Abdominal wall anatomy Classification of incisions.

1. By
Hassaan Ali Gad
Assistant lecturer of urology
Aswan University, Egypt
Surgical approaches to
the urinary system

2.  Introduction.
 Abdominal wall anatomy
 Classification of incisions.

3. Definitions
- Incision: A cut produced surgically by a sharp
instrument that creates an opening into an
organ or space in the body.

4.  Skin
 Superficial fascia
 Muscles
 Transversals fascia
 Extra peritoneal fascia
 Peritoneum

6.  Skin
squamous stratified epithelum
 Superficial fascia:
- - Camper’s fascia (Fatty Layer)
- - Scarpa's fascia (Membranous Layer)

7. A. SUPERFICIAL LAYER -
 move upper extremity
Trapezius.
Latissimus dorsi.
Levator scapulae.
Rhomboideus major.
Rhomboideus minor.
B. INTERMEDIATE
 LAYER- Respiratory muscles
levator costrum
Serratus posterior superior.
Serratus posterior inferior
C. DEEP LAYER - movetrunk and back
1. SPLENIUS
 2. ERECTOR SPINAE
 3. TRANSVERSO-SPINALIS –
 deep to Erector Spinae

8.  Anterior Group
 Rectus Abdominis
 Pyramidalis
 Lateral Group
 External Oblique
 Internal Oblique
 Transversus

9.  RECTUS ABDOMINIS
Origin: Symphasis pubis, pubic crest
Insertion: 5th, 6th and 7th costal cartilage and xiphoid
process.
Nerve Supply: Lower six thoracic nerves.
Rectus Sheath: made up of the aponeuroses of the
three anterolateral abdominal muscles as they
converge at the linea alba.
Linea Alba: fusion of the aponeuroses of the
abdominal muscles, and it separates the left and
right rectus abdominis muscles.

10. External Oblique
Origin: lower 8 ribs.
Insertion: Xiphoid process, Linea alba, pubic crest,
pubic tubercle, iliac crest.
Nerve Supply: Lower six thoracic nerves, iliohypgastric
n., ilioinguinal n.
Internal Oblique
Origin: Lumbar Fascia, iliac crest, lateral two thirds of
inguinal ligament.
Insertion: Lower three ribs, costal cartilage, Xiphoid
process, Linea alba, symphasis pubis.
Nerve Supply: Lower six thoracic nerves, iliohypgastric
n., ilioinguinal n.

11. Transversus Abdominis
Origin: lower six costal cartilage, lumbar fascia,
anterior two thirds of iliac crest, lateral third
of inguinal ligament.
Insertion: Xiphoid process, Linea alba,
symphasis pubis.
Nerve Supply: Lower six thoracic nerves,
iliohypgastric n., ilioinguinal n.

12.  SERRATUSPOSTERIOR SUPERIOR -
Origin: Vertebrae(cervical and upperthoracic
spines)
Insert: Ribs
Action: Raise ribs ininspiration
 3. SERRATUS POSTERIORINFERIOR -
Origin: Vertebrae lumbarand lower thoracic
spines;
Insert: Ribs
Action: Lower ribs in expiration
Innervation: both muscles by
Intercostal Nerves

13.  Psoas major
 Origin: inter vertebral discs T12/L1 to L4,5
 bodies of L1-5 transverse prossesL1-5
 Insertion: lesser trochanter
 Nerve supply:L1 ,2,3
Psoas minor
 Origin: bodies of T12/L1
 Insertion: fascia over Psoas major behind inguinal
ligament
 Nerve supply:L1

14.  Quadrates lumborum
 Origin: transverse prossesL5, iliolumber
ligament & posterior 1/3 iliac crest
 Insertion : medial ½ of 12th rib, transverse
prossesL1-4
 Nerve supply:T12/L4
 iliacus
 Origin : hollow of iliac fossa
 Insertion :psoas tendon below lesser
trochanter
 Nerve supply : femoral(L1,2,3)

15.  Extraperitoneal Fascia
 The thin layer of fascia and adipose tissue
between the peritoneum and fascia
transversalis.
 Thoracolumbar Fascia
Triangular-shaped sheet of tough connective
tissue.
 Partial site of origin of latissimus dorsi and
abdominal oblique muscles.

17.  Flank Approaches
 ELEVENTH RIB INCISION (CLASSIC FLANK)
 SUBCOSTAL FLANK INCISION
 DORSAL LUMBOTOMY
 Anterior Approaches
 SUBCOSTAL TRANSPERITONEAL INCISION
 BILATERAL SUBCOSTAL TRANSPERITONEAL
INCISION
 THORACOABDOMINAL INCISION

18.  Twelfth Rib or Modified Flank Incision
 Midline Abdominal Incisions
 Gibson’s Incision

19.  Infra umbilical Incision
 Lower Abdominal Transverse Incision Inguinal
Incision

21.  The incision begins posterior at the angle of the11th
rib and may extend as far as the border of the rectus
abdominus.
 The skin and subcutaneous tissues are opened
 Transecting the latissimus overlying the 11th rib.
 incision of the periosteum, along the length of the rib
..
 A periosteal elevator is used to remove the
periosteum
 The Doyen rib instrument slides into the plane
between
rib and periosteum. to complete the rib dissection.
ELEVENTHRIBINCISION

23.  The skin and subcutaneous tissues are opened
 Incision of the external abdominal oblique
muscle and latissimus dorsi.
 opening the internal oblique muscle
 The lumbodorsal fascia (the fusion of the
internal oblique andtransversalis muscle sheaths
posteriorly) is incised to enter the retro
peritoneum.
 Peritoneum is then swept awayfrom the anterior
abdominal wall.
 The transversalis fibers are separated bluntly.

25.  . The incision is limited by the 12th rib
superiorly and the iliac crest inferiorly, so
 there is no option to extend it.

27. Incision parallel with the costal margin.
(started at the midline, 2 to 5 cm below
the xiphoid and extends downwards,
outwards and parallel to and about 2.5
cm below the costal margin)
 The external oblique, internal
oblique,
 and transversalis muscles are opened
to expose the peritonium

29.  Excellent exposure to the upper abdominal
cavity andRetroperitoneum
 The incision may be continued across the
midline into a double Kocher incision
 As with any bilateral incision, care should be
taken to assure the incision is symmetrical
with respect to the midline and to the costal
margins.
 The abdomen is entered inthe same manner
as in the unilateral subcostal transperitoneal
incision.

31.  Thoracoabdominal incision offers wide exposure of theupper
abdomen, chest, and retroperitoneum for largerenal, adrenal, or
retroperitoneal tumors or
 incision is made through the eighth or ninth intercostal space
extending inferomedially to or across the midline..
 The abdominal portion of the incision is opened first .
 The costal cartilage between the tips of the two ribs on either
side of the incision is then divided with heavy scissorsor rib
cutters.
 Dissection is carried through the intercostalmuscles along the
upper border of the adjacentlower rib in order to avoid the
neurovascular bundle.
 The pleura is opened under direct visualization.
 The diaphragm is incised.
 With the diaphragm opened, the liver can be retracted into the
thorax to maximize exposure of the underlyingstructures

34.  A 12th rib incision carries less risk of pleural injur
 The positioning should be similar to an 11th rib
incision,but the patient should be rotated slightly
dorsad.
 The 12thrib is marked, and the bed developed in the
same manner as the 11th rib incision.
 the incision is angled downwardalong the lateral
border of the ipsilateral rectus muscle.If required,
 2 cm above the pubis can be made for better bladder
exposure.
 Reflecting the peritoneum medially by blunt
dissection
 gives excellent visualization of the retroperitoneum.

37. Upper Midline Incision
 From xiphoid to above umbilicus.
 Skin  superficial and deep fascia  linea alba  extraperitoneal fat
(abundant and vascular)  peritonium.
 Division of the peritoneum is best performed at the lower end of the
incision, just above the umbilicus so that falciform ligament can be seen
and avoided
Lower Midline Incision
 From the umbilicus superiorly to the pubic symphysis inferiorly.
 the peritoneum should be opened in the uppermost area to avoid
possibleinjury to the bladder.
 Allow access to pelvic organs.
Full Midline Incision
 Great exposure is needed.

38. Advantages:
◦ It is almost bloodless.
◦ No muscle fibres are divided.
◦ No nerves are injured.
◦ Good access to the upper abdominal viscera.
◦ It is very quick to make as well as to close.
Disadvantages:
◦ More painful.
◦ Chest complications.
◦ Wound infection……Ugly scar…… Incisional
hernia…. etc

40.  Now used mainly for renal transplantation.
 In the supine position, an incision is made 2–3 cm
medial to the line from the anterior superior iliac
spine to the pubis. .
 The external oblique aponeurosis is exposed. An
incisionis made along the lateral border of the
rectus abdominus.
 .

41.  If more medial exposure is needed, the rectus
maybe transected across its tendinous attachment
to the pubis.
 The inferior epigastric artery may be ligated and
divided as it passes along the posterior aspect of
therectus.
 The transversalis fascia is incised to expose the
bladder are swept medially to develop the
extraperitoneal space
 The peritoneum and bladder are swept medially to
develop the extraperitoneal space

43.  The incision is carried through the skin and
subcutaneous
 The rectus fasciais incised.
 Ending the fascial incision at the lateral borders of
therecti limits the risks of injury to the ilioinguinal
nerve andcontents of the inguinal canal.
 .

44.  Each leaf of the divided rectus fascia is grasped
approx1 cm lateral to the midline with Allis clamps
and retracted ventrally.
. A curved clamp bluntly separates the two recti,
which are retracted laterally.
 Incising the transversalis fascia,
 opens the proper plane of dissection. Sweeping the
plane
 between bladder and pelvis exposes the obturator
nervesand vessels

45. THANK YOU