Incisions

INCISIONS (incisiones), violation of the integrity of coverings, produced for therapeutic purposes. Depending on this, incisions are made according to certain principles. The gaping of a wound depends on the properties of the tissue being cut and the direction of the incision. Different tissues gape differently. In addition, the same tissue, when cut in one direction, has the greatest divergence, and in another direction the least, which is observed in incisions of the skin, muscles, tendons, nerves, etc. The study of the surface of the human body allowed Langer to create diagrams that indicate areas of greatest and least gaping, caused by the contraction of elastic fibers located in the skin (see Skin). With incisions perpendicular to Langer's lines, this divergence will be greatest, with parallel incisions - minimal. Muscular fibers connected to the skin are also of no less importance. When muscle fibers are cut, the divergence, and consequently the gaping of the wound, will be significant. To avoid bleeding and damage to nerves, incisions are made as much as possible along the course of blood vessels and nerves. Thus, the following requirements are made for incisions: 1) to have sufficient access to the area being operated on, 2) to damage tissues as little as possible, especially muscles, blood vessels and nerves, so that after the operation it is possible to completely restore them and prevent the formation of postoperative hernias, 3) cosmetically, to avoid making such incisions, especially on visible parts of the body, which later may cause disfiguring scars. In this regard, according to Langer's lines, quite satisfactory are the plastic incisions along the skin folds proposed by Kocher. These incisions are particularly valuable in plastic operations on the face, where scars in the direction of skin folds are completely invisible. When cutting heterogeneous tissues, the most physiological are incisions according to Sprengel, in which nerves and muscles are preserved (see Abdominal wall, incisions of the abdominal wall). Depending on the anatomical features of the area being operated on, the size and depth of the intervention, the above incisions are not always convenient. Therefore, for a number of operations, incisions deviating from the given schemes are proposed. Thus, on the head instead of linear incisions, oval, semicircular, flap incisions are most often used, where tissues are intersected in different directions. The most physiological are skin incisions with subsequent separation of muscles (Cushing). On the neck, transverse incisions according to Kocher are often replaced by longitudinal ones or at an angle, depending on the nature of the disease and the direction of blood vessels, nerves, fascia and muscles, the damage of which is avoided. There are even more deviations in the direction of incisions on the abdominal wall. Here the most common are longitudinal incisions along the midline or pararectal with separation of muscles and transverse ones according to Pfannenstiel (see below). In operations on the liver and spleen, oblique incisions with cutting and subsequent suturing of muscles are used (see Gallbladder, Stomach). In operations on the kidneys, oblique incisions with cutting of muscles are usually used (see Lumbar region). On the perineum, oval or transverse incisions are most common (see Prostate gland). In operations on joints, Kocher and Langenbeck incisions are most commonly used, which provide sufficient space and good functional results, in particular on the knee joint, the incision of Teodor and Pyr (see Knee joint, Ankle joint, Shoulder, Hip joint). On internal organs, incisions are made in the direction of blood vessels and ducts. Thus, on the kidneys, an incision along the posterior surface along the line of Tsondek - in the place with the smallest number of BLOOD VESSELS - is used.

A.

Bakulev. Incisions in gynecology. Gubarev-Pfannenstiel incision. The incision along the median line of the abdominal wall (longitudinal, median R.) is the most commonly used for major gynecological operations. This R. is simple, almost bloodless, without functional damage to nerves and muscles. The possibility of extending this R. to the pubic symphysis and beyond the navel presents great advantages. To prevent the formation of hernias, Lennander proposed making a longitudinal incision. If this R. is continued upward for the necessary distance, it can provide the same access as a median line incision. The longitudinal incision of the abdominal wall competes with the transverse incision. Initially, Kustner proposed, for purely cosmetic reasons, to cut only the skin in this direction, while the aponeurosis should be cut along the median line. This R. was not successful. Pfannenstiel modified this R., cutting not only the skin but also the aponeurosis in a transverse direction. The great advantage of the Pfannenstiel transverse incision is the greater guarantee against postoperative hernia and good cosmetic results. The R. according to Pfannenstiel is made along the suprapubic fold with a slight convexity facing the symphysis. The usual width of the fascial R. is to the lateral edges of the rectus muscles. The peritoneum is opened with a median R. A typically performed R. provides little access. Bumm, when a wider approach to the operative field is necessary, recommends extending the R. beyond the lateral edges of the rectus muscles, where the anterior rectus sheath is divided into separate layers. Thus, the R. is carried to the muscle fibers of m. obliquus internus et transversus. Increasing the transverse incision of the aponeurosis makes it possible to expose the rectus muscles further upward and gain several centimeters in the median peritoneal incision. Even more access is obtained if, as Franz recommends, the transverse incision is transferred higher above the suprapubic fold at the level of both spinae ant. sup. When both the upper and lower flaps are separated, sufficient access is obtained for performing major gynecological operations. However, such modifications of the typical Pfannenstiel incision do not meet with unanimous approval. Gubarev notes that extending the R. beyond the lateral edges of the rectus muscles is undesirable, as the layered restoration of the R. is difficult. In connection with this, hernia-like protrusions may form near the edges of the rectus muscles; in case of suppuration, difficult-to-treat abscesses may form. According to Faure, when the R. is made above the suprapubic fold, one of the advantages of the transverse R. is not achieved and the scar under these conditions is worse than after a median line incision. In cases where the extended aponeurosis incision still provides little access, Bumm cuts the rectus muscle on one side or even both. Under such conditions, an almost transverse incision of the abdominal wall (according to Bardenheuer) is obtained - a 'horseshoe-shaped' incision, 'large arcuate R.' Such an R., despite its significant advantages, has very major drawbacks due to the exceptionally easy access to the operative field, as extensive trauma makes primary healing difficult, and in case of suppuration of the wound, hernias easily form. More rational, therefore, is Franz's proposal to add a conventional longitudinal incision in cases of insufficiency of the transverse R. Taking all this into account, most authors limit the use of the Pfannenstiel incision to cases where the surgical intervention does not require significant access. Considering the limited possibilities with the Pfannenstiel incision and aiming to utilize the advantages of the Pfannenstiel and Lennander incisions, Gubarev proposed combining these two R.s. An incision on one side, as in the Pfannenstiel incision, which from the median line passes to the other side into a Lennander incision. The cutaneous-tendon flap is retracted to the side, the peritoneum is opened along the median line. Extraperitoneal, 'oblique' incision for draining purulent collections in the pelvis, ligation of a. uterinae, etc., is made at a distance of 2-3 cm from spina ant. sup. to the middle of the Poupart ligament. The R. should be placed on the muscular part of m. transversus abdominis, as the peritoneum lining the anterior abdominal wall is very firmly attached to the tendinous part of this muscle. All muscle layers are cut in a transverse direction; after cutting the dense fascia transversalis, penetration into the areolar space is achieved. According to Gubarev's research, the mesentery of the round ligament divides the pelvis into two halves and prevents the penetration of pus into the posterior part of the pelvis. Therefore, if it is necessary to drain a purulent collection located in front of the uterus, the incision is made parallel to the Poupart ligament, starting from the tuberculum pubis to the internal opening of the inguinal canal (almost the middle of the Poupart ligament). If access behind the uterus is needed, the incision is made more laterally and its center is opposite the spina ant. sup. *g In vaginal operations for wide access to the operative field, the Schuchard R. is used - the vagina is cut to the side with a knife and the R. is continued outside the vagina, cutting mm. constrictor cunni, transversus perinei superficialis et profundus, and finally m. levator ani. Schuchard carries the R. further backward, arc-shaped around the anal opening, without violating the integrity of the sphincter, cutting the muscle fibers of the t. coccygei. Most often the R. is performed on the left side, and if necessary, it is made bilateral. In operations for perineal repair, in plastic operations for prolapse of the posterior vaginal wall, incisions are made for tissue refreshing or for splitting with subsequent suturing. Incisions for tissue refreshing have various shapes depending on the size of the perineal tear and the degree of displacement of the vagina. The figure of refreshing initially proposed by Hegar was later modified by Fritsch in order to avoid excessive tension of the tissues in the lower part of the vagina. Ott uses the same R., but extends the lower part of the incision toward the anus.

d. gudim-leukozich.