Anatomy of Surgical Incisions for O&G

Question 1

What common O&G surgical incisions are there?

Answer 1

Lower segment Caesarean section (LSCS)
Laparotomy
Laparoscopy
Abdominal (and vaginal) hysterectomy

Question 2

What is a laparotomy?

Answer 2

A vertical midline incision

Question 3

What are other names for a lower segment Caesarean section (LSCS)?

Answer 3

Suprapubic / pfaffenstiel / “bikini-line” incision

LSCS, abdominal hysterectomy

Question 4

Label this diagram

Answer 4

Question 5

Describe where the external obliques attach

Answer 5

Attach between lower ribs and iliac crest, pubic tubercle and linea alba

Fibres run in same direction as external intercostals

Question 6

Label this

Answer 6

Question 7

Where do the internal obliques attach?

Answer 7

Attach between lower ribs, thoracolumbar fascia, iliac crest and linea alba

Linea alba

Fibres run in same direction as internal intercostals

Question 8

Label this

Answer 8

Question 9

Describe where the transverses abdominis attaches

Answer 9

Attach between lower ribs, thoracolumbar fascia, iliac crest and linea alba

Linea alba

Question 11

Describe the tendinous intersections of rectus abdominis

Answer 11

Divide each rectus abdominis
3 or 4 smaller muscles

Question 12

Describe the linea alba. Where does the linea alba run?

Answer 12

Formed by the interweaving of the muscle aponeuroses
Runs from the diploid process to the pubic symphysis

Question 13

Describe what the rectus sheath is and where it is

Answer 13

Immediately deep to superficial fascia
Combined aponeuroses of anterolateral abdominal wall muscles
Surrounds rectus abdominis muscles

Question 14

When undertaking a suprapubic incision, i.e. LSCS, where will rectus sheath be incised?

Answer 14

Anteriorly

Question 15

Label this diagram

Answer 15

Question 16

Describe nerve supply to anterolatal abdominal wall

Answer 16

Enter from lateral direction

7-11th intercostal nerves (become thorax-abdominal nerves)

Subcostal (T12)
Iliohypogastric (L1)
Ilioinguinal (L1)

Question 17

Describe blood supply to anterior abdominal wall

Answer 17

Superior epigastric arteries
- Continuation of internal thoracic artery
- Emerges at superior aspect of abdominal wall

Inferior epigastric arteries
- Branch of external iliac artery
- Emerges at inferior aspect of abdominal wall

Question 18

The superior epigastric arteries are a continuation of?

Answer 18

Internal thoracic artery

Question 19

The inferior epigastric arteries are a branch of?

Answer 19

External iliac artery

Question 20

The intercostal and subcostal arteries are a continuation of?

Answer 20

Posterior intercostal arteries

Question 21

Describe blood supply to the lateral abdominal wall

Answer 21

Intercostal and subcostal arteries
- Continuations of posterior intercostal arteries
- Emerge at lateral aspect

Question 22

What surface anatomy changes occur during pregnancy?

Answer 22

Question 23

Describe what precautions should be intake when incising muscle in a O&G surgical incision

Answer 23

Minimise traumatic injury to muscle fibres - incise in same direction as muscle fibre

Avoid damaging nerves - especially motor nerves

Avoid interrupting blood supply

Question 24

Describe what happens to the rectus muscles in a LSCS

Answer 24

Rectus muscles are not cut
Separated from each other in a lateral direction

Question 25

What layers are opened when doing an LSCS incision?

Answer 25

Skin + fascia
Anterior rectus sheath
Rectus abdominis
Fascia and peritoneum
Retract bladder
Uterine wall
Amniotic sac

Question 26

What layers do we stitch closed in a LSCS incision?

Answer 26

Uterine wall with visceral peritoneum
Rectus sheath
Skin

Question 27

What layers do we open in a laparotomy?

Answer 27

Skin + fascia
Linea alba
Peritoneum

Question 28

What layers do you stitch closed in a laparotomy?

Answer 28

Peritoneum + linea alba
Fascia skin

Question 29

Describe blood loss in a midline incision

Answer 29

Relatively bloodless
Increases the chance of wound complications e.g. dehiscence, incisional hernia

Question 30

Label this diagram

Answer 30

Question 31

What kind of incision is this?

Answer 31

Question 32

What kind of incision can you do in a laparoscopy?

Answer 32

A sub-umbilical incision may be all that is required

If a lateral port is required, care must be taken to avoid the inferior epigastric artery

Question 33

If a lateral port is required in a laparoscopy, what artery must be avoided?

Answer 33

Inferior epigastric artery

Question 34

To view the pelvic organs in a laparoscopy, the position of the uterus can be manipulated how?

Answer 34

By grasping the cervix with forceps inserted through the vagina

Question 35

What kind of incisions are these?

Answer 35

Question 36

The inferior epigastric artery is a branch of?

Answer 36

External iliac artery

Question 37

Where does the inferior epigastric artery emerge?

Answer 37

Just medial to the deep inguinal ring

Question 38

Where does inferior epigastric artery pass?

Answer 38

In a supermedial direction posterior to rectus abdominis

Question 39

Label this

Answer 39

Question 40

What is an abdominal hysterectomy?

Answer 40

Removal of the uterus via an incision in the abdominal wall

Question 41

What is a vaginal hysterectomy?

Answer 41

Removal of uterus via the vagina

Question 42

During hysterectomy, extreme care must be taken to differentiate what?

Answer 42

The ureter from the uterine artery

The ureter passes inferior to the artery (“water under the bridge”)
The ureter will often “vermiculate/wiggle” when touched