(1)
Department of Surgery Division of Surgical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Introduction
With the advent of laparoscopy and other minimally invasive approaches, more and more operations can be performed through small incisions, thereby reducing the morbidity associated with large wounds. Nevertheless, there are instances where laparoscopy is either not feasible or would be unsafe, and an open incision is the best approach.
Several different types of incisions can be used to provide access to the body cavities. In the thorax, the most common incisions are a sternotomy and a thoracotomy. In the abdomen, the vertical midline incision is the most frequently used. Other options include a unilateral or bilateral subcostal (chevron) incision, a paramedian incision, or a Pfannenstiel incision. A thoracoabdominal incision is a single, large incision that spans both body cavities. Each incision has its own advantages and disadvantages; it is up to the surgeon to choose the route of entry that provides the best exposure for the intended operation while limiting morbidity to the patient.
Once the operation is complete, the phases of wound healing begin. Normal wound healing starts with an influx of neutrophils and macrophages that remove bacteria and devitalized tissue by phagocytosis. Next, fibroblasts migrate to the site and begin the work of collagen synthesis, angiogenesis, and re-epithelialization. With time, further remodeling and maturation of the wound occurs. Although the majority of the healing process is complete at 6 weeks, the full strength and final appearance of a wound can take up to 1 year to be fully established.
Many factors contribute to wound healing and must be considered by the surgeon when planning surgery. Severe malnutrition, immunosuppression, recent chemotherapy, chronic steroid use, smoking, and diabetes are all associated with poor wound healing and higher rates of complications. To the degree possible, any such factors should be addressed prior to surgery in order to maximize the chance of normal healing. For example, in certain cases it may be advantageous to delay surgery in order to allow for a period of aggressive nutritional supplementation. In the postoperative period, attention to tight glycemic control in diabetics has been proven to reduce infectious complications.
Surgical Technique
The skin incision is made with a scalpel and carried down through the subcutaneous fat to the underlying fascia (Fig. 2.1). Once the fascia is reached, it is elevated and incised, taking care not to damage any underlying structures. Electrocautery should be used sparingly since necrotic fat promotes infection. When using a midline abdominal incision, it is important to accurately locate the linea alba where the fusion of the aponeuroses of the abdominal muscles occurs (Fig. 2.2). Making the incision through the decussation of fibers avoids the rectus muscles and allows for a stronger fascial closure. For incisions that traverse muscle groups, slow electrocautery should be used to divide the muscle fibers and achieve hemostasis.
Fig. 2.1
Surgical anatomy for abdominal incisions: skin, subcutaneous fat, external oblique muscle, internal oblique muscle, transverses abdominus muscle, preperitoneal fat, peritoneum, decussation of fibers, linea alba, internal mammary artery, superior epigastric artery, external iliac artery, and inferior epigastric artery
Fig. 2.2
Muscles of the anterior abdominal wall. [Reprinted from Prendergast PM. Anatomy of the Anterior Abdominal Wall. In: Shiffman M, Di Giuseppe A. Cosmetic Surgery: Art and Techniques. Heidelberg, Germany: Springer Verlag; 2013: 57-68. With permission from Springer Verlag.]
Upon completion of the operation, different techniques can be used to re-approximate the fascial edges. Typically a single running suture is used from both ends of the incision and tied together at the midpoint. Alternatively, multiple interrupted sutures can be used depending on the setting and surgeon preference. It is not necessary to suture together muscle or subcutaneous fat since the strength of a closure comes from the fascia. In cases where the fascia is of too poor quality to hold sutures reliably, retention sutures can be used. These sutures are placed en masse through the skin and abdominal wall, and provide greater strength to maintain abdominal closure.
In certain situations, the fascia even can be temporarily left open. For example, if the patient is too unstable to remain in the OR, or if there is too much bowel edema present for the fascial edges to reach, then a vacuum dressing can be used. A sterile sponge is placed into the incision and covered with a plastic sheet and is connected to a negative pressure machine. This dressing can be changed every 24–48 h, as needed and the fascial closure can be performed once patient has been stabilized or the bowel edema has resolved.
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