Incision and Closure



Incision and Closure


Helen Dunnington

Laurie Swaim



GENERAL PRINCIPLES



Physical Examination



  • General abdominal examination (Table 1.4.1)


  • A bimanual pelvic examination can assist with decisions regarding incision type and location by providing information about uterine size, mobility, tenderness, and the presence and character of adnexal masses.


IMAGING AND OTHER DIAGNOSTICS



  • Prior to cesarean delivery, ultrasound can confirm fetal presentation and placental location.


  • If there is concern for morbidly adherent placenta on ultrasound, magnetic resonance imaging (MRI) of the abdomen and pelvis may provide more detailed information about placental invasion.


  • Additional imaging may be warranted to determine the location of unusual anatomy or foreign bodies if indicated by patient history. For example, adnexal masses can be reasonably assessed with pelvic 2D and 3D ultrasound and Doppler, and computerized tomography (CT) or MRI scan can be employed in evaluating other pelvic conditions such as appendicitis.


PREOPERATIVE PLANNING



  • The ideal abdominal incision is that which ensures adequate surgical exposure for the necessary procedure while minimizing postoperative complications.


  • The rationale for the type and location of the incision should be a part of the informed consent discussion owing to differences in cosmetic outcomes.


  • The need for additional instruments or retractors based on patient habitus or pathology is determined during the preoperative examination. For example, surgeons may request a pannus retractor to improve access to the lower abdomen when the patient is obese. Intra-abdominal visualization may be improved in some instances with the AlexisTM retractor, which has two rigid plastic rings that are available in different sizes, connected by a sheath of plastic. These disposable devices tend to retract the entire length of the incision equally and therefore may provide improved exposure in some circumstances over handheld or metal self-retaining retractors. For improved operating room (OR) efficiency, special instrumentation should be requested in advance of the procedure date.









SURGICAL MANAGEMENT



  • Abdominal entry for most obstetric surgeries can be performed under regional, general, or in rare and exceptional circumstances, local anesthesia. The mode of anesthesia is dependent on patient presentation, acuity of the surgery, degree of urgency, and the skill of the anesthesiologist.


  • Ideally, operating facilities ensure adequate space for the surgeon, assistant, anesthesiologist, and ancillary staff, including neonatal teams if needed. The surgical suite should be equipped with appropriate medications and supplies to handle emergencies such as postpartum hemorrhage and complications of the newborn.


Positioning



  • The dorsal supine position with a leftward tilt is common during abdominal procedures on obstetric patients. This tilt improves maternal cardiac output and uteroplacental perfusion by reducing uterine compression on the aorta and inferior vena cava.


  • The low lithotomy position provides several advantages, especially when the risk of bleeding is high. This position allows for an additional surgeon to be directly at the operative site, visualization and quantification of vaginal blood loss, urethral access for cystoscopy or stent placement, and for intraoperative placement of transvaginal instruments or intrauterine devices (e.g., tamponade balloon) if needed.


Approach



  • Abdominal entry is accomplished using either open or laparoscopic methods. Gestational age, body habitus, patient history, and anticipated pathology drive decisions regarding the type of abdominal incision and the placement of laparoscopic ports. See Chapter 3.6 for laparoscopic approach.


  • Familiarity with the anterior abdominal wall anatomy is key when considering abdominal entry.



    • The anterior abdominal wall musculature includes the vertically oriented rectus abdominis and pyramidalis muscles, and the transversely oriented external and internal oblique, and transverse abdominis (Figure 1.4.1) muscles. The vertical muscles are responsible for motion and posture, whereas the transverse muscles provide most of the support strength of the anterior abdominal wall.


    • Blood flow to the anterior abdominal wall is through vessels that originate primarily from the external iliac, femoral, and anterior thoracic arteries (Figure 1.4.2). The mid-abdomen is supplied by the epigastric arteries, and the lateral abdomen by the musculophrenic and the superficial and deep circumflex iliac arteries. In addition, a rich network of anastomoses distributes blood to the abdominal wall.


    • Nerves of the anterior abdominal wall include the thoracoabdominal, iliohypogastric, and ilioinguinal nerves (Figure 1.4.3). Lateral vertical incisions may cause damage to branches of the thoracoabdominal nerves. Creation and repair of wide transverse incisions may disrupt or tether the iliohypogastric or ilioinguinal nerve. Knowledge of the anatomy of these nerves is important because injury to them can result in chronic pain or sensation changes to the mons and/or labia majora. The use of port closure devices can be associated with nerve entrapment resulting in similar symptoms depending on the distribution of the involved nerve.













  • Surgical planning requires consideration of potential anatomic changes related to pregnancy. Diastasis recti caused by the gravid uterus is a common finding during pregnancy. In women with prior pelvic surgeries, it is important to be alert for adherent muscles, fascia, or intraperitoneal adhesions. Patients with a history of herniorrhaphy may have a length of mesh at the site, in which case preoperative consultation with a general surgeon may be beneficial. During the late second and third trimesters, the umbilicus loses its usefulness as a landmark for the aortic bifurcation. The location of the uterine fundus and lateral borders, if not clearly palpable, should be identified by ultrasound prior to placing laparoscopic ports or creating incisions for procedures other than cesarean delivery.







  • Although the advantages of transverse incisions include cosmesis and strength over vertical incisions, they are not always feasible. Vertical incisions are associated with less postoperative pain and reduced blood loss as compared to the transverse option; however, the reduction in local perfusion may be associated with poorer wound healing (1). Body habitus, uterine size, need for exposure, potential need for upper abdominal exploration, and surgical history all influence the direction and type of laparotomy incision used in obstetric patients (Figure 1.4.4).







Sep 8, 2022 | Posted by in OBSTETRICS | Comments Off on Incision and Closure
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