension across the midline, around 2 cm above the pubic bone, in order to gain a better access to the bladder. The incision is then deepened down to the fascia using electrocautery. The external oblique aponeurosis is then reached and exposed with retractors. It is then carefully incised parallel to the course of its external oblique muscle fibers. The external oblique muscle fibers are then split apart, and gently retracted to expose the internal oblique aponeurosis, which is incised following the course of its fibers. The internal oblique muscle is split to expose the aponeurosis of the transversus abdominis muscle. The transversus abdominis is gently opened with blunt dissection and retracted. A self-retaining retractor or a fixed ring retractor may be used at this level. For a better exposure, the surgeon is advised to consider incising through the lateral border of the rectus muscle, or dissecting the tendinous attachment of the rectus muscle from the pubic symphysis. Peritoneal attachments are dissected off the pelvic wall, adjacent to the deep inguinal ring, Continuous gentle dissection is made to expose the peritoneum superiorly and medially, towards the umbilicus, allowing access to the retroperitoneal structures. The assistant’s hand is important for reflecting then peritoneum, after incising the transversalis layer, and allowing a better medial exposure of the iliac vessels at the level of their bifurcation, and of the ureter. Wide exposure can be obtained by placing a Bookwalter retractor. The surgeon is advised to sometimes consider ligating the epigastric vessels in order to allow a better exposure. The surgeon is now able to identify the ureter and dissect it out of the retro-peritoneum. The ureter itself needs to be cautiously manipulated, by avoiding pinching it; instead, peri-ureteral tissues may be grabbed, and a vessel loop may be placed around the ureter. In some instances, it is useful to leave a drain in place, although many kidney transplant surgeons do not leave any drainage. Closure should be done layer by layer, starting by approximating the tendinous attachments of the rectus muscle, in case it was divided, with an absorbable suture (type Vicryl). A running suture is similarly applied on the respective muscles of the abdominal wall, and for Scarpa’s fascia. Skin is closed with a running absorbable suture (Fig. 31.3).