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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

Surgical Access Incisions

Authors

Leandra A. Jelinek1; Mark W. Jones2.

Affiliations
1 Mclaren Greater Lansing
2 McLaren Greater Lansing, MSUCOM

Last Update: October 31, 2022.

Continuing Education Activity

A well-planned surgical incision is one of the most crucial steps in any surgical procedure. It is always essential to
determine the proper location of the incision for optimal visualization and to always keep in mind anatomy, and blood
supply that may harbinger complications. The exact placement and size of the incision utilized are also crucial for
aesthetic reasons. If it is a small procedure that requires only minimal entrance into the abdomen, then smaller more
strategically placed incisions are the best choice. However, if there is massive trauma, a large organ to be removed, or
the surgery is exploratory, then a larger incision may be performed to gain the most exposure possible. This activity
will explore different types of incisions, indications for each, as well as important anatomical considerations. This
activity highlights the role of the interprofessional team in recognizing which incision should be used to expose
different organs in the body.

Objectives:

Outline the different types of incisions used to access abdominal organs.

Summarize the technique of introducing surgical instruments via the laparoscopic technique

Describe the benefits of the midline abdominal incision.

Review the importance of improving care coordination amongst interprofessional team members to ensure that
the patient with an abdominal pathology undergoes the appropriate surgical incision.

Access free multiple choice questions on this topic.

Introduction
A well-planned surgical incision is one of the most crucial steps in any surgical procedure. It is always essential to
determine the proper location of the incision for optimal visualization and to always keep in mind anatomy, and blood
supply that may suffer compromise. The exact placement and size of the incision utilized are also crucial for
aesthetical reasons. If it is a small procedure that requires only minimal entrance into the abdomen, then smaller more
strategically placed incisions are the best choice. However, if there is massive trauma, a large organ to be removed, or
the surgery is exploratory, then a larger incision may be performed to gain the most exposure possible. This article
will explore different types of incisions, indications for each, as well as important anatomical considerations.[1]

Function
The anterior abdominal wall contains several muscle layers, fascial layers, and vessels. The midline of the abdomen is
where the rectus abdominis is with the linea alba (an avascular fascial plane) dividing the rectus into two sides. The

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lateral abdominal wall consists of the external and internal oblique muscles, and the transversus abdominis. The blood
supply to the anterior abdominal wall consists of the inferior epigastric, the superficial inferior epigastric, the superior
epigastric, branches of the internal mammary arteries, and the perforating branches of the obliques. Between each
muscle layer is a designated facial layer to provide support and structure to the musculature.[2]

Issues of Concern
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 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 maybe 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.[3]

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.[4]

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.[5]

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 peritoneum. The superficial epigastric, as well as
perforating branches of the inferior epigastric, may be interrupted during this incision.[6][7]

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.[7]

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

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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.[8]

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. The 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.[8]

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.[9]

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.[10]

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.[11]

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.
[12]

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

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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.[13]

Median Sternotomy

The sternotomy is a vertical incision over the sternum. It is used to access the mediastinum, pleural cavity, aorta, and
branches to the head and upper extremities, as well as the epigastric region. It is the most commonly used open heart
incision.[14]

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.[15]

Clamshell

A 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.[16]

Mercedes-Benz

This incision is a modification of 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.[17]

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.[18]

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.[19]
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Maylard Incision (Mackenrodt)

A transverse incision 6cm above the pubic tubercle 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 the inferior epigastric, as well as the superficial epigastric, will be damaged.
[20]

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.[21]

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.[22]

Neck Incisions

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.[23]

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.[24]

Tracheostomies are performed through a vertical or horizontal incision that overlays the trachea, superior to the
thyroid over the second or third tracheal rings.[25]

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.[26]

Clinical Significance
In order to access different organs in the body, surgeons need to know where to make the incisions and the length. An
improper incision not only makes the surgery difficult but may also lead to injury of other structures. In general, for
abdominal surgery, the midline incision is versatile and allows access to most organs. However, it can lead to a huge
cosmetic defect. For the chest, both the thoracotomy and median sternotomy allow exposure to many thoracic
structures. The key is for surgeons to be familiar with nearby structures and avoid injury. All incisions have the
potential for keloids and hernia formation; which patients should be told about prior to surgery.

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Enhancing Healthcare Team Outcomes

Different specialists use different types of surgical incisions to get access to the organs. However, prior to making an
incision, a time out should be called by the operating room nurses to confirm first the type of surgery and secondly the
site of the incision. The key is to avoid wrong-site surgery. For abdominal surgery, the midline incision is versatile and
allows access to most organs; for chest surgery, the median sternotomy and thoracotomy afford access to most
thoracic organs. When performing laparoscopic or thoracoscopic surgery, patients should be informed that there is a
small risk of conversion to an open procedure.

Review Questions

Access free multiple choice questions on this topic.

Comment on this article.

References
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