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Thursday, January 3, 2013

The Pfannenstiel Incision: Opening and Closing the Tummy

 The first step to getting a pfannenstiel incision, often known as a bikini incision, is a cut in the abdominal skin, , it's just above the hair line.
Once the skin is opened it exposes the underlying fat, which may have blood vessels that have to be burned or tied off. In the case of obesity, the overlying fat layer can be quite thick and require a bit of time to open. Then the middle of the fascia layer, known as the linea alba, is opened.

Next this whole fascial layer has to be cut, in many cases this can be done bluntly by finger dissection.

Many women will have a tiny muscle called the pyramidalis muscle shown here that may have to be dissected off the lower level of the rectus muscle.The rectus muscle runs down the middle of your abdomen.
Most pfannenstiel incisions avoid avoid the deep epigastric vessels that are over on the side of the rectus muscles. The next step is working the fascia off the muscles so that a big enough opening for the surgery you need can be obtained.

In this picture the surgeon is clamping a small blood vessel that may be bleeding on the surface of the muscle. Now days this will likely be burned.

Any additional room is achieved.

The muscles are separated off the underlying layer which is the peritoneum of the abdomen. A thin, almost see-through layer.

In this diagram the thin peritoneal layer is being cut, but it can be opened bluntly in many cases.

Any extra opening in the peritoneum is then achieved, depending upon the type of operation and how much room your physician needs.

Closing the abdomen at the end of the surgery just reverses the steps, closing the peritoneum first.
Sewing the muscles together is often done, they will close in with the fascia above it as well.

The fascia is then closed. And of course the skin. The skin can be closed with staples or sutures, and recent studies show that sutures cause less infection. But infections are prevented by antibiotics, good nutrition, being thin, not being a smoker, and by good wound care. Some infections still will occur regardless the care, but most heal very well with appropriate treatment.
Pictures from 1953 Atlas of Pelvic Operations.

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