Anatomy and Physiology of the Skin… The skin is the largest and heaviest organ

of the body. The two main layers that compose the integument are ….

Epidermis Dermis The combined thickness of the epidermis

and dermis ranges from 4 mm and 1.5 mm .

Epidermis…. The epidermis is the outermost layer. It contains no organs, glands, nerve

endings, or blood vessels. It renews itself every 15 to 30 days.

Epidermal layers are.. Stratum corneum Stratum lucidum Stratum granulosum Stratum spinosum Stratum basale

The dermis is composed of papillary and reticular layers of flexible connective tissue.

The dermis contains pain and touch receptors, glands, blood vessels, and lym-phatics . It is the key layer in wound repair and tissue healing.

Dermis….

Surgical Incision…. A cut made through the skin to facilitate an

operation or precedure.

It should be the aim of the surgeon to employ the type of incision considered to be the most suitable for that particular operation to be performed. In doing so, three essentials should be achieved :

1. Accessibility 2. Extensibility 3. Security

Natural line of tension correspond to the natural orientation of collagen fibers in the dermis .

Generally parallel to the orientation of the underlying muscle fibers.

Austrian anatomist, Karl Langer (1819-1887) described how incisions could be more cosmetic if natural cleavage lines were followed when planning the surgical incision.

The angle of the incision should be no more than 30 degrees at each margin .

Langer’s Line …

A correct incision provides..◦ a large area to easily

permit dissection◦Repair of lesions ◦Heal Rapidly◦Without scars limiting

mobility◦Preserve sensation◦Avoid painful scars

Correct Incisions…

They are responsible for ◦An Insufficient access

◦Necrosis ◦Contractures◦Painful scars

Incorrect incisions….

Surgical Landmarks and Quadrents …

Placement of the Surgical Incision … Before the procedure begins, the surgeon chooses

the most suitable incision for the procedure being performed. Certain things of consideration are ….

• Condition of the patient.• Knowledge of previous surgery. • Natural lines of tissue tension (Langer’s lines) .• Maximum exposure of surgical site and adjacent structures .• Ability to extend the incision if necessary .• Minimum trauma and scar formation.• Least postoperative discomfort.

Layer of Anterior Abdominal Wall.. Skin Subcutaneous tissue Superficial Fascia Deep Fascia(Gallaudet’s Fascia) Musculoaponeurotic Layer -External Oblique Muscle -Internal Oblique Muscle -Transverse Abdominal Muscle -Rectus Abdominis-Pyramidalis Muscle Fascia Transversalis Preperitoneal Fatty Tissue Peritoneum.

Abdominal Surgery….

Vertical Incisions….1) Midline Incision Almost all operations in the

abdomen and retroperitoneum Advantages : - almost bloodless - no muscle fibers are divided - no nerves are Injured - good access to upper

abdominal viscera - very quick to make as well

as to close -can be extended full lenght of

abdomen curving around umblical scar.

Vertical Incisions…..2) Paramedian Incisions Has 2 theoretical

advantages: -it offsets vertical Incision

to right or left, providing access to lateral str. such as spleen or kidney-closure is theoretically more secure because rectus muscle can act as a buttress between reapproximated posterior and anterior fascial planes. is placed 2 to 5 cm lateral to midline

2) Paramedian Incision Disadvantages: 1. It tends to weaken and strip off the muscles from its lateral

vascular and nerve supply resulting in atrophy of the muscle medial to the incision.

2. The incision is laborius and difficult to extend superiorly as is limited by costal margins.

3. It doesn’t give good access to contralateral structures.

Vertical Incisions…..

Transverse Incisions….1)Kocher Subcostal Incision It affords excellent exposure

to gall bladder and biliary tract and can be made on left side to afford access to spleen.

İs started at midline , 2 to 5 cm below the xiphoid , and extends downwards , outwards and paralel to and about 2.5 cm below costal margin

Especially used in cholecystectomy.

2) Transverse Muscle dividing In newborn and infants , this incision is preferred bcs

more abdominal exposure is gained per lenght of incision than with vertical exposure

Because infants’ abdomen longer transverse than vertical girth.

Also true of short, obese adult

Transverse Incisions….

Transverse Incisions….3) McBurney Incision (muscle split ) İncision of choice most

appendicectomies The level and lenght of incision will

vary according to thickness of abd. wall and suspected position of apendix.

is made at the junction of middle third and outer third of a line running from umblicus to anterior superior iliac spine,McBurney point.

Originally placed the incision obliquely from above laterally to below medially.

Also used in left lower quadrant to deal with certain lesion of sigmoid colon such as drainage of diverticular abscess.

Transverse Incisions…..

4) Oblique Muscle Cutting Incision. Eponym of Rutherford- Morrison Incision Extension of McBurney incision by division of oblique

fossa Can be used for right and left sided colonic resection,

caecostomy or sigmoid colostomy..

Transverse Incisions…..

Transverse Incision …..

5) Pfannenstiel Incision Used frequently by gynecologist and urologist for

access to pelvic organ, bladder, prostate and for c-section.

is usually 12 cm long and is made in skin fold approximately 5 cm above symphysis pubis.

Transverse Incisions…

6) Maylard Transverse Muscle Cutting Incision gives excellent exposure to pelvic organ Skin incision is placed above but parallel to traditional

placement of Pfannenstiel incision ..

Transverse Incisions …..

Thoracoabdominal Incisions…

Either right or left Converts pleural and peritoneal cavities into one

common cavity Thereby gives excellent exposure Right incision may be particularly useful in elective and

emergency hepatic resections Left incision may be used in resection of lower end of

esophagus and proximal portion of stomach. Incision is extended along line of 8th intercostal space,the

space immediately distal to inferior pole of scapula.

Thoracoabdominal Incisions…

Methods of wound closure include sutures, staples, clips, tapes, and glues.

Everting sutures: These interrupted (individual stitches) or continuous (running stitch) sutures are used to evert skin edges.

a. Simple continuous (running): This suture can be used toclose multiple layers with one suture. The suture isnot cut until the full length is incorporated into thetissue (see Fig. 28-8, A).b. Continuous running/locking (blanket stitch): A single suture is passed in and out of the tissue layers and looped through the free end before the needle is passed through the tissue for another stitch. Each new stitch locks the previous stitch in place.

Wound Closure….

Methods of suturing….

c. Simple interrupted: Each individual stitch is placed, tied, and cut in succession from one suture (see Fig. 28-8, C).

d. Horizontal mattress:

Stitches are placed parallel to wound edges. Each single bite takes the place of twointerrupted stitches (see Fig. 28-8, D).

e. Vertical mattress: This suture uses deep and superficial bites, with each stitch crossing the wound at right angles. It works well for deep wounds. Edges approximate well (see Fig. 28-8, E).

2. Inverting sutures:

These sutures are commonly used for two-layer anastomosis of hollow internal organs, such as the bowel and stomach. Placing two layers prevents passing suture through the lumen of the organ and creating a path for infection. A single layeris placed for other structures, such as the trachea, bronchus, and ureter. The edges are turned in toward the lumen to prevent serosal and mucosal adhesions. The number of layers is proportional to the quality of the blood supply. Stitches can be interrupted or continuous.

Endoscopic sutures are available as ligatures and preknotted loops or with curved or

straight, permanently swaged needles for use through an endoscope.

The ligatures are fashioned into loosely knotted loops

before being passed through the endoscope to tie off vessels and tissue pedicles. After the loop is placed around the target site, the knot is slid into position and tightened. The ends are cut with endoscopic scissors and removed through the endoscope.

Endoscopic suturing….

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