Abdominal Incisions

Question 1

Briefly describe Lanz Incision and Gridiron Incision

Answer 1

The Lanz and Gridiron incisions are two incisions that can be used to access the appendix, predominantly for appendicetomy.

Both incisions are made at McBurney’s point (two-thirds from the umbilicus to the anterior superior iliac spine). They involve passing through all of the abdominal muscles, transversalis fascia, and then the peritoneum, before entering the abdominal cavity.

The Lanz incision is a transverse incision, whilst the Gridiron incision is oblique (superolateral to inferomedial). Due to its continuation with Langer’s lines, the Lanz incision produces much more aesthetically pleasing results with reduced scarring.

Question 2

What incisions are shown in the image?

Answer 2

Lanz (transverse) and Gridiron (oblique) incisions at McBurney’s point.

Question 3

Briefly describe the Midline Incision

Answer 3

The midline incision is used for a wide array of abdominal surgery, as it allows the majority of the abdominal viscera to be accessed.

A midline laparotomy can run anywhere from the xiphoid process to the pubic symphysis, passing around the umbilicus. The incision will cut through the skin, subcutaneous tissue, and fascia, the linea alba and tranversalis fascia, and the peritoneum before reaching the abdominal cavity.

As well as obtaining significant exposure of the viscera, this incision causes minimal blood loss or nerve damage, and can be used for emergency procedures. Its positioning however does make it susceptible to significant scars.

Question 4

Briefly describe the Paramedian Incision

Answer 4

The paramedian incision is rarely performed in the UK. It was originally used to access much of the lateral viscera, such as the kidneys, the spleen, and the adrenal glands.

The incision runs 2-5cm lateral to the midline, cutting through the skin, subcutaneous tissue, and the anterior rectus sheath. The anterior rectus sheath is separated and moved laterally, before the excision is continued through the posterior rectus sheath (if above the arcuate line) and the transversalis fascia, reaching the peritoneum and abdominal cavity.

The incision will take a long time and is often technically difficult, however it does prevent any division of the rectus muscle and provides access to lateral structures. A paramedian incision can damage the muscles’ lateral blood and nerve supply, which may result in the atrophy of the muscle medial to the incision.

Question 5

Briefly describe the Kocher Incision

Answer 5

A Kocher incision is a subcostal incision used to gain access for the gall bladder the biliary tree.

The incision is made to run parallel to the costal margin, starting below the xiphoid and extending laterally. The incision will then pass through the all the rectus sheath and rectus muscle, internal oblique and transversus abdominus, before passing through the transversalis fascia and then peritoneum to enter the abdominal cavity.

Question 6

Briefly describe Chevron/ rooftop incision

Answer 6

Chevron / rooftop incision or modification– the extension of the Kocher incision to the other side of the abdomen.
This may be used for oesophagectomy, gastrectomy, bilateral adrenalectomy, hepatic resections or liver transplantation

Question 7

Briefly describe Mercedes Benz incision/ modification

Answer 7

Mercedes Benz incision or modification- the Chevron incision with a vertical incision and break through the xiphisternum.

This may be used for the same indications as the Chevron incision, however classically seen in liver transplantation.

Question 8

What incisions are shown in the image?

Answer 8

1. Midline incision
2. Paramedian incision
3. Kocher incision
4. Rooftop modification
5. Mercedes Benz modification