Surgical Incision in abdomens.

Common and uncommon Surgical Incision on abdomen

The only way to approach any visceral organ is to make a nick in the abdomen. No matter how big or small, without incision no organ is tangible and any intervention is next to impossible. The incision is the most comfortable access into the site of pathology. The incision over the anterior abdominal walls are made with different objectives, they have their own pros and cons.

With the advent of newer technologies like laparoscopy the size of the incision is gradually decreasing in size however the knowledge of surgical incision is almost always needed to make sure in case anything goes wrong with minimally invasive procedures.

Vertical incisions

Incision	Approaches to	Operation	Advantage	Disadvantage
Upper midline	Viscera of upper abdomen		Minimal blood loss (Linea alba) Minimal nerve damage No muscle divided. Quick to make and close Can be extended upwards and downwards Almost all the operation can be done through midline incision in abdomen and retro peritoneum.	Prominent Scarring
Lower midline	Viscera of lower abdomen	Emergency Cesarean Section		Prominent scar Bladder and bowel are prone to get injured.
Right paramedian (Equivocal)	Liver abscess, inflammatory biliary tract disease, perforated duodenal ulcer, Meckel’s diverticulitis, ileal typhoid perforation, mesenteric lymphadenitis, and appendicitis	Laparotomy	Can be extended proximally and distally Many of acute appendicitis causes are on the right side compared to the left. Can assess more of lateral structures More stronger as lateral rectus provides buttress
Right subcostal (Kocher)	Gall Bladder Liver Biliary Tract	Open cholecystectomy		Not appropriate when biliary exploration biliary anastomoses with bowel segment is needed.
Left subcostal	Spleen Distal esophagus	Hassab Suguira	Easy access to upper part of stomach and intra-abdominal esophagus

Vertical Incision in abdomen 

Horizontal incisions

Incision	Approaches to	Surgery	Advantage	Disadvantage
Left Thoracoabdominal	Lower esophagus Cardia of stomach	Resection of lower part of stomach
Roof top / Chevron (Modified Kocher incision)	Liver Adrenal Stomach	oesophagectomy, gastrectomy, bilateral adrenalectomy, hepatic resections, or liver transplantation
Bucket handle	Stomach (vagotomy and Pyloroplasty) Spleen (Splenectomy ) Appendix (Site of new kidney placement) B/L kidney (Nephrectomy) B/L ovaries(Hide the ovaries beneath pubis to prevent radiation hazard)	Renal Transplant	Single incision for almost all needed procedure during the renal transplantation surgery Good healing	Bilateral subcostal incision excessively large
Lanz	Appendix
Mc Burney	Appendix	Open Appendectomy	Good wound healing Minimal Scar	Bladder injury
Pfannestial	Pelvis	Cesarean Section Prostatic surgery	Cosmetically better
Inguinal	Inguinal Hernia	Herniorraphy	No other abdominal incision needed even if bowel slips in or resection and anastomoses of the bowel needs to be done just widen the ring at the groin

Horizontal Incision in abdomen 

There are several modifications to various surgical incision. These are the commonly performed ones. The following sources or links can be useful to learn about more of the surgical incisions in the abdomen.

Sources : SRB Manual of surgery

ABDOMINAL INCISIONS IN GENERAL SURGERY: A REVIEW. Annals of Ibadan Postgraduate Medicine. 2007;5(2):59-63.

http://medind.nic.in/jae/t01/i2/jaet01i2p170.pdf

KOCHERS- All terms named after Theodor Kocher

Emil Theoder Kocher was a 1909 Nobel laureate who was a swiss researcher and physician. many instruments, surgical procedures, incision used to open various parts of the body and many clinical signs has been named after him to commemorate his outstanding achievement in the field of medicine. The following are some of the terms named after him 

Kocher's forcep/Clamp

It is a strong hemostatic forceps with serrated blades with interlocking teeth at the tip.

Kocher's sign

When clinician places his hands on patient’s eye and lifts it higher, patients eyelids springs up more quickly than the eyebrow, seen in Graves' Ophthalmopathy.

Kocher's incision

1.     In abdomen, it is an oblique  incision in right upper quadrant for open cholecystectomy. 

2.     In neck, it is  a transverse, slightly curved incision about 2 cm above the sternoclavicular joints

All other surgical incisions in the abdomen. 

Kocher's Maneuver:

1.     Kocherisation is a surgical maneuver to expose structures in the retroperitoneum behind the duodenum and pancreas; for example to control hemorrhage from the inferior vena cava or aorta, or to facilitate removal of a pancreatic tumor.

2.     In shoulder dislocation it is a maneuver used to reduce dislocations by externally rotating the shoulder, before adducting and internally rotating it.

Kocher's Reflex:

It is a sign elicited as contraction of abdominal muscles, in response to testicular compression.

Kocher's vein

The middle thyroid vein is named as Kocher's vein.

All the conditions with Strawberry signs 

Kocher's Test: 

The test to elicit obstruction is trachea is named as Kocher's test. Slight compression of the lateral lobe of thyroid gland produces stridor. If the test is positive, it signifies that the patient has an obstructed trachea.

Kocher's Point:

Common entry point for an intraventricular catheter to drain cerebral spinal fluid from the cerebral ventricles. It is located 2.5 centimeters from the midline (at approximately the mid-pupillary line) approximately 11 cm posterior to the nasion

Kocher–Debre–Semelaigne syndrome

A type of Hypothyroidism in infancy or childhood is named as Kocher-Debre-Semelaigne Syndrome. The components of which are: lower extremity or generalized muscular hypertrophy, myxoedema, short stature and cretinism.

Exception

Though named as Kocher, the following are totally different Kochers and not to be confused with Emil Theoder Kocher.

Kocher Criteria

It is a criteria to differentiate Septic Arthritis from transient synovitis in children with hip joint inflammation .It is named after Mininder S. Kocher, who was an orthopedic surgeon.

Kocher Approach

It is a incision on the skin and deep down the muslces to elbow. It is a Posterolateral Approach to Elbow allowing the  exposure of the entire distal humerus as well as radial head, radial neck, and biceps tuberosity.

Kocher's interval

It is a interneural interval between the ANCONEUS and the Extensor carpi Ulnaris

Sources (SRB Textbook of surgery, Wikipedia and online resources)