Which of the following is true regarding paramedian incision?
Ans. cOption aFalseNo, it is done 2-5 cm lateral to the midlineOption bFalseNo, the rectus sheet is incisedOption cTrueYes, correctOption dFalseNo, there are very negligible chances of neuropathyOption eFalseNo, the rate of incisional hernia is highest with midline incisionRef.: http://www. ncbi. nlm. nih.gov/pmc/articles/PMC1290569/; Sabistion 19th edition; Bailey, 26th edition1. Vertical incision: These may bei. Midline incisionii. Paramedian incisions2. Transverse and oblique incisions:i. Kocher's subcostal Incisiona. Chevron (Roof top Modification)b. Mercedes Benz Modificationii. Transverse Muscle dividing incisioniii. McBurney's Grid iron or muscle splitting incisioniv. Oblique Muscle cutting incisionv. Pfannenstiel incisionvi. Maylard Transverse Muscle cutting Incision3. Abdominothoracic incisionsPARAMEDIAN INCSIONSThe skin incision is placed 2 to 5 cm lateral to the midline over the medial aspect of the bulging transverse convexity of the rectus muscle.Skin and subcutaneous fat are divided along the length of the wound.The anterior rectus sheath is exposed and incised, and its medial edge is grasped and lifted up with hemostats.The medial portion of the rectus sheath then is dissected from the rectus muscle, to which the anterior sheath adheres.Segmental blood vessels encountered during the dissection should be coagulated.Once the rectus muscle is free of the anterior sheath it can be retracted laterally because the posterior sheath is not adherent to the rectus muscle.The posterior sheath and the peritoneum which are adherent to each other, are excised vertically in the same plane as the anterior fascial plane.The deep inferior epigastric vessels are encountered below the umbilicus and require ligation and division if they course medially along the line of the incision.As regards option D, sabiston mentions that there is enough overlap amongst various nerves in the abdomen, that there is no chance of neuropathy in any incision on abdomen. Also in majority of paramedian incisions the rectus muscle is not cut. There is no reason to support the loss of sensation in the nerves.INCISIONAL HERNIA AND INCISIONSThe rate of incisional hernia is highest in midline incisions.The lateral paramedian incision takes longer to perform, requires a longer incision, rarely results in dehiscence, and does confer protection against incisional hernia.The rate of hernia formation is lowest in transverse incisions. Also the postoperative pulmonary complications are low in transverse incisions.Risk Factors (numbers) MidlineLateral paramedianTotalChest infection454388Wound infection181331Distension332659Jaundice161127Fistula055*Sinus448* kh2 = 3.33, 0.1 >p> 0.05Time for Incisions. Mean in Minutes (SD) MidlineLateral paramedianTime taken (Westmineter) Opening3.17(1.81)8.91 (3.02)Closing8.09 (3.37)9.88 (3.36)Opening time (Westminster and Scarborough) Less than 5 minutes10845 to 9 minutes1784>10 minutes191
Done below umbilicus
Rectus sheath is cut laterally
Rectus sheath is cut medially
Decreases sensation in rectus muscle
Hernia