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Surgical Incisions
Case: 27 year old G0 with a history of regular menstrual intervals every 27 x 4-5 days, severe progressive right greater than left sided dysmenorrhea, and serial ultrasound examinations at different times during the menstrual cycle revealing a persistent 3.4 x 2.5 cm complex right ovarian cyst that has the characteristic (ultrasound) appearance of an endometrioma. The woman has decided on surgery to remove this persistent nonfunctional ovarian cyst.
Question: What is the best abdominal incision to be used for this surgery?
Answer: The surgeon may prefer a particular type of incision (vertical versus transverse, small incision used with laparoscopy versus larger incision used during a laparotomy) based on (1) personal experience (what he or she is used to), (2) speed with which entry into the abdomen is possible (if rapid access is required since the patient is clinically unstable or she is bleeding internally then certain incisions permit more rapid entry), or (3) visibility (vertical abdominal incisions generally allow greater visibility than transverse incisions).
A patient may prefer a particular type of incision based on (1) cosmetic concerns (lower abdominal transverse incisions can often be “hidden” with clothing, smaller incisions are generally less noticeable than larger incisions), (2) recovery period (a few days on the average following laparoscopy and a few weeks on the average after laparotomy), or (3) need for hospitalization (laparoscopy is usually same day surgery while laparotomy usually requires a few day hospital stay).
Of utmost importance, the incision must allow the surgeon to complete the surgery safely and effectively. Beyond this, an incision that optimizes patient satisfaction is best.
Case: 22 year old G0 2 weeks after laparoscopy for lysis of pelvic adhesions and vaporization of endometriosis has a small white “thread” knotted at one end of the umbilical (belly button) incision sticking out (slightly) through the skin.
Question: Will the suture seen protruding from the skin incision go away by itself or does it need to be removed?
Answer: Suture is used during surgery to ligate (tie off) bleeding vessels or approximate (bring together) tissue.
Skin can be reapproximated with suture that is placed in the subcuticular space. Suture used for subcuticular stitches is generally thin (small diameter) absorbable suture with extended tensile strength.
An absorbable suture that has been commonly used for skin incisions since the 1970s (when it became available in the USA) is Vicryl (polyglactin 910). Vicryl is broken down by hydrolysis rather than digestion, giving it a relatively constant absorption rate that may result in a small amount of localized inflammation. Vicryl maintains about 50% of its tensile strength after 2-3 weeks and 10% of its tensile strength after 6 weeks. Therefore, the knot resulting from tying the Vicryl suture under the skin will often “disappear” spontaneously (fall off) after about 4-8 weeks from surgery.
Nonabsorbable sutures may also be used for reapproximation of skin. Therefore, it is important to ask the surgeon about wound care during the postoperative period, including the need for him to remove the suture that has been placed.
Case: 25 year old G0 had surgery for vaporization of pelvic endometriosis 5 days ago, has an upper respiratory infection with heavy coughing, and is worried about her insides “falling out” or getting “pushed out” through the incisions.
Question: What prevents the abdominal contents from passing through the abdominal wall?
Answer: The surgical closure of an abdominal incision is intended to minimize the chance of wound separation or evisceration.
A wound dehiscence is a separation of the surgical incision (skin, subcutaneous fat, and possibly the fascia). A wound evisceration is protrusion of an internal organ through the surgical incision. Fortunately, both of these conditions are very uncommon.
The strongest layer of abdominal wound closure is the musculo-aponeurotic (fascial) layer over the rectus abdominus muscle. This layer normally holds the abdominal viscera (organs and tissues) in place. The fascia overlying the rectus muscle is normally a thick strong layer of fibrous connective tissue (similar to the type of tissue that is found in tendons and ligaments).
The choice of suture for fascial closure is important. A suture that maintains a greater tensile strength than the surrounding fascia during the critical period of fascial repair is optimal. Fascia regains its natural strength slowly, with about 40% of its original strength being regained after 4 weeks. However, it seems as though fascia regains enough strength to withstand rupture (separation) within about 3 weeks of surgery since wound dehiscence is generally reported within 2 weeks of surgery and is rare after 18 days following surgery.
Your surgeon should select a suture for fascial closure (when closure of the fascia is required) that will provide adequate strength through at least the initial 3 weeks following surgery.
Case: 33 year old on postoperative day 1 after laparoscopic lysis of pelvic adhesions wants to shower. The incision sites are dressed (covered) with bandaids.
Question: When can a woman normally shower after laparoscopic surgery and what should she do with the bandaids covering the incisions?
Answer: Any wound dressing (bandaids, nonadhesive gauze, bandage) should be kept dry. A wet dressing can disrupt wound healing and increase the likelihood of a local infection.
A woman can generally shower on the day after laparoscopic pelvic surgery. Each individual postoperative patient should confirm that she is able to shower with her particular surgeon. If she feels at all light headed or weak while standing then she might have her husband initially watch her or she should wait until she feels better before showering.
After the bandaid or wound dressing becomes wet, it should be replaced with a dry bandaid.
Case: 31 year old G0 has an incision that is red, warm to the touch, tender and leaking a purulent substance (pus) 7 days after laparoscopic laser ablation of endometriosis and lysis of pelvic adhesions.
Question: How should this apparent wound infection be treated?
Answer: The physician should rule out (look for signs of) a systemic infection. This includes taking the temperature with a thermometer and if elevated then obtaining a fever workup (including bloodwork and any other relevant tests).
If the infection is localized to the incision site then the infected region needs to be examined. If the infection is “trapped” under the skin without an ability to drain, then opening the incision and drainage may be required. If the infected material is draining spontaneously, then application of a cleansing agent once or twice a day is usually suggested. Hydrogen peroxide that is diluted to 1/2 strength with water applied locally once every 1-2 days is often used.
Specific instructions should be reviewed with the surgeon when an infection is recognized. Localized skin infections are generally effectively treated within a few days of drainage and application of a cleansing agent.
Case: 19 year old G0 with a belly button ring is scheduled for a laparoscopy during her evaluation for chronic pelvic pain.
Question: Does the belly button ring need to be removed prior to the surgery?
Answer: Yes.
All jewelry in the regions of the surgical sites should be removed from the body prior to surgery.
Belly button rings and all other jewelry near the abdomen or vaginal vault should be removed prior to gynecological laparoscopic surgery.
Once the surgery has been concluded then the patient can replace the ornamental objects if desired.
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