TYPES OF INCISIONS

Midline Incisions

Also known as the laparotomy incision, or celiotomy, this is the most traditional of
surgical incisions. It may be variably sized depending on the type of procedure
performed. Midline incisions may be small and applied anywhere on the vertical linea
alba. However, they can also extend from the xiphoid process to the pubic bone. This
location is a mostly avascular plane and does not impose a great risk to the blood
supply. There is rarely nerve damage in this region. However, scarring will be present
and may be significant if performing multiple operations through the same incisional
scar. This incision generally provides the best visualization and intra-abdominal access
and is commonly used for exploratory procedures and traumas.

Kocher Incisions (Subcostal)

The Kocher incision is a subcostal incision on the right side of the abdomen used for
open exposure of the gallbladder and biliary tree. This incision is just inferior and
parallel to the subcostal margin. Unlike the midline incision, it is not an avascular plane.
The incision extends through the anterior rectus fascia, rectus muscle, internal oblique,
transverse abdominis, transversalis fascia, and peritoneum. The blood supply of the
abdominal wall that is interrupted is the distal aspect of the superior epigastric as well
as the inferior epigastric, perforating intercostal arteries, and external oblique
perforators. This incision is associated with a slight increase in pain during the post-
operative phase due to the severing of the rectus muscle. The incision closure is after
the procedure in a layered fashion by suturing and approximating fascial layers

Para-median Incision

The para-median incision serves to expose lateral viscera. It is made 3cm, on average,
lateral to the midline. The skin and subcutaneous tissue must be incised, the anterior
rectus sheath and the rectus muscle is deflected laterally if possible to expose the
posterior rectus sheath if above the arcuate line. Upon passing the rectus is entry to the
peritoneum. Peripheral branches of the inferior epigastric will undergo ligation.

Gridiron Incision (McBurney Incision)

This incision provides good exposure for performing open appendectomies and is
made obliquely at the McBurney point, two thirds from the umbilicus to the anterior
superior iliac spine. Dissection will have to be made down to the external oblique,
internal oblique, transversalis fascia, and the peritoneum. The superficial epigastric, as
well as perforating branches of inferior epigastric, may be interrupted during this
incision.
Lanz (Rockey-Davis)

Lanz incision is similar to a gridiron incision and is useful for open appendectomies. It is
made at the McBurney point with the same anatomical layers as well as the blood
supply. However, the Lanz incision is a horizontal incision, while the gridiron incision is
on an oblique angle.

Thoracoabdominal (Iver Lewis)

The thoracoabdominal incision is a unique incision that connects the pleural cavity and
the peritoneal cavity; it yields great exposure to lateral organs, retroperitoneal space,
pleural space, and the distal esophagus. Right-sided incisions may yield proper
exposure to the hepatic region as well as the right kidney. A left-sided incision may yield
exposure for the stomach as well as the distal esophagus.

When performing this incision, the patient is placed with their abdomen tilted 45 degrees
from horizontal, and the thorax twisted into the completely lateral position. This position
will expose the abdomen as well as the lateral thoracic region. A vertical incision
through the left or right upper quadrant is made to explore the abdominal contents first,
and then the incision is extended through the eighth intercostal space from medial to
lateral for pleural exposure. The incision will disrupt the rectus abdominis, the oblique
muscles, if placed lateral, as well as the transversus abdominis. The thoracic end
extends through the intercostals, as well as the latissimus dorsi muscle. Once the
thoracic cavity is entered, the lung is deflated. The two incisions should meet at a sharp
angle for cleaner closure. Blood supply to the latissimus dorsi is the thoracodorsal
artery. This blood supply may be interrupted during the pleural incision laterally. The
abdominal incision could lead to disruption in superior epigastric branches.

Chevron

The chevron incision is one that crosses the midline of the abdomen. It is a sub-costal
incision that extends from the mid to lateral costal ridge, across the midline to the
contralateral side. This approach may provide valuable exposure for hepatic,
pancreatic, upper gastrointestinal region, adrenal, or renal surgeries. It provides access
to the intra-abdominal cavity as well as the retroperitoneal space. The blood supplies
that may be interrupted are the bilateral superior epigastric. The abdominal wall will
have collaterals from the perforating branches through the oblique muscles as well as
the inferior epigastric meaning there will be no devascularized tissues. However, if there
is another surgery after a chevron takes place, and the incision is through the lower
abdominal wall, there may be an interruption of the inferior epigastric and middle of the
abdominal wall with the least amount of collateral blood supply may ultimately be
devascularized.
Pfannenstiel (Kerr/Pubic incision)

The Pfannenstiel is a transverse lower abdominal incision that is made superior to the
pubic ridge. Dissection is made through the skin and subcutaneous fat; the anterior
rectus sheath is divided transversely. The rectus muscle is open vertically in the midline
sparing the muscle fibers from being divided. The peritoneum is then entered through a
vertical incision. This approach is most frequently used for urologic, orthopedic, pelvic,
and cesarean sections. The major drawback of this incision is its limited exposure
beyond the pelvis. Blood supply to keep in mind is the inferior epigastric branches as
well as the superficial epigastric

McEvedy

The McEvedy is a vertical incision from the femoral canal and brought superior to
above the inguinal ligament. It opens the femoral space to allow access to the femoral
canal as well as the peritoneum. Femoral hernias may be reduced and repaired through
this incision. If the peritoneal cavity needs to be accessed, this will provide minimal
access, as the incision is not really over the peritoneal space. Due to the location on top
of the femoral canal, special care needs to be taken not to injure the femoral vein,
artery, or nerve

Subclavicular Incision (Infraclavicular incision)

Made transversely through the skin and subcutaneous tissues inferior to the clavicle,
giving access to the subclavian vessels. However, if access to the distal subclavian
artery is needed, then a supraclavicular incision may be utilized

Supraclavicular Incision

This incision is a transverse incision superior to the clavicle. It may extend along the
length of the clavicle to the midline of the sternum and will provide access from another
vantage point to the subclavian vessels. The advantage of this incision is that it can
meet a sternotomy incision or a cervical incision to provide greater exposure to cervical
anatomy or thoracic anatomy. When making this incision, care must be taken medially
to avoid the internal and external jugular veins. The platysma will be severed, and the
incision provides access to the anterior scalenes as well. This approach is most often
utilized in trauma to gain access to the subclavian vessels.

Median Sternotomy

The sternotomy is a vertical incision over the sternum. It is used to access the
mediastinum, pleural cavity, the aorta and branches to the head and upper extremities,
as well as the epigastric region. It is the most commonly used open heart incision.
Trapdoor Incision

The trapdoor incision is a combination of the collar incision, the sternotomy, as well as a
laterally extended incision from the inferior aspect of the sternotomy below the pectoral
muscles. This incision is used rarely to control bleeding from penetrating trauma to zone
three of the neck, and on occasion is used for aortic arch aneurysms. The trapdoor
incision opens a “door” to the pleural space, the mediastinum, the cervical vasculature,
and the heart. The three incisions that are used still need to be conducted carefully due
to the vascular supply as well as the nerves running along the anterior chest wall. The
blade used needs to be handled with care because if it is too deep then the lung, aorta,
or other major vascular structures may be injured, leading to hemorrhage.

Clamshell

Clamshell incision is a large transverse incision that spans across the entire chest wall.
It is also known as a bilateral thoracotomy and is used during massive chest trauma,
lung transplant, or resection of tumors in the chest. The incision extends through the
sternum, between the fourth and fifth ribs bilaterally, and extends to the mid-axillary line.
Mammary vessels will be interrupted as well as intercostal muscles with associated
intercostal nerves and vessels

Mercedes-Benz

This incision is a modification on the chevron incision. It is the classic chevron with a
vertical incision that extends through the xiphoid and the sternum. This modification is
used in liver transplants or any epigastric pathology that needs adequate exposure for
debulking or total removal

Supra-umbilical/Infra-umbilical Supra and infra-umbilical incisions are used for access

into the peritoneum through the tissues surrounding the umbilicus. Due to the umbilical
stalk, it is unwise to incise directly through the umbilicus so the incision must route
around it. Infra-umbilical incisions may be vertical (such as when gaining access for a
Hasson port) along the linea alba, which is avascular. The incision may be transverse if
the surgeon is performing an open umbilical hernia repair. Supra-umbilical incisions
may be used to gain access into the peritoneum or for open umbilical hernia repairs
when there have been previous incisions in the infra-umbilical region. If the transverse
incision is made, then it may be used in a tight “U,” or inverted “OMEGA” shape around
the umbilicus to keep the future scar hidden, or it can be curvilinear to match the natural
curve of the umbilical ridge. However, one must make sure not to de-vascularize the
umbilical stalk or the thin umbilical skin. If an incision is made along the umbilical ridge,
then there must be enough untouched skin on the opposing side of the incision to
provide sufficient blood supply.
Pararectus

A para-rectus is an incision that is made through the semilunar line laterally to the
rectus abdominis muscle. This incision may be used for a Spigelian hernia, or if
modified, can be used for an ostomy. If the incision is made circularly and the rectus
abdominis is not incised but retracted, then the incision can be carried through to the
peritoneum to retrieve the intestine for ostomy formation. How inferior or superior the
incision is located will affect blood supply either from the inferior epigastric, the superior
epigastric or in the watershed zone between the two main arteries.

Maylard Incision (Mackenrodt)

A transverse incision 6cm above the pubic tubercle that is made through the rectus
abdominis to gain access to pelvic structures. The incision is made through the rectus
abdominis on both sides, through the linea alba, and the medial aspects of the obliques.
The portions of inferior epigastric, as well as the superficial epigastric, will be damaged

Gibson (either side but conventionally left)

Three centimeters above and parallel to the inguinal ligament is the Gibson incision. It
is used in gynecological procedures as well as urological procedures.

Inguinal incision (Groin)

The inguinal incision is a transverse or oblique incision over the inguinal canal. This
incision is used for open inguinal hernia repairs. The incision is made through the skin
to the subcutaneous fat, through Camper and Scarpa fascia. The superficial epigastric
veins are commonly encountered and ligated. This incision reaches the external oblique
aponeurosis and provides access to the inguinal canal

Carotid/thyroidectomy/tracheostomy

A carotid incision is used to access the carotid sheath for carotid endarterectomy. It is
made along the anterior aspect of the sternocleidomastoid muscle in a vertical direction.
There needs to be are to avoid hitting the external jugular vein or the internal jugular
vein. The incision will need to go through the platysma.

Thyroidectomies are performed through a transverse incision superior to the sternal

notch, and it travels parallel to the clavicles, preferably in the neck crease. Care needs
to be taken to not to cut the anterior veins by cutting too deep too quickly, or this will
result in heavy bleeding

Tracheostomies are performed through a vertical or horizontal incision that overlays the
trachea, superior to the thyroid over the second or third tracheal rings
Laparoscopic Incisions

Initial access is usually best achieved at the umbilicus either by using a Veress needle
or the cut-down method using a Hassan trochar. A Visi port is a special port that allows
for laparoscope placement in the trochar itself, then after an incision is made, direct
visualization with twisting of the port and steady downward pressure is applied to gain
access to the intraperitoneal space. When additional trochars are placed, it is wise to
avoid any vessels that are traveling through the abdominal wall that may be illuminated
by the laparoscope inserted through the previously inserted larger port. If access at the
umbilical site is not advisable due to multiple surgeries, the presence of scar tissue, or
large wall deformities, then the next best initial access site is the left upper abdomen.
Decompression of both the stomach and bladder is recommended before any initial
trochar insertion