Surgical Scars Flashcards
Determinants of laparoscopic port placements?
Away from areas of high risk (previous scars, adhesions, organomegaly)
Vessels of anterior abdominal wall should be avoided, esp inferior epigastric artery
Minimum number of ports possible should be used
Positioned so as to have the target organ at the apex of an imaginary diamond
10mm port for camera and removal of organs (gallbladder)
5mm port for all others
Advantages and disadvantages of laparoscopic surgery
Advantages:
Shorter hospital stay and rehabilitation, less post-op pain, better cosmetic result, less wound complications, decreased handling of organs (bowel), less trauma to tissues, reduced incidence of post-op adhesions
Disadvantages: longer operation time, less tactile feedback to surgeon, more technical expertise required, expensive equipment, difficulty in controlling massive bleeding, increased risk of iatrogenic injury to surrounding organs, not always feasible due to contraindications (adhesions)
Advantages and disadvantages of midline laparotomy scar
Advantages: Provides good access Can be easily extended Speed of closure and opening Relatively avascular (linea alba)
Disadvantages:
Incision more painful than transverse incision
Scar crosses Langer’s lines, poor cosmetic appearance
Narrow linea alba below umbilicus, therefore it can damage the bladder
When surgical scar is visible
Try name it eponymously Describe scar, location, length Possible reasons for scar Determine recent or old *check for incisional hernias, patient cough or raise head off the bed*
Midline laparotomy scar
Exploratory laparotomy, hemicolectomy, Hartmanns, AAA repair
Upper: splenectomy (massive)
Lower: paraumbilical hernia repair, colectomy
Kocher’s or right subcostal scar
Open cholecystectomy, partial liver resection, any biliary surgery
Reversed Kocher’s or left subcostal scar
Open splenectomy
Double Kocher’s or rooftop scar or right and left subcostal scar
Oesophagectomy, complex pancreatic/gastric surgery
Mercedes scar or extended rooftop scar
Complex upper GI surgery eg gastrectomy, McKeown oesophagectomy
Left nephrectomy scar or loin incision
Nephrectomy or specialist renal surgery
McBurney’s scar
Appendicectomy
McBurney’s point: imaginary midpoint between ASIS and umbilicus
Pfannenstiel (Panty line bilateral scar)
Gynaecological: Caesarean section, cystectomy, hysterectomy
Pelvic surgery: bladder resection, prostectomy, bilateral hernia repairs
Rutherford Morrison (RIF concave rounded scar)
Renal transplant
What structures would you go through in an appendicectomy scar?
Skin, subcutaneous tissue
Scarpa’s fascia, linea alba
Muscles layers: external oblique, internal oblique then transverse abdominis
Transversalis fascia
Extra peritoneal fat then parietal peritoneum
What structures would you go through in the midline laparotomy scar?
Skin, subcutaneous tissue
Scarpa’s fascia, linea alba
Transversalis fascia
Extraperitoneal fat then parietal peritoneum
