O and G surgical incisions

Question 1

name 4 types of common O + G surgical incisions

Answer 1

• lower segment caesarean section (LSCS)
• laparotomy
• laparoscopy
• abdominal (and vaginal) hysterectomy

Question 2

what kind of procedure involves a vertical midline incision?

Answer 2

• laparotomy

Question 3

what 2 procedures involve a supra-pubic incision?

Answer 3

• LSCS, abdominal hysterectomy

Question 4

describe layers of anterolateral abdominal wall

Answer 4

• skin
• superficial fascia
• rectus sheath
• rectus abdomnis
  laterally
• external oblique muscle
• internal oblique muscle
• transversus abdominis

then reach internal lining of abdominal cavity

Question 5

external obliques run in what kind of direction

Answer 5

• anteroinferior direction from ribs 5-12
• run in same direction as external intercostals

Question 6

where do external oblique muscles attach between?

Answer 6

• lower ribs and iliac crest, pubic tubercle, and linea alba

Question 7

at mid-clavicular line and spino-umbilical line (line between ASIS and umbilical area) turns into an aponeurosis and this is described as a

Answer 7

• flattened tendon

Question 8

internal obliques run in the same direction as

Answer 8

• the internal intercostals (Opposite direction of external obliques)

Question 9

internal obliques attach between where?

Answer 9

• lower ribs, thoracolumbar fascia, iliac crest and linea alba

Question 10

fibres from external oblique blend in with what other fibres?

Answer 10

• internal obliques

Question 11

transversus abdominis attach between where?

Answer 11

• between lower costal cartilages, thoracocolumbar fascia, iliac crest and linea alba

Question 12

rectus abdomins lie between where

Answer 12

• 5-6th costal cartilages towards pubic symphysis

Question 13

rectus abdominis divide into 3 or 4 smaller muscles by

Answer 13

• tendinous intersections
  > why you have 6 pack/8 pack

Question 14

within linea alba there is a defect called the

Answer 14

• umbilical ring
• fetal umbilical vessels pass here to reach placenta

Question 15

how is linea alba formed?

Answer 15

• formed by interweaving of muscle aponeuroses

Question 16

where is rectus sheath located

Answer 16

• immediately deep to superficial fascia

Question 17

what is rectus sheath

Answer 17

• combined aponeuroses of anterolateral abdominal wall muscles
• surrounds rectus abdominis muscles (external oblique (anterior), internal oblique, transverse abdominis muscle and more centrally rectus abdominis)

Question 18

what else runs through rectus sheath

Answer 18

• nerves and vessels

Question 19

what is always contributing to anterior rectus sheath?

Answer 19

• external oblique muscles

Question 20

below belly button describe rectus sheath

Answer 20

• anterior rectus sheath, as muscles all aponeurose anteriorly to rectis abdominis muscle
• does this about a 1/3 of the way between umbilicus and pubic crest

Question 21

above belly button describe rectus sheath

Answer 21

• anterior and posterior rectus sheath

Question 22

internal surface of abdominal wall

Answer 22

from most superficial
- tranversalis fascia
- layer of extra peritoneal fat
- parietal peritoneum (most internal)

once through this in peritoneal cavity and can access abdominal organs

Question 23

nerves that supply anterolateral abdominal wall enter from what direction?

Answer 23

• lateral direction
• come from 7th to 11th intercostal nerves (intercostal space) and become thoracoabdominal nerves (abdominal wall)
  > continuation

Question 24

describe 3 other nerve supplies to anterolateral abdominal wall and where they arise from?

Answer 24

• subcostal (T12)
• iliohypogastric (L1)
• ilioinguinal (L1)

> these nerves supply both motor and sensory innervation to abdominal wall muscles

Question 25

nervous supply to anterolateral abdominal wall is found where

Answer 25

- between internal oblique and transverse abdominis muscle

Question 26

what supplies anterior abdominal wall

Answer 26

- superior epigastric arteries - continuation of internal thoracic - emerges at superior aspect of abdominal wall

Question 27

sup epigastric arteries anastomose just above umbilicus with what artery?

Answer 27

- inferior epigastric artery > branch of external iliac arteries - emerges at inferior aspect of abdominal wall

Question 28

what supplies lateral abdominal wall

Answer 28

- intercostal and subcostal arteries > continuations of posterior intercostal arteries - emerge at lateral aspect

Question 29

from about 12 weeks gestation what can be palpated on a pregnant women

Answer 29

- uterine fundus just above pubic symphysis > grows about 1cm a week

Question 30

incising muscle - what are 3 important things to consider?

Answer 30

- minimise traumatic injury to muscle fibres - incise in same direction in muscle - avoid damaging nerves - particularly motor nerves - avoid interrupting blood supply

Question 31

LSCS incision - what layers are incised?

Answer 31

- skin and superficial fascia - anterior rectus sheath - rectus abdominis - these muscles are not cut - separated in a lateral direction - fascia and peritoneum are then incised, ensure bladder is retracted - uterine wall - amniotic sac

Question 32

what layers are stitched closed in LSCS incision?

Answer 32

- uterine wall w visceral peritoneum - rectus sheath - skin

Question 33

laparotomy - what layers are opened?

Answer 33

- skin and fascia - linea alba - peritoneum

Question 34

laparotomy - what layers are stiched closed?

Answer 34

- peritoneum and linea alba - fascia - skin

Question 35

midline incision in laparotomy - what are complications?

Answer 35

- relatively bloodless area > however this increases chance of wound complicationse.g. dehiscence, incisional hernia

Question 36

laparoscopy - what kind of incision?

Answer 36

- sub-umbilical incision may be all that is required - however if lateral port in required - care must be taken to avoid damaging inferior epigastric artery

Question 37

laparoscopy - what can you do to enable view of pelvic organs

Answer 37

- position of uterus can be manipulated by grasping cervix w forceps inserted through vagina

Question 38

avoiding inferior epigastric artery is particularly important in what procedure

Answer 38

- laparoscopy

Question 39

inferior epigastric artery is a branch of?

Answer 39

- external iliac artery - emerges just medial to deep inguinal ring/femoral pulse point (midway between ASIS and pubic tubercle)

Question 40

inferior epigastric artery passes in what direction?

Answer 40

- superomedial direction post to rectus abdominis - forms post aspect of inguinal triangle - site of direct inguinal hernias

Question 41

what 2 ways can a hysterectomy be performed?

Answer 41

- abdominal - LSCS incision - vaginal

Question 42

during hysterectomy, extreme care must be taken to differentiate ureter from uterine artery - what direction does ureter pass in relation to artery?

Answer 42

- passes inferior to artery - water under the bridge > ureter will often 'vermiculate' (wiggle) when touched