Agnew's incision

An incision used to release pus in the lacrimal sac in acute phlegmonous dacryocystitis. It is named after Cornelius Rea Agnew

[edit]Alexander incision
[edit]Auvray incision
[edit]Bar’s incision
[edit]Battle incision
[edit]Bardenheuer incision
[edit]Bergmann’s incision
[edit]Bevan’s incision
[edit]Cherney incision
[edit]Chernez incision
[edit]Chevron incision
[edit]Circular incision
[edit]Clute incision
[edit]Deaver’s incision
[edit]Dührsen incision
[edit]Fergusson’s incision
[edit]Fowler’s incision
[edit]Girdiron's incision

An oblique incision made in the right lower quadrant of the abdomen, classically used for appendectomy

[edit]Graefe incision
[edit]Heerman’s incision
[edit]Hartmann incision
[edit]Kehr’s incision
[edit]Kocher’s incision

An oblique incision made in the right upper quadrant of the abdomen, classially used for open cholecystectomy. Named after Emil Theodor

Kocher. It is ppropriate for certain operations on the liver, gallbladder and biliary tract.[1][2] This shares a name with the Kocher incision used

for thyroid surgery: a transverse, slightly curved incision about 2 cm above the sternoclavicular joints;

[edit]Kustner’s incision
[edit]Langenbeck’s incision
[edit]LaRoque’s incision
[edit]Lynch’s incision
[edit]Mac Arthur's incision
[edit]Marylard incision

A variation of Pfannenstiel incision is the Maylard incision in which the rectus abdominis muscles are sectioned transversally to permit

wider access to the pelvis.[3]

[edit]McBurney incision

This is the incision used for open appendectomy, it begins 2 to 5 centimeters above the anterior superior iliac spine and continues to a point

one-third of the way to the umbilicus (McBurney's point). Thus, the incision is parallel to the external oblique muscle of the abdomen which
allows the muscle to be split in the direction of it's fibers, decreasing healing times and scar tissue formation. This incision heals rapidly and

generally has good cosmetic results, especially if a subcuticular suture is used to close the skin. [4]

[edit]Median sternotomy

This is the primary incision used for cardiac procedures. It extends from the sternal notch to the xiphoid process. The sternum is divided, and

a finochietto retractor used to keep the incision open. [5]

[edit]Midline incision

The most common incision for laparotomy is the midline incision, a vertical incision which follows the linea alba.

 The upper midline incision usually extends from the xiphoid process to the umbilicus.

 A typical lower midline incision is limited by the umbilicus superiorly and by the pubic symphysis inferiorly.

 Sometimes a single incision extending from xiphoid process to pubic symphysis is employed, especially in trauma surgery.

Midline incisions are particularly favoured in diagnostic laparotomy, as they allow wide access to most of the abdominal cavity.

[edit]Mackenrodt incision
[edit]Parker's incision
[edit]Perthes' incision
[edit]Péan's incision
[edit]Pfannanstiel’s incision

The Pfannenstiel incision, a transverse incision below the umbilicus and just above the pubic symphysis. [6][7] In the classic Pfannenstiel

incision, the skin and subcutaneous tissue are incised transversally, but the linea alba is opened vertically. It is the incision of choice

forCesarean section and for abdominal hysterectomy for benign disease.

[edit]Rocky-Davis’ incision

The Davis or Rockey-Davis "muscle-splitting" right lower quadrant incision for appendectomy.

[edit]Schuchardt’s incision
[edit]Shambaugh incision
[edit]Yorke-Mason’s incision
[edit]Warren incision
[edit]Wilde's incision

170

J. Anat. Soc. India 50(2) 170-178 (2001)

J Anat. Soc. India 50(2) 170-178 (2001)

Surgical Incisions—Their Anatomical Basis

Part IV-Abdomen

*Patnaik, V.V.G.; **Singla, Rajan K.; ***Bansal V.K..

Department of Anatomy, Government Medical College, *Patiala, **Amritsar, ***Department of Surgery,
Govt. Medical College &

Hospital, Chandigarh, INDIA.

Abstract. The present paper is a continuation of the previous ones by Patnaik et al 2000 a, b & 2001.
Here the anatomical basis of

the various incisions used in anterior abdominal wall their advantages & disadvantages are discussed. An
attempt has been made to add

the latest modifications in a concised manner.

Key words : Surgical Incisions, Abdomen, Midline, Paramedian, McBurney, Gridison, Kocher.

Introduction :

It is probably no exaggeration to state that, in

abdominal surgery, wisely chosen incisions and

correct methods of making and closing such wounds

are factors of great importance (Nygaard and

Squatrito, 1996). Any mistake, such as a badly

placed incision, inept methods of suturing, or illjudged selection of suture material, may result in

serious complications such as haematoma

formation, an ugly scar, an incisional hernia, or,

worst of all, complete disruption of the wound

(Pollock, 1981; Carlson et al, 1995).

Before the advent of minimally invasive

techniques, optimal access could only be achieved

at the expense of large high morbidity incisions.

Endoscopic and laparoscopic technology has,

however revolutionized these concepts facilitating

patient friendly access to even the most remote of

abdominal organs (Maclntyre, 1994).

It should be the aim of the surgeon to employ

the type of incision considered to be the most

suitable for that particular operation to be

performed. In doing so, three essentials should be

achieved (Zinner et al, 1997):

1. Accessibility

2. Extensibility

3. Security

The incision must not only give ready and

direct access to the anatomy to be investigated but

also provide sufficient room for the operation to be

performed (Velanovich, 1989). The incision should

be extensible in a direction that will allow for any

probable enlargement of the scope of the operation,

but it should interfere as little as possible with the

functions of the abdominal wall. The surgical

incision and the resultant wound represent a major

part of the morbidity of the abdominal surgery.

Planning of an abdominal incision :

In the planning of an abdominal incision,

Nyhus & Baker (1992) stressed that the following

factors must be taken into consideration (a) preoperative diagnosis (b) the speed with which the

operation needs to be performed, as in trauma or

major haemorrhage, (c) the habitus of the patient,

(d) previous abdominal operation, (e) potential

placements of stomas (Funt, 1981; Telfer et al,

1993). Ideally, the incision should be made in the

direction of the lines of cleavage in the skin so that

a hairline scar is produced.

The incision must be tailored to the patients

need but is strongly influenced by the surgeon’s

preference. In general, re-entry into the abdominal

cavity is best done through the previous laparotomy

incision. This minimizes further loss of tensile

strength of the abdominal wall by avoiding the

creation of additional fascial defects (Fry & Osler,

1991).

Care must be taken to avoid ‘tramline’ or

‘acute angle’ incisions (Figure 1), which could lead

to devascularisation of tissues. It is also helpful if

incisions are kept as far as possible from

established or proposed stoma sites and these171

J. Anat. Soc. India 50(2) 170-178 (2001)

Classification of incisions :

The incisions used for exploring the abdominal

cavity can be classified as :

(A) Vertical incision : These may be

(i) Midline incision

(ii) Paramedian incisions

(B) Transverse and oblique incisions :

(i) Kocher's subcostal Incision

(a) Chevron (Roof top

Modification)

(b) Mercedes Benz Modification

(ii) Transverse Muscle dividing incision

(iii) Mc Burney’s Grid iron or muscle

spliting incision

(iv) Oblique Muscle cutting incision

(v) Pfannenstiel incision

(vi) Maylard Transverse Muscle cutting

Incision

(C) Abdominothoracic incisions

A. Vertical incisions :

Vertical incisions include the midline incision,

paramedian incision, and the Mayo-Robson

extension of the paramedian incision.

(i) Midline Incision (Figure 2) :

Almost all operations in the abdomen and

retroperitoneum can be performed through this

universally acceptable incision (Guillou et al, 1980).

Advantages (a) It is almost bloodless, (b) no muscle

fibres are divided, (c) no nerves are injured, (d) it

affords goods access to the upper abdominal

viscera, (e) It is very quick to make as well as to

close; it is unsurpassed when speed is essential

(Clarke, 1989) (f) a midline epigastric incision also

can be extended the full length of the abdomen

curving around the umbilical scar (Denehy et al,

(1998).

In the upper abdomen, the incision is made in

the midline extending from the area of xiphoid and

ending immediately above the umbilicus (Ellis,

1984). Skin, fat, linea alba and peritoneum are

divided in that order. Division of the peritoneum is

best performed at the lower end of the incision, just

above the umbilicus so that falciform ligament can

(a) (b)

Fig. 1. (a) Tramline Incision. (b) Acute angle incision.

stomas should be marked preoperatively with skin

marking pencils to avoid any mistakes (Burnand &

Young, 1992).

Cosmetic end results of any incision in the

body are most important from patients’ point of view.

Consideration should be given wherever possible, to

siting the incisions in natural skin creases or along

Langer’s lines. Good cosmesis helps patient morale.

Much of the decision about the direction of the

incision depends on the shape of the abdominal

wall. A short, stocky person sometimes has a longer

incision and frequently better exposure, if the

incision is transverse. A tall, thin, asthenic patient

has a short incision if it is made transversally,

whereas a vertical incision affords optimal exposure

(Greenall et al, 1980).

Certain operations are ideally done through a

transverse or subcostal incision, for example

cholecystectomy through a right Kocher’s incision,

right hemicolectomy through an infraumbilical

transverse incision, and splenectomy through a left

subcostal incision. Vagotomy and antrectomy can be

done through a bilateral subcostal incision with a

longer right and shorter left extension if the patient

is stocky or obese (Grantcharov & Rosenberg,

2001).

Certain incisions, popular in the past, have

been abandoned, and appropriately so. One

example of this is the para-rectus incision made at

the lateral border of the rectus sheath. This incision

was used until the mid 1940 primarily for the

removal of the gall bladder, the spleen, and the left

colon. It denervates the rectus muscle and produces

an ideal environment for the development of

postoperative ventral hernia, and has absolutely

nothing to recommend it (Nyhus & Baker, 1992).

Patnaik, V.V.G., et al172

J. Anat. Soc. India 50(2) 170-178 (2001)

be seen and avoided. If necessary for exposure, the

ligament can be divided between clamps and

ligated. A few centimeters of upwards extension can

be gained by extending the incision to either side of

the xiphoid process, or actually excising the xiphoid

(Didolkar & Vickers, 1995). The extraperitoneal fat is

abundant and vascular in this area, and small

vessels here need to be coagulated with diathermy.

The infraumbilical midline incision also divides

the linea alba. Because the linea alba is

anatomically narrow at the inferior portion of the

abdominal wall, the rectus sheath may be opened

unintentionally, although this is of no consequence.

In the lower abdomen, the peritoneum should be

opened in the uppermost area to avoid possible

injury to the bladder.

It is a good practice to place a bladder catheter

before any surgery on the lower abdomen and to

curve the properitoneal and peritoneal incisions

laterally when approaching the pubic symphysis to

avoid entry into the bladder (Nyhus & Baker, 1992).

Special care is needed when operating on

patients with intestinal obstruction or when reexploring following previous abdominal surgery (Fry

& Osler, 1991). In intestinal obstruction, distended

bowel loops may be there immediately below the

incision and in re-exploration, the bowel may be

adherent to the peritoneum. The way to avoid this is

to open the peritoneum in a virgin area at the upper

or lower part of the incision (Levrant et al, 1994).

(ii) Paramedian Incision (Figure 3)

The paramedian incision has two theoretical

advantages. The first is that it offsets the vertical

incision to the right or left, providing access to the

lateral structures such as the spleen or the kidney.

The second advantage is that closure is theoretically

more secure because the rectus muscle can act as

a buttress between the reapproximated posterior

and anterior fascial planes (Cox et al, 1986).

Fig. 2. Midline Incision

Fig. 3. Paramedian Incisions

The 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. Extra

access can be obtained by sloping the upper

extremity of the incision upwards to the xiphoid

(Didolkar et al, 1995).

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 haemostats. 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 (Brennan et

al, 1987). 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 (Chuter et al, 1992).

A paramedian incision below the umbilicus is

made in a similar manner. The only difference is

that inferior epigastric vessels are exposed in the

posterior compartment of the rectus sheath and the

transversalis fascia is found in the anterior fascial

Surgical Incisions-Abdomen173

J. Anat. Soc. India 50(2) 170-178 (2001)

layer below the semicircular line of Douglas.

some surgeons still prefer to split the rectus

muscle rather than dissect it free (Guillou et al,

1980). In this rectus-splitting technique, the muscle

is split longitudinally near its medial border (medial

1/3rd or preferably one-sixth), after which posterior

layer of the rectus sheath and peritoneum are

opened in the same line. This incision can be made

and closed quickly and is particularly valuable in

reopening the scar of a previous paramedian

incision. In such circumstances, it is very difficult, or

indeed impossible to dissect the rectus muscle away

from the rectus sheath.

Disadvantages :

1. It tends to weaken and strip off the

muscles from its lateral vascular and

nerve supply resulting in atrophy of the

muscle medial to the incision.

2. The incision is laborius and difficult to

extend superiorly as is limited by costal

margin.

3. It doesn’t give good access to

contralateral structures.

The Mayo-Robson extension of the

paramedian incision is accomplished by curving the

skin incision towards the xiphoid process. Incision of

the fascial planes is continued in the same direction

to obtain a larger fascial opening (Pollock, 1981).

(B) Transverse Incisions (Figure 4)

Transverse incisions include the Kocher

subcostal incision, transverse muscle dividing,

McBurney, Pfannenstiel, and Maylard incisions.

(i) Kocher subcostal incision (Figure 5)

Theodore Kocher originally described the

subcostal incision; it affords excellent exposure to

the gall bladder and biliary tract and can be made

on the left side to afford access to the spleen

(Kocher, 1903). It is of particular value in obese and

muscular patients and has considerable merit if

diagnosis is known and surgery planned in advance.

Fig. 4. Transverse and transverse-oblique

Incisions. A. Kocher incision. B. Transverse

Incision. C. Rockey-Davis incision. D. Maylard

incision. E. Pfannenstiel incision

Fig. 5. Kocher’s Incision

The subcostal incision is started at the midline,

2 to 5 cm below the xiphoid and extends

downwards, outwards and parallel to and about 2.5

cm below the costal margin (Hardy 1993; Dorfman

et al, 1997). Extension across the midline and down

the other costal margin may be used to provide

generous exposure of the upper abdominal viscera.

The rectus sheath is incised in the same direction as

the skin incision, and the rectus muscle is divided

with cautery; the internal oblique and transversus

abdominis muscles are divided with cautery. Some

authors have described the retraction of rectus

muscle instead of dividing it (Brodie et al, 1976; Fink

& Budd, 1984).

Special attention is needed for control of the

branches of the superior epigastric vessels, which

lie posterior to and under the lateral portion of the

rectus muscle. The small eighth thoracic nerve will

almost invariably be divided; the large ninth nerve

must be seen and preserved to prevent weakening

of the abdominal musculature. The incision is

deepened to open the peritoneum (Dorfman et al,

1997).

In the recent years, many surgeons have

advocated the use of a small 5-10 cm incision in the

subcostal area for cholecystectomy - mini-lap

Patnaik, V.V.G., et al174

J. Anat. Soc. India 50(2) 170-178 (2001)

because the incision passes between adjacent

nerves without injuring them. The rectus muscle has

a segmental nerve supply, so there is no risk of a

transverse incision depriving the distal part of the

rectus muscle of its innervation. Healing of the scar,

in effect, simply results in the formation of a man

made additional fibrous intersection in the muscle

(Pemberton and Manaz, 1971).

(ii) Transverse Muscle-dividing incision (Figure 6)

The operative technique used to make such an

incision is similar to that for the Kocher incision. In

newborns and infants, this incision is preferred,

because more abdominal exposure is gained per

length of the incision than with vertical exposure

because the infant’s abdomen has a longer

transverse than vertical girth (Gauderer, 1981). This

is also true of short, obese adults, in whom

transverse incision often affords a better exposure.

(iii) McBurney Grid iron or Muscle-split incision

(Figure 7)

The McBurney incision, first described in 1894

by Charles McBurney is the incision of choice for

most appendicectomies (McBurney, 1894). The

level and the length of the incision will vary

according to the thickness of the abdominal wall and

the suspected position of the appendix (Jelenko &

Davis 1973; Watts & Perrone, 1997). Good healing

and cosmetic appearance are virtually always

achieved with a negligible risk of wound disruption

or herniation.
cholecystectomy (Seenu & Misra, 1994). This

incision is similar to the Kocher’s incision except for

the length of the incision. The major advantages of

this incision are lesser postoperative pain, early

recovery from the surgery and return to work and

good cosmetic results (Coelho et al, 1993). But

diadvantage is less exposure, which can be

dangerous in cases of difficult anatomy or lot of

adhesions and chances of injury to bile ducts or

other structures (Kopelman et al, 1994; Gupta et al,

1994).

(a) Chevron (Roof Top) Modification :

The incision may be continued across the

midline into a double Kocher incision or roof top

approach (Chevron Incision) (Figure 6), which

provides excellent access to the upper abdomen

particularly in those with a broad costal margin

(Chute et al, 1968; Brooks et al, 1999). This is

useful in carrying out total gastrectomy, operations

for renovascular hypertension, total

oesophagectomy, liver transplantation, extensive

hepatic resections, and bilateral adrenalectomy etc

(Chino & Thomas, 1985; Pinson et al, 1995;

Miyazaki et al, 2001).

Fig. 6. A.. A: Rooftop incision; B..: Mercedes Benz extension

(b) The Mercedes Benz Modification :(Fig. 6)

Variant of this incision consists of bilateral low

Kocher’s incision with an upper midline limb up to

and through the xiphisternum (Sato et al, 2000).

This gives excellent access to the upper abdominal

viscera and, in particular to all the diaphragmatic

hiatuses (Yoshinaga, 1969; Motsay et al, 1973;

Brooks et al, 1999).

The rectus muscle can be divided transversely.

Its anterior and posterior sheaths are closed without

any serious weakening of the abdominal muscle

Classically, the McBurney incision is made at

the junction of the middle third and outer thirds of a

Fig. 7. Surface markings of the right iliac fossa

appendicectomy incision. A. The Classic McBurney incision

is obnliquely placed. B. Most surgeons today use a more

transverse skin-crease incision

Surgical Incisions-Abdomen175

J. Anat. Soc. India 50(2) 170-178 (2001)

line running from the umbilicus to the anterior

superior iliac spine, the McBurney point (Watts,

1991). However, if palpation reveals a mass, the

incision can be placed directly over the mass.

McBurney originally placed the incision obliquely,

from above laterally to below medially. However, the

skin incision can be placed in a skin crease

transversely [Rockey-Davis Incision (Fig 4c) or Lanz

Incision or Bikini Incision], which provides a better

cosmetic result (Delany & Carnevale, 1976;

Pleterski & Temple, 1990). Otherwise, the two

incisions are similar.

If it is anticipated that it may be necessary to

extend the incision, then the incision should be

placed obliquely, which enables it to be extended

laterally as a muscle splitting incision (Losanoff &

Kjossev, 1999).

After the skin and subcutaneous tissue are

divided, the external oblique aponeurosis is divided

in the direction of its fibres; exposing the underlying

internal oblique muscle. A small incision is then

made in this muscle adjacent to the outer border of

the rectus sheath. The opening is enlarged to permit

introduction of two index fingers between the muscle

fibres so that internal oblique and transversus can

be retracted with a minimal amount of damage. The

peritoneum is then grasped with a thumb forceps,

elevated and opened.

If further access is required, the wound can be

easily enlarged by dividing the anterior sheath of the

rectus muscle in line with the incision, after which

rectus muscle is retracted medially (Jelenko &

Davis, 1973; Moneer, 1998). Wide lateral extension

of the incision can be affected by combination of

division and splitting of the oblique muscles along

the line of their fibres in the lateral direction (Weir

extension) (Askew, 1975).

This incision also may be used in the left lower

quadrant to deal with certain lesions of the sigmoid

colon, such as drainage of a diverticular abscess.

The ilioinguinal and iliohypogastric nerves

cross the incision for appendectomy and their

accidental injury should be prevented which can

predispose the patient to inguinal hernia formation in

the postoperative period (Mandelkow & Loeweneck,

1988).

(iv) Oblique Muscle-cutting incision

This incision bears the eponym of the

Rutherford-Morrison incision (Talwar et al, 1997).

This is extension of the McBurney incision by

division of the oblique fossa and can be used for a

right or left sided colonic resection, caecostomy or

sigmoid colostomy.

(v) Pfannenstiel incision (Figure 4)

The Pfannenstiel incision is used frequently by

gynaecologists and urologists for access to the

pelvis organs, bladder, prostate and for caesarean

section (Ayers & Morley, 1987; Mendez et al, 1999;

Hendrix et al, 2000). The skin incision is usally 12

cm long and is made in a skin fold approximately 5

cm above symphysis pubis. The incision is

deepened through fat and superficial fascia to

expose both anterior rectus sheaths, which are

divided along the entire length of the incision. The

sheath is then separated widely, above and below

from the underlying rectus muscle. It is necessary to

separate the aponeurosis in an upward direction,

almost to the umbilicus and downwards to the pubis.

The rectus muscles are then retracted laterally and

the peritoneum opened vertically in the midline, with

care being taken not to injure the bladder at the

lower end.

The incision offers excellent cosmetic results

because the scar is almost always hidden by the

patient’s pubic hair postoperatively (Griffiths, 1976).

Because the exposure is limited this incision should

be used only when surgery is planned on the pelvic

organs (Mendez et al, 1999).

(vi) Maylard Transverse Muscle Cutting Incision

(Figure 4)

Many surgeons prefer this incision because it

gives excellent exposure of the pelvic organs

(Helmkamp & Kreb, 1990; Brand, 1991). The skin

incision is placed above but parallel to the traditional

placement of Pfannenstiel incision. The rectus

fascia and muscle are then cut transversely, and the

incision is continued laterally as far as necessary,

dividing external and internal oblique muscles; the

transverses abdominis and transversalis fascia are

opened in the direction of their fibres.

Patnaik, V.V.G., et al176

J. Anat. Soc. India 50(2) 170-178 (2001)

(C) Thoracoabdominal Incision (Figures 8 & 9)

The thoracoabdominal incision, either right or

left, converts the pleural and peritoneal cavities into

one common cavity and thereby gives excellent

exposure. Laparotomy incisions, whether upper

midline, upper paramedian or upper oblique can be

easily extended into either the right or left chest for

better exposure (Nyhus & Baker, 1992).

The right incision may be particularly useful in

elective and emergency hepatic resections (Kise et

al, 1997). The left incision may be used effectively

in resection of the lower end of the esophagus and

proximal portion of the stomach (Molina et al, 1982;

Ti, 2000).
When liver resection is anticipated, it is now

more common to give a sternum splitting incision

than to extending it into the right pleural space (Sato

et al, 2000). The reasons for this are that the

sternum heals with considerably less pain than does

the costochondral junction; the exposure is as good,

and the intrapericardial vena cava can be controlled

through this incision if there is untoward venous

bleeding (Miyazaki et al, 2001).

The thoracic incision is carried down through

the subcutaneous fat and the lattismus dorsi,

serratus anterior and external oblique muscles. The

intercostals muscles are divided with cautery and

pleural cavity is opened and lung allowed to

collapse. The incision is continued across the costal

margin, and the cartilage is divided in a V shape

manner with a scalpel so that the two ends

interdigitate and can be closed more securely. A

chest retractor is inserted and opened to produce

wide spreading of the intercostal space. After

ligation of the phrenic vessels in the line of the

incision, the diaphragm is divided radially (Zinner et

al, 1997).

References :

1. Askew, A.R. (1975) : The Fowler-Weir approach to

appendicectomy. British Journal of Surgery, 62(4): 303-4.

2. Ayers, J.W., Morley, G.W. (1987): Surgical incision for

caesarean section. Obstetrics Gynaecology, 70(5): 706-8.

3. Brand, E. (1991): The Cherney incision for gynaecologic

cancer. American Journal of Obstetrics and Gynaecology,

165(1): 235.

4. Brennan, T.G., Jones, N.A., Guillou, P.J. (1987): Lateral

paramedian incision. British Journal of Surgery, 74(8): 736-7.

5. Brodie. T.E., Jackson, J.T., McKinnon, W.M. (1976): A

muscle retracting subcostal incision for cholecystectomy.

Surgery Gynaecology Obstetrics 143(3): 452-3.

6. Brooks, M.J., Bradbury, A., Wolfe, H.N. (1999) : Elective

repair of type IV thoraco-abdominal aortic aneurysms;

experience of a subcostal (transabdominal) approach.

European Journal of Vascular Endovascular Surgery, 18(4):

290-3.

7. Burnand, K.G., Young, A.E.: The New Aird’s Companion in

Surgical Studies. Churchil Livingstone Edinburgh (1992).

8. Carlson, M.A., Ludwig, K.A., Condon, R.E. (1995): Ventral

hernia and other complications of 1,000 midline incisions.

Southern Medical Journal Apr; 88(4): 450-3.

Fig. 9. Surface markings of the thoracoabdominal incision

Fig. 8. ‘‘Corkscrew’’ position for throaco abdominal incision

The patient is placed in the “cork-screw”

position. (Fig. 8) The abdomen is tilted about 45°

from the horizontal by means of sand bags, and the

thorax twisted into fully lateral position. This position

allows maximal access to both abdomen and the

thoracic cavity (Morrissey & Hollier, 2000). The

abdomen is explored first through the abdominal

incision to assess for the operative exposure and

necessity for thoracic extension. The incision is

extended along the line of the eighth interspace, the

space immediately distal to the inferior pole of the

scapula (Dudley, 1983). (Fig. 9)

Surgical Incisions-Abdomen177

J. Anat. Soc. India 50(2) 170-178 (2001)

9. Chino, E.S., Thomas, C.G. (1985): An extended Kocher

incision for bilateral adrenalectomy. American Journal of

Surgery, 149(2): 292-4.

10. Chute, R., Baron, J.A. Jr., Olsson, C.A. (1968): The

transverse upper abdominal “chevron” incision in urological

surgery. Journal of Urology, 99(5): 528-32.

11. Chuter, T.A., Steinberg, B.M., April, E.W. (1992): Bleeding

after extension of the midline epigastric incision. Surgery

Gynaecology Obstetrics, 174(3): 236.

12. Clarke, J.M. (1989): Case for midline incisions. Lancet, Mar

18; 1 (8638): 622.

13. Coelho, J.C., de Araujo, R.P., Marchensini, J.B., Coelho, I.C.,

de Araujo, L.R. (1993): Pulmonary function after

cholecystectomy performed through Kocher’s incision, a

mini-incision, and laparoscopy. World Journal of Surgery.

17(4): 544-6.

14. Cox, P.J., Ausobsky, J.R., Ellis, H., Pollock, A.V. (1986):

Towards no incisional hernias: lateral paramedian versus

midline incisions. Journal of Royal Society of Medicine, Dec.

79(12): 711-12.

15. Delany, H.M., Carnevale, N.J. (1976): A “Bikini” incision for

appendicectomy. American Journal of Surgery; 132(1): 126-

27.

16. Denehy, T.R., Einstein, M., Gregori, C.A., Breen, J.L. (1998):

Symmetrical periumbilical extension of a midline incision: a

simple technique. Obstetrics Gynaecology 91(2): 293-94.

17. Didolkar, M.S., Vickers, S.M. (1995): Perixiphoid extension of

the midline incisions. Journal of American College of

Surgery, 180(6): 739-41.

18. Dorfman, S., Rincon, A., Shortt, H. (1997): Cholecystectomy

via Kocher incision without peritoneal closure. Investigation

Clinics, 38(1): 3-7.

19. Dudley, H.: Robe and Smith’s Operative Surgery. In:

Alimentary Tract and abdominal wall. Volume 1 General

Principles, 4th edn. Butterworths London: (1983).

20. Ellis, H. (1984): Midline abdominal incisions. British Journal

of Obstetrics and Gynaecology; 91(1): 1-2.

21. Fink, D.L., Budd, D.C. (1984): Rectus muscle preservation in

oblique incisions for cholecystectomy. American Journal of

Surgery. 50(11): 628-36.

22. Fry D.E., Osler, T. (1991): Abdominal wall considerations and

complications in reoperative surgery. Surgery Clinics of North

America, 71(1): 1-11.

23. Funt, M.I. (1981): Abdominal incisions and closures. Clinical

Obstetrics Gynaecology, 24(4): 1175-85.

24. Gauderer, M.W.L. (1981): A rationale for the routine use of

transverse abdominal incision in infants and children. Journal

of Paediatric Surgery 16 (Sup.1): 583.

25. Grantcharov, T.P., Rosenberg, J. (2001): Vertical compared

with transverse incision in abdominal surgery. European

Journal of Surgery: 167(4): 260-7.

26. Greenall, M.J., Evans, M., Pollock, A.V. (1980): Midline or

transverse laparotomy ? A random controlled clinical trial.

Part I: Influence on healing. British Journal of Surgery, 67(3):

188-90.

27. Grriffiths, D.A. (1976): A reappraisal of the Pfannenstiel

incision. British Journal of Urology, 46(6): 469-74.

28. Guillou, P.J., Hall, T.J., Donaldson, D.R., Broughton, A.C.,

Brennan, T.G. (1980): Vertical abdominal incisions - a

choice ? British Journal of Surgery, 67(6): 395-9.

29. Gupta, S., Elanogovan, K., Coshic, O., Chumber, S. (1994):

Minicholecystectomy: can we reduce it further ? Journal of

Surgery Oncology, 56(3): 167.

30. Hardy, K.J. (1993): Carl Langenbuch and the Lazarus

Hospital: events and circumstances surrounding the first

cholecystectomy. Australian Journal of surgery, 63(1): 56-64.

31. Helmkamp, B.F., Krebs, H.B. (1990): The Maylard incision in

gynaecologic surgery. American Journal of Obstetrics and

Gynaecology, 163(5Pt.1): 1554-7.

32. Hendrix, S.L., Schimp, V., Martin, J., Singh, A., Kruger, M.,

McNeelay, S.G. (2000): The legendary superior strength of

the pfannensteil incision: a myth ? American Journal of

Obstetrics and Gynaecology, 182(6) : 1446-51.

33. Jelenko C 3rd., Davis, L.P. (1973): A transverse lower

abdominal appendicectomy incision with minimal muscle

deranagement. Surgery Gynaecology Obstetrics, 136(3):

451-2.

34. Kise, Y., Takayama T., Yamamoto, J., Shimada, K., Kosuge,

T., Yamasaki S., Makuuchi, M. (1997): Comparison between

thoracaobdominal and abdominal approaches in occurrence

of pleural effusion after liver cancer surgery.

Hepatogastroenterology, 44(17): 1397-1400.

35. Kocher, T. Textbook of operative surgery, 2nd ed. Black

London, England: (1903)

36. Kopelman, D., Schein, M., Assalia, A., Meizlin, V.,

Harshmonia, M. (1994): Technical aspects of

minicholecystectomy. Journal of American College of

Surgery. 178(6): 624-5.

37. Levrant, S.G., Bieber, E., Barnes, R. (1994): Risk of anterior

abdominal wall adhesions increases with number and type of

previous laparotomy. Journal of American Association of

Gynaecology Laparotomy, 1 (4, Part 2): 19.

38. Losanoff, J.E., Kjossev, K.T. (1999): Extension of

McBurney’s incision: old standards versus new options.

Surgery Today, 26(6): 584-6.

39. Mandelkow, H., Leoweneck, H. (1988): The iliohypogastric

and ilioinguinal nerves. Distribution in the abdominal wall,

danger areas in surgical incisions in the inguinal and pubic

regions and reflected visceral pain in their dermatomes.

Surgery Radiology Anatomy, 10(2): 145-9.

40. Maclntyre,, I.M.C.: Pratical Laparoscopic Surgery for General

Surgeons. Butterworth-Hennemann. Oxford: (1994)

41. McBurney, C. (1894): The incision made in the abdominal

wall in cases of appendicitis, with a description of a new

method of operating. Annals of Surgery, 20: 38.

42. Mendez, L.E., Cantuaria, G., Angioli, R., Mirhashemi, R.,

Gabriel, C., Estape, R., Penalver, M. (1999): Evaluation of the

Pfannensteil incision for radical abdominal hysterectomy with

pelvic and para-aortic lymphadenectomy. International

Journal of Gynaecology Cancer, 9(5): 418-20.

43. Miyazaki, K., Ito, H., Nakagawa, K., Shimizu, H., Yoshidome,

H., Shimizu, Y., Ohtsuka, M., Togawa, A., Kimura, F. (2001):

An approach to intrapericardial inferior vena cava through the

abdominal cavity, without median sternotomy, for total hepatic

vascular exclusion. Hepatogastroenterology, 48(41): 1443-6.

44. Molina, J.E., Lawton, B.R., Myers, W.O., Humphrey, E.W.

(1982): Esophagogastrectomy for adenocarcinoma of the

cardia. Ten years’ experience and current approach. Annals

of Surgery, 195(2): 146-51.

45. Moneer, M.M. (1998): Avoiding muscle cutting while

extending McBurney’s incision: a new surgical concept.

Surgery Today, 28(2): 235-9.

46. Morrissey, N.J., Hollier, L.H. (2000): Anatomic exposures in

thoracoabdominal aortic surgery. Semin Vascular Surgery,

13(4): 283-9.

Patnaik, V.V.G., et al178

J. Anat. Soc. India 50(2) 170-178 (2001)

47. Motsay, G.J., Alho, A., Lillehei, R.C. (1973): Diastolic

hypertension corrected by operation: a review. Journal of

Surgical Research, 15(6): 433-49.

48. Nygaard, I.E., Squatrito, R.C. (1996): Abdominal incisions

from creation to closure. Obstetrics Gynaecology Surgery

51(7): 429-36.

49. Nyhus, L.M. & Baker, R.J. : Mastery of Surgery In :

Abdominal Wall Incisions. 2nd Edn Little Brown & Co.

Boston. : 444-452 (1992).

50. Patnaik, V.V.G., Singla, R.K., Bala Sanju (2000a): Surgical

Incisions-Their anatomical basis. Part-I Head & Neck.

Journal of The Anatomical Society of India 49(1): pp 69-77.

51. Patnaik, V.V.G., Singla, R.K., Gupta, P.N. (2000b): Surgical

Incisions-Their anatomical basis. Part-II Upper limb. Journal

of The Anatomical Society of India 49(2): pp 182-190.

52. Patnaik, V.V.G., Singla, R.K., Gupta, P.N. (2001): Surgical

Incisions-Their anatomical basis. Part-III Lower limb. Journal

of The Anatomical Society of India 50(1): pp 48-58.

53. Pemberton, L.B., Manaz, W.G. (1971): Complications after

vertical and transverse incisions for cholecystectomy.

Surgery Gynaecology Obstetrics, 132(5): 892-4.

54. Pinson, C.W., Drougas, J.G., Lalikos, J.L. (1995): Optimal

exposure for hepatobiliary operations using the Bookwalter

self-retaining retractor. American Journal of Surgery, 61(2):

178-81.

55. Pleterski, M., Temple, W.J. (1990): Bikini appendicectomy

incision as an alternative to the McBurney approach for

appendicitis. Canadian Journal of Surgery, 33(5): 343-5.

56. Pollock, A.V. (1981): Laparotomy. Journal of Social Medicine

74(7): 480-4.

57. Sato, H., Sugawara, Y., Yamasaki, S., Shimada, K.,

Takayama, T., Makuuchi, M., Kosuge, T. (2000):

Thoracoabdominal approaches versus inverted T incision for

posterior sgementectomy in hepatocellular carcinoma.

Hepatogastroenterology, 47(32): 504-6.

58. Seenu, V., Misra, M.C. (1994): Mini-lap cholecystectomy - an

attractive alternative to conventional cholecystectomy.

Tropical Gastroenterology, 15(1): 29-31.

59. Talwar, S., Laddha, B.L., Jain, S., Prasad, P. (1997): Choice

of incision in surgical management of small bowel

perforations in enteric fever. Tropical Gastroenterology, 18(2):

78-9.

60. Telfer, J.R., Canning, G., Galloway, D.J. (1993): Comparative

study of abdominal incision techniques. British Journal of

Surgery, Feb; 80(2): 233-5.

61. Ti, T.K. (2000): Surgical approach and results of surgery in

adenocarcinoma of the gastro-oesophageal junction.

Singapore Medical Journal, 41(1): 14-8.

62. Velanovich, V. (1989): Abdominal incision, Lancet, 4;1(8636):

508-9.

63. Watts. G.T. (1991): McBurney’s point-factor or fiction. Annals

of Royal College of Surgery England, 73(3): 199-200).

64. Watts, G.T., Perone, N. (1997): Appendicectomy. Southern

Medical Journal, 90(2): 263.

65. Yoshinaga, K. (1969): Operable hypertensions. Japanese

Circ Journal, 33(12): 1627-8.

66. Zinner, M.J., Schwartz, S.I., Ellis, H. Maingot’s abdominal

operations In: Incisions, closures and management of the

wound. Ellis, H. (Edr), 10th Edn. Prentice Hall International

Inc. N. Jersey, pp. 395-426. (1997)

J Anat. Soc. India 50(1) 48-58 (2001)

Surgical Incisions — Their Anatomical Basis Part III - Lower Limb

Patnaik, V.V.G.,

Singla, Rajan, K.,

Gupta, P.N.

Department of Anatomy, Government Medical College, Patiala

, Amritsar

, Department of Orthopedics Government Medical

College, Chandigarh

INDIA .

For Reprints, request the first author.

Abstract. The present paper is a continuation of the previous one by the same authors in the last issue.
Here, we have made an

attempt to delineate various incisions for exposing different bones & joints of lower limb along with
important anatomical landmarks to be

taken care while designing & executing these.

Key words : Surgical Incisions, Hip, Knee, Ankle, Femur, Tibia, Calcaneus, Toes.

Introduction :

Numerous new approaches to the different

regions of lower limb have been described during

the past few years, most of which are based on

older approaches & are modified for a specific

surgical procedure. We will discuss the anatomical

basis of the most widely used approaches. Various

approaches in lower limb can be classified

according to the site as follows :

(A) Approaches to Hip Joint :

(i) Anterior approaches :

1. Smith Peterson approach.

- Schaubel Modification.

2. Somerville Bikni Incision.

(ii) Antero lateral approach (Smith Peterson,

Cave & Van Gorder)

(iii) Lateral Approaches :

1. Watson Jones approach.

2. Harris approach.

3. Mc Farland & Osborne approach.

4. Hardinge approach.

5. Mc Lauchlan approach.

(iv) Postero Lateral Approaches :

1. Gibson approach.

2. Marcy & Fletcher Modification.

(v) Posterior Approaches :

1. Osborne Incision

2. Moore Incision

(vi) Medial Approach (Ludloff) :

(vii) Antero Medial Approach (Zanepen &

Gamidov) :

(i) Anterior Approaches

1. Smith Peterson :—It is also known as

Anterior ilio femoral approach. Here, the incision is

begun at the middle of the iliac crest & carried

anteriorly to the anterior superior iliac spine & then

distally & slightly laterally for 10-12 cm. (Fig 1a) .

Attachments of gluteus medius & tensor fascia lata

muscle are freed from iliac crest. Dissection is

carried between tensor fascia lata laterally &

sartorius & rectus femoris medially. Ascending

branch of lateral circumflex femoral artery lies 5 cm

distal to hip joint which is clamped & ligated. Lateral

cutaneous nerve of thigh passes over sartorius 2.5

cm. distal to anterior superior iliac spine; it has to be

retracted medially. This exposes the capsule of hip

joint which can be incised along its attachment to

acetabulum after cutting the origin of rectus femoris.

Schaubel Modification (1980) : Schaubel found

reattachment of fascia lata to the fascia on iliac

crest difficult so instead of dividing the fascia lata at

iliac crest, he performed an osteotomy of iliac crest

between attachments of external oblique muscle

medially & fascia lata laterally. Tensor fascia lata,

gluteus medius & gluteus minimus attachments

were subperiostealy dissected distally to expose hip

joint capsule.

2. Somerville ‘Bikni’ Incision :—Somerville

(1953) described an anterior approach using a

transverse ‘bikni’ incision for irreducible congenital

dislocation of hip joint in a young child.

A straight skin incision is made beginning

anteriorly, medial & inferior to anterior superior iliac

spine& coursing obliquely superiorly & posteriorly to

middle of iliac crest. (Fig 1b). The abductor muscles

are reflected subperiosteally from iliac bone distally

to capsule of hip joint. Tensor fascia lata is

separated from sartorius for about 2.5 cm inferior to

anterior superior iliac spine. Reflected head of

rectus femoris is separated from acetabulum &

capsule. For a wide exposure its straight head may

also be divided & reflected distally.

(ii) Antero lateral approach :—It is used for

open reduction & internal fixation of fracture femoral

neck. It retains the advantage of anterior ilio femoral

approach but exposes the trochanteric region

laterally. Since the superior retinacular vessels

which are major source of supply to the head of

femur do not come in the way the chances of

avascular necrosis of head of femur are less.

48

J. Anat. Soc. India 50(1) 48-58 (2001)Fig. 1. Approaches to Hip Joint (a) Smith Peterson approach. (b)
Somerville Bikni Incision. (c) Watson Jones lateral approach.

(d) Harris technique (e) Mc Farland Osborne technique. (f) Hardinge Modification (g) Mc Lauchlan
Incision (h) Gibson’s

Postero Lateral approach. (i) Osborne’s posterior approach (j) Moore’s Southern approach (k) Ludloff’s
Medial approach.

49

J. Anat. Soc. India 50(1) 48-58 (2001)

Patnaik, V.V.G. et al50

J. Anat. Soc. India 50(1) 48-58 (2001)

Surgical Incisions Lower Limb

The incision is made along anterior third of

iliac crest & then along anterior border of tensor

fascia lata, curving posteriorly across the insertion

of this muscle into iliotibial tract in the subtrochanteric region (usually 8 to 10 cm below the

base of greater trochanter) & end there. Lateral

cutaneous nerve of thigh is saved & retracted

medially as in anterior ilio femoral approach.

Abductor muscles are reflected as in Somerville

Incision above & capsule is exposed.

(iii) Lateral Approaches :

1. Watson Jones Technique (1935) :—This is

the most commonly used approach among the

lateral approaches. The incision is begun 2.5 cm

distal & lateral to the anterior superior iliac spine &

curved distally & posteriorly over the lateral aspect

of greater trochanter & lateral surface of femoral

shaft to a point 5 cm distal to the base of trochanter

(Fig. 1c). The interval between Gluteus medius &

tensor fascia lata is often difficult to delineate.

However, Brackett (1912) pointed out that it can be

done more easily by beginning the separation

midway between anterior superior iliac spine &

greater trochanter before tensor fascia lata blends

with its fascial insertion. The capsule can be

approached through this interval. This approach is

used commonly for open reduction of fracture neck

of femur & for joint replacement surgery.

2. Harris Technique :—Harris (1973)

recommended this approach for an extensive

exposure of hip. In this, a U shaped incision is made

with its base at posterior border of greater

trochanter. It is begun 5 cm posterior & slightly

proximal to anterior superior iliac spine, curved

distally & posteriorly to posterior superior corner of

greater trochanter & then extended longitudinally for

8 cm. Finally it is curved anteriorly & distally making

2 limbs of U symmetrical (Fig. 1d). The approach

permits dislocation of femoral head both anteriorly &

posteriorly but requires an osteotomy of the greater

trochanter with the resulting risk of non union or

trochanteric bursitics. Also, as reported by Testa &

Mazus (1988), incidence of significant or disabling

hetrotropic ossification is increased by this method.

3. Mc Farland Osborne Technique (1954) :—In

this, a midlateral skin incision is made centred over

the greater trochanter, its length depending upon

amount of sub cutaneous fat (Fig. 1e) Gluteal fascia

& iliotibial tract are divided in line with skin incision.

This technique considers the gluteus medius &

vastus lateralis muscles to be in direct functional

continuity through thick periosteum covering greater

trochanter.

4. Hardinge Modification (1982) :—This is a

modification of Mc Farland & Osborne (1954)

technique based on the observation that gluteus

medius inserts on the greater trochanter by a strong,

mobile tendon that curves around the apex of

trochanter. In this a posteriorly directed lazy ‘J’

incision is made centred over the greater trochanter

(Fig. 1f). Fascia lata is incised in line with skin

incision. Tensor fascia lata is retracted anteriorly &

gluteus maximus posteriorly to expose origin of

vastus lateralis & insertion of gluteus medius. These

are partially divided to reach the anterior aspect of

capsule which can be incised as desired. This

approach is used for hip replacement surgery.

5. Mc Lauchlan Incision (1984) :—It is a lateral

longitudinal skin incision centered midway between

anterior & posterior borders of greater trchanter &

extending an equal distance proximal & distal to the

tip of greater trochanter (Fig. 1g). Tensor fascia lata

is incised in line with skin incision & greater

trochanter is exposed with gluteus medius attached

proximally & vastus lateralis attached distally. The

muscles are split in line of their fibres & greater

trochanter is cut in form of 2 rectangular slices (with

osteotome) having gluteus medius attached

proximally & vastus lateralis attached distally on

both of these. One is retracted anteriorly & one

posteriorly to expose hip joint.

(iv) Postero lateral approach (Gibson, 1953) :—

In this, the proximal limb of incision is begun at

a point 6-8 cm anterior to posterior superior iliac

spine & just distal to iliac crest overlying the anterior

border of gluteus maximus muscle. It is extended

distally to anterior border of greater trochanter &

further distally in line of femur for 15-18 cm. (Fig.

1h) Iliotibial tract is incised in line with direction of its

fibres. Next, gluteus minimus et medius are divided

at their insertion to expose the capsule.

(v) Posterior approaches

In posterior approaches to the hip the joint is

exposed by cutting the posterior aspect of capsule.

These approaches are commonly used for hip

replacement surgery but less popular for open

reduction & internal fixation of fracture neck of the

femur as the superior retinacular vessels & the

ascending branch of medial circumflex femoral

artery is in jeopardy thereby leading to avascular

necrosis of the head of femur.

1. Osborne approach (1931) :—The incision is

begun 4-5 cm distal & lateral to posterior superior

iliac spine & continued laterally & distally remaining

parallel to fibres of gluteus maximus to posterior

superior angle of greater trochanter & then distally

along posterior border of greater trochanter for 5 cm

(Fig 1i). Gluteus maximus fibres are separated

parallel to skin incision. Since branches of superior

gluteal artery are in proximal half of the muscle &

those of inferior gluteal artery are in distal half of51

J. Anat. Soc. India 50(1) 48-58 (2001)

Patnaik, V.V.G. et al

muscle so little bleeding occurs. Insertion of gluteus

maximus to fascia lata is divided for 5 cm

corresponding to long limb of incision. Piriformis &

gamelli are detached near their insertion & retracted

medially. These protect the sciatic nerve & the

capsule is now exposed.

2. Moore’s approach (1959) :—It is also known

as “Southern Exposure”. The incision is started 10

cm distal to posterior superior iliac spine & extended

distally & laterally parallel to fibres of gluteus

maximus to posterior margin of greater trochanter.

Then it is directed distally for 10-12 cm parallel to

femoral shaft (Fig. 1j). Rest of exposure is almost

same as in osborne’s technique.

(vi) Medial Approach :—(Ludloff, 1908) It was

developed to permit surgery on a congenitally

dislocated hip. The incision is placed on medial

aspect of thigh beginning 2.5 cm distal to pubic

tubercle & over the interval between gracilis &

adductor longus muscle. (Fig 1k). A plane is

developed between adductor longus et brevis

anteriorly & gracilis & adductor magnus posteriorly.

Posterior branch of obturator nerve & neurovascular

bundle to gracilis is exposed & protected. Capsule is

located in the floor of wound.

(vii) Antero Medial Approach :—(Zazepan &

Gamidov, 1972) In this, a longitudinal incision is

made 15-20 cm long, 2-3 cm medial to femoral

artery & 2 cm distal to inguinal ligament. Pectineus

& adductor longus are exposed. Next external

pudendal & medial circumflex femoral vessels are

identified & retracted laterally. Muscles are

separated by sharp dissection & lesser trochanter is

exposed. Iliopsoas tendon is freed & capsule is

exposed.

(B) Approaches to Femur :

(i) Antero Lateral Approach :—The skin

incision is placed over the middle third of femur in a

line between anterior superior spine & lateral margin

of patella (Fig. 2a) Dissection is carried in the

interval between rectus femoris & vastus lateralis.

Vastus intermedius is divided in line with its fibres &

femur is exposed.

This approach is suitable for only middle third

of femur. In proximal third, injury to lateral

circumflex femoral artery & nerve to vastus lateralis

can occur, while in distal third supra patellar pouch

is encountered which if cut can lead to knee

stiffness by formation of adhesions.

(ii) Lateral Approach :—The skin incision of

desired length is made over the lateral aspect of

thigh along a line from greater trochanter to the

lateral femoral condyle (Fig. 2b) Vastus lateralis et

intermedius are divided in line with direction of

fibres to expose the shaft. A branch of lateral

circumflex femoral artery is encountered when

exposing proximal fourth of femur & superior lateral

genicular artery in distal fourth. These can cause

troublesome bleeding so should be isolated &

ligated. With this method, though entire femoral

shaft can be exposed but it can lead to scarring of

vastus lateralis to prevent which postero lateral

approach is used where the muscle is erased from

its origin on the linea aspra.

(iii) Postero Lateral Approach :—Here

incision is made from base of greater trochanter to

lateral condyle (Fig. 2c). Dissection is carried out

posterior to vastus lateralis to reach linea aspra.

There, this muscle along with vastus intermedius

can be erased subperiosteally. In middle third of

thigh, 2nd perforating branch of profunda femoris

artery has to be ligated & divided. Damage to sciatic

nerve & profunda femoris vessel can be prevented

by not separating long & short heads of biceps.

(iv) Posterior Approach :—This approach is

rarely used. The skin is incised longitudinally in the

middle of posterior aspect of thigh from just distal to

gluteal fold to proximal margin of popliteal fossa.

(Fig 2d). Dissection is carried out along lateral

border of lateral head of biceps, in proximal part

retracting it medially, while in distal part, dissection

is done between this head & semitendinosis,

retracting lateral head of biceps along with schiatic

Fig. 2. Approaches to Femur. (a) Antero lateral (b) Lateral (c)

Postero lateral (d) Posterior (e) & (f) Lateral & Medial

approaches to posterior surface of lower third of

femur (g) Lateral approach to proximal shaft &

trochanteric region.

2a52

J. Anat. Soc. India 50(1) 48-58 (2001)

Surgical Incisions Lower Limb

nerve laterally. A branch of sciatic nerve, supplying

to short head of biceps may be saved or divided,

depending upon requirement of incision, because it

doesn’t compose the entire nerve supply of this part

of muscle.

The approach may damage the sciatic nerve

because of rough handling & prolonged or strenous

retraction causing disturbing symptoms after surgery

or even a permanent disability in the leg so this

approach is rarely used.

(v) Lateral approach to posterior surface of

lower 1/3rd of femur :—(Henry 1927) With knee

slightly flexed, the incision is made for 15 cm along

posterior margin of iliotibial tract following the angle

of knee to the head of fibula (Fig. 2e) Popliteal fossa

is reached between posterior border of iliotibial tract

& short head of biceps. Branches of perforating

vessels are ligated & divided, while popliteal vessels

& tibial nerve are retracted posteriorly to expose

posterior surface of femur.

(vi) Medial approach to posterior surface of

lower 1/3rd of femur :—(Henry 1927) With the

knee slightly flexed, the incision is begun 15 cm

proximal to adductor tubercle & continued distally

along adductor tendon following the angle of knee to

5 cm distal to tubercle (Fig 2f) Dissection is carried

posterior to sartorius and avoiding damage to

synovial membrane, saphenous nerve lying

posterior to sartorius & adductor tendon, retracting

large vessels & nerves posteriorly ligating & dividing

small vessels. Tabial & lateral peroneal nerve lie

latero posterior so are not encountered.

(vii) Lateral approach to proximal shaft &

trochanteric region :—This is the excellent

approach for reduction & internal fixation of

trochanteric fractures or for subtrochanteric

osteotomy. The skin incision is placed 5 cm

proximal & anterior to greater trochanter & curved

distally & posteriorly over postero lateral aspect of

trochanter & then distally over lateral surface of

thigh parllel to femur for 10cm. (Fig. 2g) Fascia lata

is divided longitudinally posterior to tensor fascia

lata to avoid splitting this muscls. Vastus lateralis

thus exposed can be erased subperiosteally from its

origin or divided. Care should be exercised to ligate

& cut perforating arteries before these retract

beyond linea aspra.

(C) Approaches to Knee Joint :—

(i) Antero Medial Approach :—It was Ist

described by Langhen beck (1874). The incision is

begun at medial border of quadriceps tendon 7–10

cm proximal to patella, curved around the medial

border of patella back towards midline to end it at or

distal to tibial tuberosity (Fig. 3a). Deep dissection is

carried out between vastus medialis & medial border

of quadriceps tendon to reach the capsule.

Abbot & Carpentor (1945) pointed out that wide

access to joint can be attained in following ways :—

(a) Extending incision proximally (b)

Extending proximal past of incision

obliquely medially (c) Dividing medial alar

fold longitudinally (d) mobilising medial

part of insertion of patellar tendon

subperiosteally.

If contracture of quadriceps prevents sufficient

exposure. the tibial tuberosity may be detached &

reattached later with a screw (Fernandes, 1988).

During any of anterior medial approaches, infra

patellar branch of saphenous nerve should be

protected. Saphenous nerve courses posterior to

sartorius, pierces fascia lata between this muscle &

gracilis to become subcutaneus. It gives a large

infra patellar branch to supply, skin over anterior

medial aspect of knee. Kummel & Zazanis (1974) &

Chambers (1972) noted several variations in its

location & distribution so no single incision can

avoid it for certain. So blunt dissection is adviced

between skin & joint capsule to locate & save its

branches. Chambers (1972) reported several

incidences of unsuccessful surgeries on knee

because of neuromas in scar.

(ii) Antero lateral approach (Kochar, 1911)

:—Usually this approach is not as satisfactory as

antero medial because (i) it is more difficult to

displace patella medially than laterally (ii) it requires

a longer incision (iii) often pateller tendon must be

partly freed subperiosteally.

Incision is begun 7.5 cm proximal to patella at

insertion of vastus lateralis into quadriceps tendon,

continuing distally along lateral border of this

tendon, patella & patellar tendon to end 2.5 cm

distal to tibial tuberosity. (Fig. 3b)

(iii) Postero lateral approach :—(Henderson

1921) :—With the knee flexed at 90°, a curved

incision is made on lateral side of knee just anterior

to biceps femoris tendon & head of fibula (Fig. 3c)

thus avoiding common peroneal nerve passing over

lateral aspect of neck of fibula. The popliteus tendon

lies in between biceps tendon & fibular collateral

ligament. It is retracted posteriorly to expose postero

lateral aspect of joint capsule.

(iv) Postero Medial approach :—With knee

flexed 90°, a curved incision is made, slightly

convex anteriorly & approximately 7.5 cm long

along the course of tibial collateral ligament anterior

to relaxed tendons of semimembranosus,

semitendinosus, gracills & sartorius (Fig. (3d))53

J. Anat. Soc. India 50(1) 48-58 (2001)

Patnaik, V.V.G. et al

Fig. 3. Approaches to knee joint. (a) Antero medial (b) Antero

lateral (c) Postero lateral (d) Postero medial (e) Medial

(f) & (g) Lateral [f-Bruser; g-Hoppenfield & Deboer] (h)

Extensile anterior (Fernandes) (i) & (j) Posterior [iBrackett & Osgood; j-Minkoff et al.] (k, l, m) Extensile

(Mc Connel) (n) Cave’s approach for medial meniscus.54

J. Anat. Soc. India 50(1) 48-58 (2001)

Surgical Incisions Lower Limb

oblique part of tibial collateral ligament is incised to

expose the capsule.

(v) Medial approach (Hoppen field & Deboer,

1984) :—Incision is begun 2 cm proximal to

adductor tubercle of femur, curved antero inferiorly

about 3cm medial to medial border of patella &

ended 6 cm distal to joint line on anterior medial

aspect of tibia. (Fig. (3e)) Saphenous nerve & its

infra patellar branch are saved. Next 3 muscles of

pes anserinus are retracted posteriorly & tibial

collateral ligament is exposed. Joint may be opened

anterior or posterior to it depending upon the need.

(vi) Lateral approach :—Lateral approaches

permit good exposure for complete excision of

lateral meniscus. These don’t require division or

release of fibular collateral ligament.

(a) Bruser Technique — (1960) :—Knee is

flexed fully so that foot rests on table. The incision is

begun anteriorly where patellar tendon crosses the

lateral joint line, continued posteriorly along joint line

ended at an imaginary line extending from proximal

end of fibula to lateral femoral condyle (Fig. 3f) Next

iliotabial tract is splitted in line of its fibres. Fibular

collateral ligament is relaxed & lying posteriorly.

Joint capsule is reached anterior to it.

(b) Brown et al (1975) Modification :—It is

done for lateral menisectomy where in addition to

Bruser approach a varus strain in created to open

the lateral joint space.

(c) Pogrund technique (1976) :—The skin

incision is begun near infero lateral aspect of patella

& curved gently distally & posteriorly for 4-5cm.

Capsule is exposed anterior to iliotibial tract.

(d) Hoppen field & Deboer technique (1984)

:—Incision is begun 3 cm. lateral to middle of

patella, extended distally over Gardy’s tubercle on

tibia to end it 4-5 cm distal to joint line. Incision is

completed proximally by curving it along the line of

femur. (Fig. (3g) Further dissection is done between

iliotibial tract anteriorly & biceps tendon with

common peroneal nerve posteriorly to expose

fibular collateral ligament.

(vii) Anterior approaches :

(a) Split Patellar approach (Insall, 1984) :—In

this a lateral parapatellar skin incision is made. Next

quadriceps tenden is split in its middle begining 8

cm proximal to patella extending distally over

middle of patella through patellar tendon to tibial

tuberosity. Longitudinal fibres of extensor

mechanism are carefully separated from medial 1/2

of patella. Patella is dislocated laterally, & medial 1/

2 of qudriceps tendon retracted medially to expose

anterior surface of joint capsule.

(b) Extensile anterior approach (Fernands

(1988) :—A lateral parapatellar incision is begun 10

cm proximal to lateral joint line continued distally

along lateral border of patella, pateller tendon &

tibial tuberosity to end it 15 cm distal to lateral joint

line. (Fig. 3h).This approach allows easy access to

both medial & lateral condyles by : (i) Extensive

osteotomy of tibial tuberosity allowing proximal

reflection of patella & patellar tendon. (ii) transecting

anterior horn & anterior portion of coronary ligament

of medial or lateral meniscus or both as required.

(viii) Posterior approaches :—

These involve the structures, those if damaged

produce a proximal serious disability so a thorough

knowledge of anatomy of popliteal space is

mendatory. (Putti, 1974; Abbot & Carpenter, 1945)

1. Brackelt & Osgood (1911) technique :—In

this a curvilinear incision, 10-15 cm long is

centered over popliteal space. Its proximal

limb follows tendon of semi tendinosus

distally to level of joint, it is then curved

laterally across posterior aspect of joint for

5 cm & then distally over lateral head of

gastrocnemius (Fig. 3i) Posterior nerve of

calf is identified in popliteal fossa Ist of all

which is a guide to further dissection.

Lateral to it the short saphenous vein

pierces deep fascia to drain into popliteal

vein. Nerve is traced proximally to its

origin from tibial nerve which further helps

rests of dissection as popliteal artery &

vein lie deep to it. Later are retracted

gentally to approach posterior surface of

knee joint.

2. Minkoff et al (1987) technique :—Skin

incision is begun 1-2cm below the popliteal

crease slightly medial to midline of knee. It

is carried transversally & then curving

distally just medial & parallel to head of

fibula, ending 5-6cm distal to it (Fig 3j).

Lateral cutaneus nerve of calf, sural nerve

& common peroneal nerve are to be saved

in this dissection. This approach gives a

good exposure of posterior aspect of

lateral tibial plateau & proximal tibiofibular

joint.55

J. Anat. Soc. India 50(1) 48-58 (2001)

Patnaik, V.V.G. et al

(ix) Extensile approach to knee : (McConnel,

1976 Technique)

McConnell described an extensile approach to

the knee that allows access to the anterior, posterior,

medial and lateral sides of the knee through a single

incision. In addition to excellent exposure, it leaves

an unobrusive scar. The incision has the anterier

cosmesis of a typical tansverse incision; it is hidden

by the skin creases and is less prone to hypertrophy

than a longitudinal incision. The medial extension is

partially hidden by the contralateral extremity and

the lateral extension is less noticeable because it

lies in the skin depression along the posterior border

of the iliotibial band.

With the knee in acute flexion, the transverse

anterior part of incision is made between 3 pointsi.e. medial flexion crease, lower pole of patella &

lateral flexion crease (Fig. 3k) Its lateral extension is

made proximally along posterior margin of iliotibial

tract while medial is made postero medially in a

distal direction from apex of medial flexion crease

for 9-10 cm. (Fig 31 & m respectively)

(x) Exposure of Medial Meniscus :

(i) Transverse approach :—The advantage of

this approach is that (a) scar has no contact with

femoral articular surface. (b) Convalescense is more

rapid after menisectomy through this than through

other incisions (Charmley 1948).

A 5 cm long transverse incision is made at the

level of articular surface of tibia extending laterally

from medial border of patellar tendon to anterior

border of tibial collateral ligament. Capsule is

incised along the same line to reach the meniscus.

(ii) Cave’s approach :—If posterior horn of

medial meniscus can’t be excised by transverse

approach, then this approach is useful as it allows

exposure of both anterior & posterior ends. With

knee flexed to right angle, the incision is begun 1

cm posterior to & at level with medial femoral

epicondyle. i.e. approximately 1 cm proximal to joint

line. It is carried distally anterior to a point 0.5 cm

distal to joint line & then anteriorly to border of

patellar tendon (Fig 3n)

D. Exposure of Tibia :

(i) Anterior approach :—The tibia is a

superficial bone and can be easily exposed

anteriorly without damaging any important structure

except the tendons of the tibialis anterior and

extensor hallucis longus muscles, which cross the

tibia anteriorly in its lower one fourth.

A curved incision is made on either side of

anterior border of bone. Periosteum is stripped as

little as possible because its circulation is a source

of nutrition for the bone.

(ii) Medial approach :—It is used for inserting

a bone graft in delayed union or non union. Here a

longitudinal incision is made along postero medial

border of the tibia. Periosteum is reflected from

posterior surface (Phemister, 1947).

(iii) Postero lateral approach :—This

approach is valuable in exposure of middle 2/3rd of

tibia when anterior & antero medial aspects are

badly scarred. The incision is placed along lateral

border of gastrocnemius on the postero lateral

aspect of ligament. A plane is developed between

gastrocnemius, soleus & flexor hallucis longus

posteriorly & peronei anteriorly. The approach

provides a complete exposure of flat posterior

surface of tibia except its proximal fourth which lies

in close relation to popliteus muscle, proximal parts

of posterior tibial vessels & nerve. (Harmon, 1945).

(iv) Posterior approach to superomedial

region :—(Bank & Laufman, 1953) With patient

prone, the transverse segment of hockey stick

incision is begun at lateral end of flexion crease of

knee & extended across the popliteal space. Then it

is turned distal wards along medial side of calf for 7-

10 cm (Fig 4) Deep fascia is incised in the line with

skin incision. Upper 1/4th of posterior surface of

tibia can be exposed by this incision.

Fig. 4. Posterior approach to

superomedial region of

Tibia.

E. Exposure of Fibula :—

It can be exposed by a postero lateral

approach devised by Henry (1927). The incision is

begun 13 cm proximal to lateral malleolus & then

carried proximally along posterior border of fibula to

posterior margin of its head & then further

proximally for 10 cm along posterior border of

biceps femoris, Common peroneal nerve has to be

isolated & saved in the proximal part of the incision

near the upper end.

F. Approaches to Ankle joint & tarsus :—

(i) Anterolateral approach :—gives excellent

access to the ankle joint, the talus, and most other56

J. Anat. Soc. India 50(1) 48-58 (2001)

Surgical Incisions Lower Limb

tarsal bones and joints, and it avoids all important

vessels and nerves, since so many reconstructive

operations and other procedures involve the

structures exposed, it may well be called the

“universal incision” for the foot and ankle. It permits

excision of the entire talus. The only tarsal joints

that it cannot reach are those between the navicular

and the second and first cuneiforms.

The incision is begun over antero lateral

aspect of ankle medial to fibula & 5 cm proximal to

ankle joint. It is carried distally over the joint, antero

lateral aspect of body of talus & calceneo cuboid

joint; to end at base of 4th metatarsal bone.

Superior & Inferior extensor retinaculae are incised

down to the periosteum of tibia, & capsule of ankle

joint. The dissection usually divides antero lateral

malleolar & lateral tarsal arteries while superficial &

deep peroneal nerves are saved.

(ii) Anterior approach :— It is considered

better than antero lateral approach if both malleoli

are to be exposed. Usually the approach is

developed between extensor hallucis longus &

extensor digitorum longus but Nicola (1945) advises

developing it between tabialis anterior & extensor

hallucis longus.

The incision is begun on anterior aspect of leg

7.4-10 cm proximal to ankle joint & extended distally

to about 5 cm distal to joint. Periosteum, capsule

&synovium are incised in line with skin incision.

(iii) Kocher Approach (1911) :— It gives

excellent exposure of midtarsal, subtalar & ankle

joints. From a point just lateral and distal to the head

of the talus, curve the incision 2.5 cm inferior to the

tip of the lateral malleolus, then posteriorly and

proximally, and end it 2.5 cm posterior to the fibula

and 5cm proximal to the tip of the lateral malleolus.

(Fig. 5a)

The disadvantage of this procedure is that the

skin may slough about the margins of the incision,

especially if dislocation of the ankle has been

necessary, as in a talectomy. Further, the peroneal

tendons must usually be divided.

(iv) Ollier Approach (1892) :— This is

excellent for triple orthodesis. The skin incision is

begun over dorso lateral aspect of talo-navicular

joint, extending it obliquely infero posteriorly &

ending 2.5 cm below lateral malleolus. (Fig 5b)

Inferior extensor retinaculum is divided in line with

skin incision & dissection is extended to expose

subtalar, calcaneo cuboid & talonavicular joints.

(v) Postero lateral approach :— (Gatellier &

Chastang, 1924) Incision is begun 12 cm proximal

to tip of lateral malleolus extending distally along

posterior margin of fibula to tip of malleolus. Then it

is curved anteriorly for 2.5 cm in line of peroneal

tendons. (Fig. 5c). Peroneal retinaculae are incised

to displace the tendons anteriorly. Lateral aspect of

the joint is exposed dividing the fibula 10 cm

proximal to tip of lateral malleolus. Great care

should be used in children to avoid creating a

fracture through distal fibular epiphysis, when

reflecting fibula.

(vi) Posterior approach :— With patient

prone a 12 cm incision is made along postero lateral

border of tendo achillis down to its insertion on

calcaneus. The tendon is lengthened by Z plasty or

retracted to expose the ankle joint from posterior

aspect.

(vii) Medial approach :— It was given by

Koening & Schaefer (1929) but not a popular

method because despite utmost care it is possible to

injure tibial vessels & nerve. The other unimportant

approaches are those by Broomhead (1932) &

Colonna & Ralston (1951). For details of these, the

readers are advised to consult original articles.

G. Approaches to Calcaneus :—

(i) Medial approach :—Incision is begun 2.5

cm anterior & 4cm inferior to medial malleolus. It is

carried posteriorly along medial surface of foot to

tendo calcaneus. Abductor hallucis is retracted

dorsal wards to reach medial & inferomedial aspects

of calcaneus. Its inferior surface can be exposed

sub periosteally avoiding medial calcaneal nerve &

nerve to abductor digiti minimi.

(ii) Lateral Approach :— Incision is begun on

Fig. 5. Approachjes to ankle joint. (a) Kocher’s (b) Ollier

(c) Postero lateral57

J. Anat. Soc. India 50(1) 48-58 (2001)

Patnaik, V.V.G. et al

lateral margin of tendo calcaneus near its insertion

& passed distally to a point 4 cm inferior & 2.5 cm

anterior to lateral malleolus. Peroneal tendons may

be divided by Z plasty if needed.

(iii) U approach:— This is used to access the

entire planter surface of calcaneus. With patient

prone, the 2 approaches described above are joined

to form a large U shaped incision around the

posterior four fifth of the bone. (Fig. 6a).

Medial approach :— A 5cm long curved

incision is made on medial aspect of joint (Fig 7a). It

is begun just proximal to proximal interphalangeal

joint, curved over dorsum of metatarsophalangeal

joint medial to extensor hallucis longus tendon

ended on medial aspect of 1st metatarsus proximal

to the joint. 1st dorsal metatarsal artery & branch of

superficial peroneal nerve are retracted laterally as

these supply medial side of great toe. This exposes

the bunion over medial aspect of matatarsal head.

Then a curved incision is made through bursa &

capsule of joint. (Fig 7b) It is begun over the

dorsomedial aspect of joint, continued proximally

(iv) Split heel approach is seldom used

except for osteomyelitis of calcaneus. In this, a

midline incision is given on plantar surface of heel.

Its advantage is that the scar retracts inside so there

is no problem in weight bearing.

(v) Kocher approach (Curved L) :—It is

suitable for complete excision of calcaneus. The

skin is incised over medial border of tendo

calcaneus from a point 7.5 cm proximal to calcaneal

tuberosity to its postero inferior aspect. Then the

incision is continued transversely around the

posterior aspect of calcaneus, then distally along

lateral surface of the foot to tuberosity of 5th

metatarsal. (Fig 6b)

H. Approaches for Toes.

(i) Interphalangeal joints:—For interphalangeal joint of great toe, a 2.5 cm long

incision is made on medial aspect of the

toe & for interphalangeal joint of 5th toe,

a similar incision is made on lateral

aspect of 5th toe. The interphalangeal

joints of other 3 toes can be approached

through incisions made just lateral to

corresponding extensor tendons. Care

should be exercised to save dorsal or

planter digital vessels & nerve. Capsule

can be opened longitudinally or

transversely.

(ii) Metatarsophalangeal Joints.

(a) M.P. joint of great toe can be approached

in either of the 2 common ways.

Fig. 6. Approaches to Calcaneus (a) U approach (b) Curved L

approach

6b

7a

7b

Fig. 7. Medial Approach for great toe.

(a) Skin Incision (b) Line of Incision through bursa &

capsule of Joint.

dorsal to the metatarsal head & then planter wards &

distalwards around the joint & ended distally on

medio planter aspect of matatarso phalangeal joint.

The incision forms an elliptical, racquiet shaped flap

attached to base of proximal phalanx. Although the

distal reflection of flap exposes the 1st metatarso

phalangeal joint, yet healing of the flap may be

delayed so dorso medial approach is prefered.

Dorsomedial approach :— The incision is

begun just proximal to joint continued proximally for

5 cm parallel & medial to extensor hallucis longus

tendon. Further dissection can be carried in plane of

skin incision or as in medial approach.

(b) M. P. joint of 2nd to 5th toe :— All these

are reached by dorso lateral incisions

parallel to the corresponding extensor

tendons.

References :

1. Abbott, L.C; and Carpenter, W. F. (1945) : Surgical

approaches to the knee joint, Journal of Bone & Joint

Surgery 27 : 277.

2. Banks, S. W., and Laufman, H: An atlas of surgical

exposures of the extremities, WB Saunders Co.

Philadelphia, (1953).58

J. Anat. Soc. India 50(1) 48-58 (2001)

Surgical Incisions Lower Limb

3. Bracett, E. G. and Osgood, R. B. (1911) : The popliteal

incision for the removal of “joint mice” in the posterior

capsule of the knee joint : a report Boston Medical surgical

Journal 165 : 975.

4. Brackett, E. (1912) : A study of the different approaches to

the hip joint, with special reference to the operations for

curved trochanteric osteotomy and for arthrodesis Boston

Medical Surgical Journal 166 : 235

5. Brown, C. W., Odam, J. A; Messner D. G. & Mitchel, R. G.

(1975) : A simplified operative approach for lateral meniscus.

Journal of Sports Medicine. 3 : 265.

6. Bruser, D. M. (1960) : A direct lateral approach to the lateral

compartment of the knee joint, Journal of Bone & Joint

Surgery 42 B: 348.

7. Cave, E. F. (1935) : Combined anterior posterior approach to

the knee joint. Journal of Bone & Joint Surgery 67 : 427.

8. Chambers, G. H. (1972): The prepatellar nerve : a cause of

suboptimal results in knee arthrotomy. Clinical Orthopaedics

82 : 157.

9. Charnley, J: (1948) : Horizontal approach to the medial

semilunar cartilage, Journal of Bone & Joint Surgery 30-

B:659.
10. Colanna, P. C. and Ralston, E. L (1951) : Operative

approaches to the ankle joint. American Journal of surgery

82 : 44.

11. Fernandez, D. L. (1988) : Anterior approach to the knee with

osteotomy of the tibial tubercle for bicondylar tibial fractures,

Journal of Bone & Joint Surgery 70-A : 208.

12. Gatellier, J. & Chastang P. (1924): Access to fractured

malleolus with piece chipped off at back. Journal of

Chirology 24 : 513

13. Gibson, A. (1950) : Posterior exposure of the hip joint,

Journal of Bone & Joint surgery 32-B : 183.

14. Gibson, A. (1953) : The posterolateral approach to the hip

joint, AAOS Instrumental Course Lecture 10 : 175.

15. Hardinge, K. (1982) : The direct lateral approach to the hip,

Journal of Bone & Joint Surgery : 64-B: 17.

17. Harmon, P. H. (1954):, A simplified surgical approach to the

posterior tibia for bone grafting and fibular transference,

Journal of Bone & Joint Surgery 49-A : 891,

18. Harris, W.H. (1973) : Extensive exposure of the hip joint,

Clinical Orthopedics 91 : 58.

19. Henderson, M.S. (1921): Posterolateral incision for the

removal of loose bodies from the posterior compartment of

the knee joint, Surgery Gynaecology Obstetrics 33 : 698.

20. Henry, A. K. (1924) : Exposure of the humerus and femoral

shaft, British Journal of Surgery 12 : 84.

21. Henry A.K: Exposure of long bones and other surgical

methods. John Wright & Sons, Ltd. Bristol, England, (1927).

22. Hoppenfeld, S. and deBoer, P.: Surgical exposures in

orthopaedics : the anatomic approach, JB Lippincott Co.

Philadelphia, (1984).

23. Install, J. : Surgery of the knee, Churchill Living stone, Inc.,

New york. (1984)

24. Kaplan, E.B. (1957) : Surgical approach to the lateral

(peroneal) side of the knee joint. Surgery Gynaecology

Obstetrics 104 : 346

25. Kocher, T. Textbook of operative surgery, ed 3 (translated by

Sitles HJ and Paul (CB). Adam & Charles Black, London,

(1911).

26. Koening, F. and Schaefer, P: (1929) : Osteoplastic surgical

exposure of the ankle joint. In Forty-fist report of progress in

orthopedic surgery, p 17 (Abstracted from Z Chir 215 : 196.

27. Kummel, B. M. and Zazanis, G. A. (1974) : Preservation of

infrapatellar branch of saphenous nerve during knee surgery

Orthopedics Review. 3 : 43.

28. Langenbeck, B von (1974) : Uber the Schussverletzungen

des Huftgelenks, Arch klin Chir 16: 263.

29. Ludloff, K. (1908) : Zur blutigen Eihrenkungder

Angeoborenen Huftluxation, Z Orthop Chir 22 : 272.

30. McConell B. E. (1976) : A dynamic transpatellar approach to

the knee. Southern Medical Jounral 69 : 557.

31. McFarland, B. and Osborne, G. (1954) : Approach to the hip

: a suggested improvement on Kocher’s method, Journal of

Bone & Joint Surgery 36-B : 364.

32. McLauchlan, J. (1984) : The Stracathro approach to the hip.

Journal of Bone & Joint surgery 66-B : 30.

33. Minkoff, J, Jaffe, L., and Menendez, L: (1987) : Limited

posterolateral surgical approach to the knee for excision of

osteoid osteoma, Clinical Orthopedics 223 : 237.

34. Moore, A.T. (1957) : The self-locking metal hip prosthesis,

Journal of bone & Joint Surgery 39-A : 811.

35. Moore, A. T (1959) : The Moore self-locking Vitallium

prosthesis in fresh femoral neck fractures : a new low

posterior approach (the southern exposure), AAOS

Instrumental Course Lecture 16 : 309.

36. Nicola, T: Atlas of surgical approaches to bones and joints,

Macmillan Publishing Co, Inc., New York. (1945)

37. Ollier, P: Traite des resections, Paris, 1892. (Quoted in

steindler A: A Textbook of operative orthopedics, D appleton

& Co. New York, (1925).

38. Phemister, D. B. (1947) : Treatment of ununited fractures by

onlay bone grafts without screw or tie fixation and without

breaking down of the fibrous union, Journal of Bone & Joint

Surgery 29 : 946.

39. Pogrund, H. (1976) : A practical approach for lateral

menisectomy, Journal of Trauma 16 : 365.

40. Putti, V. (1920) : Arthroplasty of the knee joint, Journal of

Orphopedic Surgery 2 : 530.

41. Osborne, R. P. (1931) : The approach to the hip joint : a

critical review & a suggested new route. British Journal of

Surgery 18 : p 49.

42. Schaubel, H. J. (1980): Modification of the anterior

iliofemoral approach to the hip, Internal Surgery 65 : 347.

43. Smith-Petersen, M. N. : (1917) A new supra-articular

subperiosteal approach to the hip joint. American Journal of

Orthopedic Surgery 15 : 592.

44. Smith-Petersen, M. N. (1949): Approach to and exposure of

the hip joint for mold arthroplasty, Journal of Bone & Joint

Surgery 31-A : 40.

45. Somerville, E. W. (1953): Open reduction in congenital

dislocation of the hip,Journal of Bone & Joint Surgery 35-B :

363.

46. Testa, N.N. and Mazus, K. U. (1988) : Heterotopic

ossification after direct lateral approach and

transtrochanteric approach to the hip, Orthopedic Review

17 : 965, 1988.

47. Thomson, J. E. (1918) : Anatomical methods of approach in

operations on the long bones of the extremities, Anatomic

surgery 68 : 309.

48. Watson Jones, R. (1935-1936) : Fractures of the neck of the

femur, British Journal of Surgery 23 : 787.

49. Zazapen, S. and Gamidov, E (1972) : Tumors of the lesser

trochanter and their operative management, Am Dig Foreign

Orthop Lit Fourth quarter, p 191.

Surgical Incisions-Their Anatomical Basis

Part V - Approaches to spinal column

*Patnaik, V.V.G. ** Singla Rajan K; ***Gupta, P.N.; ****Bala, Sanju

Department of Anatomy, Govt. Medical College, *Patiala, **Amritsar ***Department of Orthopaedics,

Govt. Medical College,

Chandigarh ****Department of Oral & Maxillofacial Surgery, S.G.R.D. Dental College, Amritsar. INDIA

Abstract. The present paper is a continuation of the previous one by Patnaik et al (2001). Here the
anatomical bases of various

incisions used for the exposure of different parts of vertebral column are discussed Brief steps of
dissection & important anatomical

landmarks to be taken care are delineated. Since this part of the body falls in the domain of not only
orthopaedician, & neurosurgeon but

also otolaryngologist & oral & mexillo facial surgeon, an emphasis has been laid on a multidisciplinary
approach. For the same reasons, the

authors feel that the article would be of help, apart from the anatomists to the disciples of other
specialities mentioned above.

Key words : Surgical incisions, spine, vertebral column.

Introduction :

The spine is composed of 33 vertebral segments of which 7 are cervical, 12 thoracic, 5 lumbar,

5 sacral and 4 are coccygeal. The sacral and the

coccygeal vertebrae are fused as single masses,

separately. A typical vertebra consists of a body that

lies anteriorly, and a posterior arch that further consists of 2 pedicles, 2 laminae that are joined together
and give rise to the spinous process. The

posterior complex also consists of 2 transverse processes and a pair each of superior and inferior
articular facets. In the intervening spaces between any
two adjacent vertebral bodies are the intervertebral

discs, which have outer fibrous portion, called annulus fibrosus and an inner gelatinous, nucleus

pulposus. The normal spine is lordotic at cervical

and lumbar levels and kyphotic at dorsal and sacral

levels. The segmental nerves and vessels pass

through the intervertebral foramina formed by superior and inferior borders of pedicles of adjacent
vertebrae.

Surgical approaches to spine :

Spine may be approached by any of the following routes :

(A) Anterior approaches :

I. Anterior approach from occiput to C3 vertebra

1. Trans oral approach

2. Anterior retropharyngeal approach

3. Subtotal maxillectomy

4. Extended maxillotomy

II. Anterior approach from C3-C7

1. Southwich & Robinson (1957) technique

III. Anterior approach to cervico thoracic

junction

1. Low anterior cervical approach

2. High transthoracic approach

3. Trans-sternal approach

IV. Ant. approach to thoracic spine

V. Ant. approach to thoracolumbar junction

VI. Ant. approach to lumbar spine

1. Ant. retroperitoneal approach (L1-L5)

2. Ant. Transperitoneal approach to L5S1

B. Posterior approaches :

I. Post. approach to cervical spine (occiput

to C2)

II. Post. approach to cervical spine (C3-C7)

III. Post. approach to thoracic spine (T1-T12)

1. Midline approach

2. Costo transeversectomy

IV. Post. approach to lumbar spine (L1-L5)

1. Midline approach

2. Paraspinous approach

V. Post approach to lumbosacral spine (L1-

sacrum)

A. Anterior approaches to spine : With the

posterior approaches for correction of spinal deformity well estblished, in recent years more attention

has been placed on the anterior approach to the77

J. Anat. Soc. India 51(1) 76-84 (2002)

Patnaik, V.V.G. et al

spinal column. Common use of anterior approach

for spinal surgery did not evolve until the 1950s

(Crenshaw, 1992). Leaders in anterior approach to

the cervical and lumbar spine have been Cloward,

1958; Southwick & Robinson, 1957; Bailey & Bagley,

1960; Bohlman et al, 1982; Burrington et al, 1976;

Conchoix & Binet, 1957; Charles & Govender, 1989;

Fang & Ong, 1962; Fang et al, 1964; Hall, 1972;

Charles & Hodgson et al, 1960; Micheli & Hood,

1983; Mirbaha, 1973; Riseborough, 1973; etc.

Indications : In general, anterior approaches

to the spine are indicated for decompression of the

neural elements (spinal cord, conus medullaris,

cauda equina or nerve roots), when anterior neural

compression has been documented by

myelography, CT Scan or MRI. Crenshaw (1992)

has listed followings as the most accepted indication

for these approaches.

A. Traumatic

1. Fractures with documented

neurocompression secondary to bone or

disc fragments anterior to dura.

2. Incomplete spinal cord injury (for cord recovery) with anterior extradural compression.

3. Complete spinal cord injury (for root recovery) with anterior extradural compression.

4. Late pain or paralysis after remote injuries with anterior extradural compression.

5. Herniated intervertebral disc.

B. Infections

1. Open biopsy for diagnosis

2. Debridement and anterior strut grafting

C. Degenerative

1. Cervical spondylitic radiculopathy

2. Cervical spondylitic myelopathy

3. Thoracic disc herniation

4. Cervical, thoracic, and lumbar interbody

fusions

D. Neoplastic

1. Extradural metastatic disease

2. Primary vertebral body tumor

E. Deformity

1. Kyphosis - congenital or acquired

2. Scoliosis - congenital, acquired, or idiopathic

Anterior approaches have the propensity to

cause significant morbidity as potential dangers include iatrogenic injury to the visceral and

neurovascular structures. Injury to specially the neural structures is irreversible and may defeat the very

purpose for which the surgery was planned for;

therefore, a thorough knowledge of anatomy is essential.

The choice of approach depends upon :

(a) preference and experience of the surgeon.

(b) Patient’s age, (c) Medical condition of the patient, (d) Segment of the spine involved, (e) Underlying
pathological process, (f) Presence or absence

of signs of neural compression.

Various anterior approaches are described below :

I. Anterior approach from occiput to C3.

1. Trans oral approach (Spetzler, 1983)

The patient is placed supine and the head is

stabilized either by skull traction tongs or by MayField head holding device. Uvula and the soft palate

are retracted by tying a rubber catheter, which is

passed from each nostril, and pulling it. The endotracheal tube required for general anaesthesia is
retracted to one side using special retractors. Anterior

arch of C1(atlas) can be palpated in the depth of

posterior wall of pharynx. A midline longitudinal incision is chosen to expose the anterior aspects of C1

and C2 as the midline is relatively avascular. Retracting the flaps laterally can further increase the

exposure. After the wound is closed, it is desirable

to keep the endotracheal tube in situ for a further

period of 12-24 hours to maintain adequate airway.

This approach is commonly used for caries involving the anterior arch of C1 or vertebral bodies of C2,

C3 and also for transoral odontoidectomy.

2. Anterior retropharyngeal approach (McAffee et

al, 1987)

This approach is extra-mucosal and avoids all

the complications associated with transoral approach. One of the common indications is caries

involving C1 , C2 region. The technique has been78

J. Anat. Soc. India 51(1) 76-84 (2002)

Surgical Incisions-Spinal Column

described by Mc Affee et al. (1987) A thorough understanding of anatomical tissue planes and fascial

spaces as described by Singh et al (2000) is mandatory before undertaking this approach. A T-shaped

incision is given in right submandibular region

(Fig. 1). The platysma muscle is cut and its flaps

The patient is maintained in skeletal traction in

the postoperative period with the head end of the

bed elevated to reduce swelling. Endotracheal tube

is continued until pharyngeal edema subsides, usually by 48 hours.

3. Subtotal maxillectomy
Cocke et al (1990) have described an extended maxillotomy and subtotal maxillectomy as

an alternative to the transoral approach for exposure

and removal of tumor or bone anteriorly at the base

of the skull and cervical spine to C5. This approach

has been used in a limited number of procedures,

and the indications have not yet been firmly established. This procedure is technically demanding and

requires a thorough knowledge of head and neck

anatomy. It should be performed by a team of surgeons, including an otolaryngologist, a

neurosurgeon, an orthopaedist and oral & maxillofacial surgeon.

mobilized. The marginal mandibular branch of 7th

nerve is identified and protected. The

retromandibular vein is ligated at its junction with

the internal jugular vein. This brings the

sternomastoid muscle in view with its overlying superficial layer of deep cervical fascia; this layer is

cut and the sternomastoid muscle is retracted. Next

pulsations of the carotid artery are felt and it is protected. Submandibular gland is resected and its duct

is ligated to prevent formation of a salivary fistula.

Tendon of digastric is identified and divided. Traction injury to the facial nerve can be caused by superior
retraction on the stylohyoid muscle and one

should be careful regarding that. The hyoid bone

and hypopharynx are then mobilized medially, preventing exposure of the esophagus, hypopharynx,

and nasopharynx out of harm’s way. Next, hypoglossal nerve is identified and retracted superiorly.
Dissection is continued to the retropharyngeal space

between the carotid sheath laterally and the larynx

and pharynx medially. Exposure is increased by

ligating branches of the carotid artery and internal

jugular vein, which prevent retraction of the carotid

sheath laterally. The superior laryngeal nerve is

identified and mobilized. Following adequate retraction of the carotid sheath laterally, alar and

prevertebral fascial layers are divided longitudinally

to expose the longus colli muscles which are erased

subperiosteally from the anterior aspect of the arch

of C1 and the body of C2, taking care to avoid injury

to the vertebral arteries. Next, meticulously debride

the involved osseous structures and, if needed, perform bone grafting with either autogenous iliac or

fibular bone. During closure it is important to repair

the digastric muscle.

The maxilla is exposed through a modified

Weber Ferguson skin incision (Fig. 2). A vertical

incision is made through the upper lip in the philtrum

from the nasolabial groove to the vermillion border.

Lower end in extended to the midline and then vertically in the midline through the buccal mucosa to

the gingivobuccal gutter. Upper lip is divided and

labial arteries are ligated. External skin incision is

extended transversely from the upper end of the lip

incision in the nasolabial groove to beyond the nasal

ala and then superiorly along the nasofacial groove

to the lower eyelid. Central incisor is extracted and a

vertical midline incision is made through the

mucoperiosteum of maxilla from gingivobuccal gutter to the central incisor defect and then transversely
through the buccal gingiva adjacent to the

Fig. 1
Anterior retropharyngeal

Approach

Fig. 2

Extended maxillotomy and

subtototal maxillectomy79

J. Anat. Soc. India 51(1) 76-84 (2002)

Patnaik, V.V.G. et al

teeth to the retromolar area. Skin, subcutaneous tissue, periosteum and mucoperiosteum of maxilla is

elevated to expose maxilla, nasal bone, piriform aperture of nose inferior orbital nerve and zygomatic

bone (Crenshaw, 1992). Further steps of dissection

are beyond the scope of this article and interested

readers are referred to the original article.

4. Extended maxillotomy : Skin incision and

initial steps to expose maxilla are same as subtotal

maxillectomy with a difference that central incisor

tooth is not extracted. For the rest of the steps original article may be consulted.

II. Anterior Approach to C3-C7 :

Cervical spine in region of C3 to C7 can be

approached through a longitudinal or a transverse

incision. The approach is carried out medial to the

carotid sheath. A lot of vital structures come in the

way, so as thorough knowledge of fascial planes and

spaces, as described by Singh et al (2000) allows a

safe and direct approach to this area.

Cervical traction is recommended during surgery. Spinal cord monitoring should be used if available to
prevent inadvertent injury to the spinal cord.
A left sided approach minimizes the risk of injury to

recurrent laryngeal nerve as it has a more predictable course than its right counterpart.

anterior border of sternomastoid muscle. The superficial layer of deep cervical fascia is incised
longitudinally and the carotid vessels are located by palpation. The middle layer of deep cervical fascia
enclosing omohyoid muscle is then incised and the

carotid sheath and the sternomastoid muscle are

retracted laterally. The cervical bodies can be exposed by retracting the esophagus and the trachea

medially. The deep layer of deep cervical fascia,

which overlies the bodies, is dissected by blunt dissection and the longus coll muscle is reflected laterally
to further increase the exposure. The lateral dissection should be limited till the Uncovertebral joints

to prevent injury to the vertebral vessels as they

pass through the foramen. Appropriate vertebral/

disc level is identified radiographically.

III. Anterior approach to cervicothoracic junction

The rapid transition from cervical lordosis to

thoracic kyphosis results in an abrupt change in the

depth of the wound. Also there is a confluent area of

vital structures that are not readily retracted.

The cervicothoracic junction can be approached either by a low anterior cervical approach,

which can expose cervical vertebral bodies as well

as thoracic spine upto T2 level, or by a high transthoracic approach, which is especially suitable in

scoliosis involving the cervicothoracic junction, or by

trans-sternal approach, which gives exposure from

C4 to T4.

1. Low anterior cervical approach :

Enter on the left side by a transverse incision

placed 1 finger breadth above the clavicle. Extend it

well across the midline, taking particular care when

dissecting about the carotid sheath in the area of

entry of the thoracic duct. The latter approaches the

jugular vein from its lateral side, but variations are

not uncommon. Further steps in exposure follow

those of the conventional anterior cervical approach.

2. High trans-thoracic approach

A kyphotic deformity of the thoracic spine

tends to force the cervical spine into the chest, in

which instance a high transthoracic approach is a

logical choice. Make a periscapular incision (Fig. 4)

and remove the second or third rib; removing the

latter is necessary to provide sufficient working

space in a child or if a kyphotic deformity is present.

A longitudinal or transverse incision is given at

the anterior border of sternomastoid muscle (Fig. 3)

at the desired level. In general, an incision 3-4 finger

breadths above the clavicle is required to expose

C3-C5 and an incision 2-3 finger breadths above the

clavicle allows exposure of C5-C7. Platysma muscle

is cut in line with the skin incision to expose the

Fig. 3

Anterior approach to C3-C780

J. Anat. Soc. India 51(1) 76-84 (2002)

Surgical Incisions-Spinal Column

This exposes the interval between C6

&T

Excision .

of Ist or 2nd rib is adequate in adults.

leaves a slight postoperative enlargement of the left

upper extremity that is not apparent unless carefully

assessed. This approach provides limited access,

and its success depends on accuracy in

preoperative interpretation of the deformity and a

high degree of surgical precision.

IV. Anterior approach to thoracic spine (Transthoracic approach)

The anterior approach to the thoracic spine

provides access from T2 to T12. Most of the times a

left sided approach is preferred as in right -sided

approach presence of liver especially in the lower

thoracic area can limit the exposure. Moreover the

inadvertent injury to aorta, which lies on the left

side, is easier to handle as compared to injury to the

inferior vena cava, which has thinner wall.

3. Trans-sternal appraoch :

Make a Y shaped or straight incision with the

vertical segment passing along the midsternal area

form the suprasternal notch to just below the xiphoid

process (Fig. 5). Next, extend the proximal end diagonally to the right and left along the base of the
neck for a short distance. To avoid entering the abdominal cavity, take care to keep the dissection
beneath the periosteum while exposing the distal end

of the sternum. At the proximal end of the sternal

notch take care to avoid the inferior thyroid vein. By

blunt dissection reflect the parietal pleura from the

posterior surfaces of the sternum and costal

cartilages and develop a space. Pass one finger or

an instrument above and below the suprasternal

space, insert a Gigli saw, and split the sternum. Now

spread the split sternum and gain access to the center of the chest. In children the upper portion of the

exposure will be posterior to thymus and bounded

by the innominate, the carotid arteries and their

venous counterparts. Next, dissect the left side of

this area bluntly. In patients with kyphotic deformity

the innominate vein may now be divided as it

crosses the field; it may be very tense and subject

to rupture. This division is recommended by Fang et

al (1964). The disadvantage of ligation is that it

The patient is placed in lateral position with

left side up. Incision is then given over the rib of

corresponding or 1-2 level higher vertebra depending on the level and the extent of exposure required

(Fig. 6). The rib is dissected subperiosteally by cutting the subcutancous tissue and the muscles overlying
it. The rib is removed by cutting at the

costochondral junction and disarticulating the rib

from the transverse process. During this process

one should be careful not to injure the intercostal

nerves. The parietal pleura are then incised in line

with the skin incision and the lung and the other

contents of mediastinum are retracted by a retractor.

The parietal pleura overlying the vertebral bodies is

dissected to expose the segmental vessels, which

are identified and cut after ligating. The periosteum

is elevated from the vertebral bodies to expose the

vertebral bodies and the pedicles. The excised rib

can be used as a strut graft for fusion of the spine. If

extended exposure is required like for scoliosis correction, 2 ribs can be removed either at adjacent

levels or at different levels by another skin incision.

Fig. 4

Patient poistioning and

periscapular incision for

high transthoracic approach

Fig. 5

Transternal approach to cervicthoracic spine

Fig. 6

Transthoracic approach81

J. Anat. Soc. India 51(1) 76-84 (2002)

Patnaik, V.V.G. et al

V. Anterior approach to thoracolumbar junction

The presence of the diaphragm originating

from the upper lumbar vertebrae and the twlfth ribs

poses technical problems in exposure. The position

is similar as for thoracic exposure. The incision is

centered on 10th rib, which allowes exposure between T10 and L2. It is made curvilinear with ability

to extend either the cephalad or caudal end (Fig. 7).

to avoid the liver and IVC, which is more difficult to

repair then the aorta, should vascular injury occur

during the surgery. The skin incision is placed parallel to the 12th rib, in the abdominal region,
depending on the level of exposure required (Fig. 8). The

subcutaneous tissue, external oblique, internal oblique, transversus abdominus, and the transversalis

fascia are all cut in the line with skin incision. At this

point care is taken not to enter the peritoneal cavity.

The peritoneum is reflected anteriorly using blunt

dissection to expose the psoas muscle. The exposure can be widened by applying a Finochitto rib

retractor between the costal margin and the iliac

crest. The sympahetic chain, which lies between the

psoas and the vertebral bodis, and the genito-femoral nerve, which lies anteriorly on the psoas, need to

be protected. Also the aorta and the inferior vena

cava, which lie anterior on, the vertebral bodies requires to be identified and carefully protected. The

appropriate vertebral body is exposed by elevating

the psoas muscle from the lumbar vertebral bodies.

The lumbar segmental vessels, which come in the

way, should be ligated. The pedicles of the vertebral

bodies are next identified to locate the neural foramen. The affected bodies and the pedicles can be

removed using bone rongeurs to expose the dura.

The wound is closed over a drain in the retroperitoneal space.

2. Anterior transperitoneal approach to L5-S1.

Anterior transperitoneal approach is especially

useful in lumbosacral junction area as the retroperitoneal approach gives a limited exposure at the

level because of presence of the iliac crest. However, this approach has the disadvantage that the

hypogastric plexus, which carries sympathetic fibres

to the urogenital system can be injured and can

cause retrograde ejaculation in males. However, injury to the hypogastric plexus can be avoided by

careful opening of the posterior peritoneum and

blunt dissection of the prevertebral tissue from left

to right and by opening the posterior peritoneum

higher over the bifurcation of the aorta and then

extending the opening down over the sacral promontory. In addition, electrocautery should be kept to

a minimum when dissecting within the aortic bifurcation, and until the anulus of the L5 to S1 disc is

The diaphragm is identified and is incised after carefully retracting the lung. The incision of the
diaphragm should be done at the periphery to minimize

the risk of postoperative paralysis of diaphragm as

the phrenic nerve supplies it from the center to the

periphery. Now take care in entering the abdominal

cavity. Since the transversalis fascia and the peritoneum do not diverge, dissect with caution and
identify the two cavities on either side of the diaphragm.

Incise the diaphragm 2.5 cm away from its insertion

and tag it with sutures for later closure. Incise the

prevertebral fascia. The rest of the dissection is the

same as for anterior thoracic and lumbar exposure.

VI. Anterior aproach to lumbar spine.

1. Anterior retroperitoneal approach (L1-L5)

The patient is positioned with right side down.

The approach is made most often from the left side

Fig. 7

Thoracolumbar appraoch

Fig. 8

Anaterior retroperitoneal

appraoch82

J. Anat. Soc. India 51(1) 76-84 (2002)

Surgical Incisions-Spinal Column

clearly exposed, no transverse scalpel cuts on the

front of the disc should be made.

The position is supine and a midline abdominal

incision is given (Patnaik et al, 2001). The peritoneum is reached by incising the rectus abdominis

sheath in the midline. The peritoneum is opened

and the bowel is packed to expose the posterior

peritoneum, which lies over the sacral promontory

region. The aorta is palpated at its bifurcation and

the posterior peritoneum is carefully incised in midline in that region avoiding damage to the great
vessels. The dissection is then carried along the right

common iliac vessels till its division into external

and intrnal iliac vessels, and then the dissection is

curved medially to avoid ureter from being injured,

which is identified and protected. The soft tissues

are dissected using blunt gauze from left to the right

side from the level of left common iliac vessels,

which will protect the hypogastric plexus from being

injured. The middle sacral artery, which is the terminal branch of aorta, and also the middle sacral vein,

needs to be protected during the exposure of L5/S1

disc. Confirmation of L5/S1 disc should be done by

intraoperative roentgenograms as L5 body may be

frequently mistaken for the sacrum.

B. Posterior approaches :—

The posterior approach through a midline longitudinal incision provides access to the posterior

elements of the spine at all levels, including cervical, thoracic, and lumbosacral. It is the most direct

access to the spinous processes, laminae, and facets and, in addition, the spinal canal may be explored
and decompressed over a large area after

laminectomy. Under most circumstances the choice

of approach to the spine should be dictated by the

site of the primary pathological condition. Posterior

approaches to the spine rarely are indicated when

the anterior spinal column is the site of an infectious

process or a metastatic disease. The posterior elements usually are not involved in the pathological

process and provide stabilization for the uninvolved

structures of the spinal column. Removal of the

uninvolved posterior elements, as in laminectomy,

may result in subluxation, dislocation, or severe

angulation of the spine, causing increased compression of the neural elements and worsening of any

neurological deficit.

I. Post. approach to cervical spine (Occiput

to C2)

Patient is positioned prone and skull traction

tongs are applied. A midline longitudinal skin incision is given from occiput to spinous process of C2.

(Fig 9) Deeper dissection is carried out in the midline raphe (nuchal ligament) to minimize the bleeding,
as it is avascular.
One has to be careful in C1/Occiput junction

and the dissection should not be carried out more

than 1.5 cm from midline to avoid injuring the vertebral vessels. Second cervical ganglion is the
landmark taken for the lateral dissection, which lies in

the groove for vertebal artery.

The posterior arch of C1 lies deeper in comparison to the spinous process of C2. Care should

be exercised while dissecting near to C1 arch because it is thin and vulnerable to fracture during

dissection and secondly the dura is also vulnerable

to injury at superior as well as inferior aspect of C1.

II. Post. approach to cervical spine (C3-C7)

Patient is positioned prone and skull traction

tongs are applied. A midline longitudinal skin incision is given from spinous process of C2 to spinous

process of C7, depending on the area to be dissected. Deeper dissection is carried out in the midline
raphe (nuchal ligament) to minimize the bleeding, as it is avascular. The exposure can be safely

done up to the level of facet joints without endangering any important structure.

III. Post. approach to thoracic spine (T1-T12)

1. Mid line incision : Patient is positioned prone

and a midline longitudinal skin incision is given from

spinous process of T1 to spinous process of T12,

depending on the area to be dissected. Deeper disFig. 9

Posterior approach to upper cervical spine83

J. Anat. Soc. India 51(1) 76-84 (2002)

Patnaik, V.V.G. et al

section is carried out in the midline. The

paraspinous muscles are erased from the posterior

elements using a cobb’s periosteum elevator. Lateral exposure can be done to the level of transverse
processes safely and no important structure comes

in the way. This approach is commonly used for

posterior spinal stabilization, for scoliosis correction

and instrumentation and also for intradural surgery.

2. Costotransversectomy

The thoracic vertebrae may be alternatively

approached through a costotransversectomy when

direct access to the transverse processes and

pedicles of the thoracic spine and limited access to

the vertebral bodies are indicated.

Costotransversectomy should be considered for

simple biopsy or local debridement. It should be

noted, however, that this approach does not provide

the working operative area or length of exposure to

the thoracic vertebral bodies that is afforded by a

transthoracic approach or the midlongitudinal posterior approach.

and neurovascular structures have been identified,

proceed with dissection directly anteriorly on the

pedicle to the vertebral body along a path that is

relatively free of major vessels or nerves. Carefully

dissect the parietal pleura anteriorly to expose the

anterolateral aspect of the vertebral body, raising

the sympathetic trunk and parietal pleura. Exposure

may be increased by removal of the transverse process, pedicle, and facet joints as necessary. After

completion of the spinal procedure, check for air

leaks in the pleura. Close the wound in layers over a

drain to prevent hematoma collection. Should a leak

occur, an intercostal chest tube drainage should be

used.

IV. Posterior approach to lumbar spine (L1-L5)

The lumbar spine can be approached posteriorly either by a midline or through the Paramedian

approach. Through the posterior midline approach

the spine can be easily reached upto the transverse

processes, though, it is much easier to reach the

more lateral areas by the Para-median approach,

the disadvanage is that the latter causes more

bleeding. Posterior approach to the spine is commonly used for disc excision in cases of prolapsed

intervertebral disc, posterior stabilization in cases of

fracture & scoliosis of spine and also for approaching any intra-dural pathology.

1. Posterior midline approach

Patient is positioned prone and a midline longitudinal skin incision is given from spinous process of

L1 to spinous process of L5, depending on the area

to be dissected. Deeper dissection is carried out in

the midline. The spinous processes are reached and

the paraspinous muscles are erased from the posterior arch to reach upto the tips of the transverse

processes as required. The dissection can be extended proximally to the dorsal or distally to the

sacral region if required.

Placing the patient on a padded spinal frame

or kneeling position and keeping the abdomen free

helps to minimize the bleeding during surgery.

2. Posterior paraspinous approach :

Recently, Wiltse and Spencer (1988) refined

the paraspinal approach to the lumbar spine, which

involves a longitudinal separation of the

sacrospinalis muscle group to expose the posterolateral aspect of the lumbar spine. This approach is

especially useful in removing far lateral disc

Position the patient prone or lateral. Make a

curved incision with its apex lateral to the midline at

the desired level (Fig. 10). Deepen the dissection

through the subcutaneous tissues and the trapezius

and latissimus dorsi muscles and the lumbodorsal

fasciae, which are divided longitudinally. Dissect the

paraspinal muscles sharply from their insertions on

the ribs and transverse processes, and retract them

medially. Expose the transverse process and posterior aspects of the associated rib subpriosteally and

remove a section of rib 5 to 7.5 cm long at the level

of involvement, disarticulating from the rib facet.

The rib generally is transected at its prominent posterior angle. Take care to remain subperiosteally and

extra pleural during this part of the exposure and to

protect the intercostal neurovascular bundle. Anterior to the transverse process is the vertebral

pedicle, and above and below the pedicle lie the

neuroforamina. Once the pedicles, neuroforamina,

Fig. 10

Skin incision for

Costotransversectomy84
J. Anat. Soc. India 51(1) 76-84 (2002)

Surgical Incisions-Spinal Column

herniation, pestero lateral fusion, and inserting

pedicle screws.

Patient is positioned prone and a midline longitudinal skin incision is given from spinous process of

L1 to spinous process of L5, depending on the area

to be dissected. Dissection is done upto the deep

fascia and retraction is done to expose paraspinal

muscles on the desired side. Cleavage is then created between the multifidus and the latisimus dorsi

muscles by blunt dissection to reach the area of the

facet joints. Further exposure can be gained by

subperiosteal dissection of the muscles. This approach is commonly used for inter-transverse spinal

fusion.

V. Posterior approach to lumbosacral spine

(L1-Sacrum).

A longitudinal skin incision is given over the

spinous processes of the appropriate vertebrae. The

superficial fascia, lumbodorsal fascia, and the

supraspinous ligaments are incised longitudinally,

over the tips of processes. The ligament is divided

longitudinally between the 2 spinous processes in

the most distal part of the wound. Keeping a small,

blunt periosteal elevator in this opening, and with a

scalpel, muscles are striped subperiosteally from

distal to proximal.
Expose the spinous processes from distal to

proximal as just described because the muscles

may then be stripped from the spinous processes in

the acute angle between their insertions and the

bone. If exposure in the opposite direction is attempted, the knife blade or periosteal elevator will

tend to follow the direction of the fibers into the

muscle and divide the vessels, thus increasing

haemorrhage.

This approach exposes the spinous processes

and medial part of the laminae. Divide the

supraspinous ligament precisely over the tip of the

spinous processes and denude subperiosteally the

sides of the processes because this route leads

through a relatively avacular field; otherwise the arterial supply to the muscles will be encountered.

References :

1. Bailey, R.W.; Bagley, C.E. (1960): Stabilization of the cervical

spine by anterior fusion. Journal of Bone and Joint Surgery,

42-A: 565.

2. Bohmlan, H.H., Eismonst, F.J. (1982): Surgical technique of

anterior decompression and fusion for spinal cord injuries.

Clinical Orthopaedics, 154: 57.

3. Bohlman, H.H.; Ducker, T.B.; Lucas, J.T: Spine and spinal

cord injuries. In The spine, Rothman R.H., Simeone, F.A.,

editors: ed.2, W.B. Saunders. Philadelphia. (1982)

4. Burington, J.D.; Brown, C; Wayne, E.R.; Odom, J (1976):

Anterior approach to the thoracolumbar spine: technical

considerations. Archieves of Surgery, 111: 456.

5. Conchoix, J.; Binet, J.P. (1957): Anterior surgical approaches

to the spine. Annals of Royal College of Surgery, 21: 237.

6. Charles, R; Govender, S. (1989): Anterior approach to the

upper thoracic vertebrae. Journal of Bone & Joint Surgery.,

71-B: 81.

7. Cloward, R.B. (1958): The anterior approach for ruptured

cervical discs. Journal of Neurosurgery, 15: 602.

8. Crenshaw, A.H.: Campbell’s Operative Orthopaedics In:

Spinal Anatomy & Surgical Approaches Leventhal MR Edr

8th Edition Vol. V, Mosby Year Book Inc USA : pp. 2681-2793

(1992).

9. Cocke, E.W. Jr; Robertson, J.H.; Robertson, J.R.; Crook,

J.P. Jr (1990): The extended maxillotomy and subtotal

maxillectomy for excision of skull base tumors. Archieves of

Otolaryngology and Head Neck Surgery, 116: 92.

10. Fang, H.S.Y., Ong, G.B.; Hodgson, A.R. (1964): Anterior

spinal fusion : the operative approaches. Clinical

Orthopaedics, 35: 16.

11. Fang, H.S.Y; Ong, G.B. (1962): Direct anterior approach to

the upper cervical spine. Journal of Bone and Joint Surgery,

44-A: 1588.

12. Hall, J.E. (1972): The anterior approach to spinal deformities.

Orthopaedics Clinics of North America, 3: 81.

13. Hodgson, A.R; Stock, F.E; Fang, H.Y.S.; Ong, G.B. (1960):

Anterior spinal fusion; the operative approach and

pathological findings in 412 patients with Pott’s disease of the

spine. British Journal of Surgery, 48: 172.

14. McAffee, P.C.; Bohlman, H.H.; Riley, L.H. Jr et al (1987): The

anterior retropharyngeal approach to the upper part of the

cervical spine. Journal of Bone and Joint Surgery, 69-A:

1371.

15. Micheli, L.J.; Hood, R.W. (1983): Anterior exposure of the

cervicothoracic spine using a combined cervical and thoracic

approach. Journal of Bone and Joint Surgery, 65-A: 992.

16. Mirbaha, M.M. (1973): Anterior approach to the thoracolumbar junction of the spine by a
retroperitoneal-extrapleural

technique. Clinical Orthopaedics, 91: 41.

17. Patnaik, V.V.G.; Singla, R.K.; Bansal, V.K. (2001): Surgical

incisions – their anatomical basis. Part IV – Abdomen.

Journal of the Anatomical Society of India, 50(2). 170-8.

18. Riseborough, E.J. (1973): The anterior approach to the spine

for the correction of deformities of the axial skeleton. Clinical

Orthopaedics. 92: 207.

19. Robinson R.A.; Riley L.H. Jr (1975): Techniques of exposure

and fusion of the cervical spine. Clinical Orthopaedics, 109:

78.

20. Singh, T.P; Bala Sanju; Kalsey, G. & Singla, R.K. (2000):

Applied anatomy of fascial spaces in head and neck. Journal

of the Anatomical Society of India, 49(1): 78-88.

21. Southwick, W.O; Robinson, R.A (1957): Surgical approaches

to the vertebral bodies in the cervical and lumbar regions.

Journal of Bone and Joint Surgery, 39-A: 631.

22. Spetzler, R.F: Transoral approach to the upper cervical spine.

In Surgery of the musculoskeletal system, Evarts, C.M.,

editor: Vol. 4, Churchill Livingstone New York, (1983).

23. Wagoner, G (1937): A technique for lessening haemorrhage

in operations on the spine. Journal of Bone Joint Surgery, 19:

469.

24. Wiltse, L.L; Spencer, C.W. (1988): New uses and

refinements of the paraspinal approach to the lumbar spine.

Spine 13: 696.

This Article Can be Downloaded / Printed Free from

http:\\jasi.net surgical practice, deciding on the right type of surgical access for a specific condition would be a skill of its own
for a surgeon. The decision to select a specific incision would depend on the several elements. These would be,

Problem site Related anatomical structures Easy access Less complications Quicker healing Minimum scar

But, at instances, all these options might not be fulfilled and the surgeons have to make a professional judgment as to decide on

what's best for the patients' condition and act fast in order to save the life of the patient.

Out of many areas in the body, abdomen could be one area which sees many surgical incisions for different kinds of surgical

necessities. This article will discuss predominantly on abdominal incisions and its uses in surgical practice.

1. Grid iron incisions

Also known as 'McBurneys incision', the incision is the most commonly used incision for 'appendicectomy'. The incision will be

placed at the McBurney's point which is at the junction between the middle one third and the outer one third of a line extending from

umbilicus towards the anterior superior iliac spine. It's commonly places obliquely and has the potential to be expended in case the

need arise.

2. Pfannansteil incision

The incision is the usual procedure adopted for surgical access towards pelvic organs and mainly for cesarean sections. The

incision is placed horizontally about 5 cm above the pubic symphysis and is about 12 cm in length.
3. Kocher subcostal incision

The incision is placed below the costal margin or the lower margin of the rib cage and could be on either left or in the right. But, most

often the incision will be placed on the right side of the body to gain access to the gall bladder and the billiary tree.

4. Mid line incision

The incision placed on the middle of the abdomen will run vertically and will give the surgeon enough access to almost all abdominal

organs and will facilitate good visualization as well. There are several advantages of this kind of incision and being blood less plain

is one of the most important. This incision is widely used in surgeries related to bowel pathologies and especially in situations which

require the necessity to remove part of the bowel.

Paramedian incisions are also used when the need arise to access certain organs towards a particular site.

Cheveron incision and Mercedes Benz Modifications are some of the other incisions which will allow the surgeons better access to

upper abdominal organs.

Apart from these, it is vital to remember that a surgeon will be able to make a decision based on his clinical experience on the

placement of the incision as well as the required size of the incision. Therefore, the art of doing a surgery would not be limited to text

book patterns of incisions, but you can be assured that the above described incisions will account for many of these decisions.

Learn more about this author, Dr Pandula Siribaddana.

 Click here to send this author comments or questions.