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Caesarean Section
Published in Gowri Dorairajan, Management of Normal and High Risk Labour During Childbirth, 2022
Pfannenstiel incision (Kerr incision): Opening of the abdomen by low transverse suprapubic incision. The incision is kept just above the pubic symphysis, so the hairline will later almost cover the incision. A horizontal incision that is slightly curved at the ends is made on the skin and deepened to the subcutaneous fat till the rectus sheath. The rectus sheath is cut horizontally to get access to the abdominal cavity. The rectus muscles are separated along the midline raphe and retracted laterally. The posterior rectus sheath above the arcuate line and the fascia transversalis below is incised, and the peritoneum is opened vertically. One must be careful while retracting the muscles laterally. There is a risk of injuring the vessels under the muscle, and life-threatening hematomas can form under the rectus sheath. For this reason, the author avoids this incision in patients who have preoperative coagulation failures like severe abruption or liver failure cases.
Lateral Hernias
Published in Jeff Garner, Dominic Slade, Manual of Complex Abdominal Wall Reconstruction, 2020
These curious hernias arise through the Spigelian fascia, named after Adriaan van de Speighel, a Flemish anatomist based in Padua in the 1600s. This thin fascial layer comprises the fused aponeuroses of the transversus abdominis and internal oblique, between the muscle bellies and the rectus sheath (Figure 15.8). The Spigelian fascia extends from the costal margin to the inguinal canal, and hernias can arise anywhere along this line, appearing clinically as a swelling at the lateral edge of the rectus sheath (Figure 15.9). They are most common in the so-called Spigelian Belt, just below the level of the umbilicus, where the abdominal wall tension is at its greatest and the fascial layer at its widest and thinnest. For years it was proposed that they emerged just below the level of the arcuate line owing to a weakness of the abdominal wall at that point but this is now known not to be the case.12
Abdomen
Published in Bobby Krishnachetty, Abdul Syed, Harriet Scott, Applied Anatomy for the FRCA, 2020
Bobby Krishnachetty, Abdul Syed, Harriet Scott
The rectus sheath completely covers the upper three-quarters of the rectus muscles and the anterior portion of the lower one quarter, but the posterior one quarter is uncovered by the rectus sheath, instead being in contact with the transversalis fascia. The horizontal line that demarcates the lower limit of the posterior rectus sheath is called the arcuate line, found midway between the umbilicus and the pubic symphysis (Figure 3.9).
Surgical flap delay to allow primary transabdominal transplantation of extended rectus abdominis myocutaneous flaps in increasingly complex pelvic wound reconstructions
Published in Journal of Plastic Surgery and Hand Surgery, 2023
Maurits Lange, J. Joris Hage, Arend Aalbers, Esther M. K. Wit, Frédéric Amant, Marije J. Hoornweg
Abdominal donor site closure started by double-breasted vest-over-pants suturing of the arcuate line of the posterior lamina of rectus sheet to the inferior remnant of the anterior lamina resulting after flap harvesting [7]. The remaining lateral and cranial edges of the anterior lamina defect were, likewise, sutured onto the posterior lamina. Such primary fascial closure may well be achieved in most patients [4,8]. A mesh to prevent cicatricial herniation was sutured in between both layers only in cases where the quality and quantity of both the inferior superficial rectus fascia and the superior deep rectus fascia were deemed insufficient to allow adequate double-breasted closure [8,9]. The decision to do so was left to the discretion of the plastic surgeon operating. Consequently, a mesh was applied in 14 of the 43 female patients (0.33) and 12 of the 62 male patients (0.19) (p = 0.13). Of these, five men and two women were operated on by the one plastic surgeon who routinely applied a mesh in all cases.
Rectus sheath hematoma following enoxaparin administration
Published in Baylor University Medical Center Proceedings, 2020
Ryan E. Dean, Ganesh Maniam, Thien Vo
The adverse effects of LMWH have been well established, but life-threatening abdominal hematomas following administration are rare, with very few reported cases. Many of these cases occur in older patients,4–7 which raises the question of whether enoxaparin administration is appropriate in these patients. One such case led the authors to report that risk factors for the development of severe spontaneous hematomas include higher doses of LMWH, preexisting renal impairment, older age, and concomitant administration of medications that affect hemostasis.7 Another notable risk factor for RSH is direct injury to the muscle or indirect damage due to excessive forceful contraction—including activities with increased Valsalva effort.8 This is perhaps the most applicable risk factor in this case, other than advanced age and anticoagulation therapy, as the patient had been found unconscious and hypotensive on the commode due to a vasovagal event secondary to constipation. The lack of a posterior rectus sheath below the arcuate line allows for inferior epigastric artery RSH to be more massive due to this lack of anatomical restriction, and this absence of a tamponade effect may partially explain the increased mortality rate associated with RSH.8
Is extralevator abdominoperineal resection necessary for low rectal carcinoma in the neoadjuvant chemoradiotherapy era?
Published in Acta Chirurgica Belgica, 2020
Hikmet Erhan Güven, Bülent Aksel
Laparoscopic mesorectal mobilization was achieved dissecting the surgical field bordered by the upper edge of the coccyx, autonomous nerves, and inferior border of seminal vesicles or cervix of the uterus. Patients were given a modified lithotomy position for APR and a conventional APR was performed without removing the coccyx. During ELAPR, patients were given a prone jackknife position. The perineal incision was extended towards the lateral portion of the external anal sphincter. Dissection was extended through the ischioanal fossa until the insertion of the levator muscle is reached. Levator muscles were divided from their origin above the arcuate line and included in the specimen. Coccyx was routinely resected during ELAPR.