Surgical Incisions

Question 1

Give examples of common surgical incisions used in obs and gynae practice.

Answer 1

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

Question 2

What is the “rectus sheath” in the abdomen and why is it clinically relevant to surgical incision?

Answer 2

• immediately deep to superficial fascia
• Made up of combined aponeuroses of anterolateral abdominal wall muscles
• surrounds rectus abdominis muscles
• strong, fibrous layer stitched closed after operation
  => increase strength of the wound
  => reduce complications e.g. incisional hernia

Question 3

Which of the anterior or posterior rectus sheath will be cut during a caesarean section incision?

Answer 3

anterior rectus sheath will be cut

Question 4

What is the nerve supply to the anterolateral abdominal wall, and why is this clinically relevant to surgical incision?

Answer 4

• 7th-11th intercostal nerves
  (thoracoabdominal)
• subcostal (T12)
• iliohypogastric (L1)
• ilioinguinal (L1)
• May be injured during surgery

Question 5

What is the blood supply to the anterolateral abdominal wall?

Answer 5

• Anterior abdominal wall
  => superior epigastric arteries (from internal thoracic)
  => inferior epigastric arteries (from external iliac artery)

Lateral abdominal wall
- intercostal and subcostal arteries (from posterior intercostal arteries)

Question 6

How should surgeons aim to minimise traumatic injury to muscle fibres whilst completing an incision?

Answer 6

incise in same direction as muscle fibre

Question 7

The rectus abdominis muscles are not cut in a lower segment caesarean section incision. TRUE/FALSE?

Answer 7

TRUE

• Rectus muscles are not cut
• separated from each other in lateral direction
• moving them toward their nerve supply

Question 8

What layers must be passed through during an LSCS incision?

Answer 8

• Skin and fascia
• (anterior) Rectus sheath
• separate Rectus abdominis laterally
• Fascia and peritoneum
• Retract bladder (urinary catheter already inserted)
• Uterine wall
• Amniotic sac

Question 9

What layers must be stitched closed after completion of an LSCS incision?

Answer 9

• Uterine wall with visceral peritoneum
• Rectus sheath
• Fascial layer if increased BMI
• Skin

Question 10

What layers are incised into and stitched back up during a laparotomy procedure?

Answer 10

Incise

• Skin and fascia
• Linea alba
• Peritoneum

Layers to stitch closed:

• Peritoneum & Linea alba
• Fascia (if increased BMI)
• Skin

Question 11

Why is healing poorer in a midline incision?

Answer 11

• lack of good blood supply
  => poor healing
  => increases chance of wound complications e.g. dehiscence, incisional hernia

Question 12

How many ports are normally needed if a laparoscopic approach is being used?

Answer 12

• sub-umbilical incision may be all that is required

- sometimes a lateral port is required

Question 13

What structure must be avoided if a lateral port is needed?

Answer 13

inferior epigastric artery
- emerges medial to deep inguinal ring
(half way between ASIS and pubic tubercle)

• passes in superomedial direction posterior to the rectus abdominis

Question 14

How can the position of the uterus be manipulated during a laparoscopic procedure?

Answer 14

Manipulated by grasping cervix with forceps inserted through the vagina

Question 15

What is an abdominal hysterectomy and what incision is used to complete this procedure?

Answer 15

• removal of uterus via incision in the abdominal wall

- same incision as for LSCS

Question 16

What is a vaginal hysterectomy?

Answer 16

removal of uterus via the vagina

Question 17

How can the ureter and the uterine artery be differentiated during hysterectomy?

Answer 17

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