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A “bikini” incision for appendectomy
A “Bikini”
Incision for Appendectomy
Harry M. Delany, MD, FACS, Bronx, New York Nino J. Carnevale, MD, FACS, Bronx, New York
As modern advertising continues to glorify the blemish-free face and body, an exposed abdominal scar is viewed as most objectionable. For women the appeal of the “bikini,” with its wide areas of exposed abdomen, has been sustained since its introduction by designer Jacques Hyme. As a result, general surgeons should consider the cosmetic effects of abdominal incisions, especially if this consideration does not lead to increased morbidity or significant prolongation of abdominal surgical procedures. Appendectomy is usually performed through the incision introduced by McBurney [I] in 1894. The efficiency of this incision is well established. It has a low complication rate and provides excellent access to the cecum. The common and continued use of this incision attests to its value as a surgicalcontribution. However, several alternative incisions exist and have gained popular use. The Rockey-Davis and paramedian incisions are adequate for appendectomy and lower abdominal exploration. The dual requirement for appropriate access to the abdominal cavity and the simultaneous preservation of the integrity of the exposed abdominal wall skin favor the use of incisions that avoid unsightly scars. The strong desire of women to avoid abdominal scars has encouraged many surgeons to use a variety of incisions that are hidden from exposure. Incisions in the pubic hair line and transverse incisions of very short length have been used. The Pfannenstiel incision is an example of this approach. With the advent of the bikini bathing suit and considering the common permanent blemish produced by the standard approach to simple appendectomy, an incision has been designed to achieve access to the appendix and at the same time assure preservation of the normal contour and appearance of the lower abdomen. A short skin flap is required that would widen the area of wound infection in the presence of marked suppuration; therefore, this “bikini” incision is for use in patients with simple, nonperforated appendicitis. It is also not
From the Department of Surgery, Montefiore Hospital and Medical Center. Montefiore-Morrisania Affiliate, Albert Einstein College of Medicine, Src+w, New York. Reprint requests should be addressed to Harry M. Delany, MD. Morris&a City Hospital, 1230 Gerard Avenue, Bronx, New York 10452.
recommended in complicated diagnostic circumstances or when a very wide exploration of the abdomen is indicated. Technic
The “bikini” incision is in the lateral low transverse position located below the pubic hair line. It extends from approximately 2 to 3 cm below the anterior superior spine medially across the inguinal ligament to approximately 1 cm from the midline. The incision is carried down to the aponeurosis of the external oblique muscle. (Figure 1.) A flap is then developed on the aponeurosis of the external oblique upward to the level of the line extending from the anterior spine to the umbilicus. This is the level of the standard McBurney incision in the aponeurosis of the external oblique muscle. (Figure 2.) From this point the sequence of steps are exactly the same as for the classic McBurney incision. (Figure 3.) An alternative approach is to primarily incise the anterior rectus sheath at its lateral border using the technic of Jelenko and Davis [2]. (Figure 4.) The rectus muscle can then be retracted medially and the peritoneal cavity entered through the transversalis fascia and peritoneum. The aponeurosis of the oblique and transverse muscle can be incised as part of the incision or to enlarge a lateral muscle-splitting incision. The only unusual requirement for the incision is upward retraction on the skin and subcutaneous fat to allow access to the aponeurosis of the external oblique or rectus fascia. To achieve this the skin incision must be longer than the standard McBurney oblique incision. The completed incision is located below the level of most bathing suit wear including the bikini. The skin should then be closed in a technic that minimizes scar formation. A running subcuticular wire or absorbable suture with tape approximation of the skin has been our standard technic. The ultimate cosmetic effect is quite satisfactory. (Figures 5A and 5B.) The clinical experience so far has been satisfactory. The incision has been used in twelve patients. There have been no wound infections or other untoward complications. Some tenderness and pain has been noted postoperatively at the site of upper retraction on the flap; however, this tenderness subsides within three to four days postoperatively. TheAmerkan
Journal of Surgery
AppendectomyIncision
Figure 1. The in&don extends trom 2103cmbeknvtheante~qerior qlne nmdtaliy to approximately one centimeter tram the mkiline. Figure 2. Up’ward retraction on the sk~nandaubcutaneoustlssueisused to approach the area to be entered. Figure 3. A muscte-sptftting inc&lon is used for access to the perttoneai cav/ty aHer upward retraction on the skin flap. Figure 4. An alternatlve rectus retr&ting a#m#ach can be used for
%
I’
Figure 5A. The completed /n&ion is below the upper edge of the pubic hak line. Figure 581.Thepatlent can wear “biklni” bafhhg auif wfthout exposlw the appendectomy scar.
Summary
References
An incision is described for adaptation to the young female requiring an appendectomy. The incision is designed to allow the use of brief bathing suits and to preserve the normal contoured appearante of the abdominal wall.
1. McBurney C: The incision made in the abdominal wall in cases of appendicitis with a description of the method of operation. Ann Surg 20: 38, 1894. 2. Jelenko C, Davis L: A transverse lower abdominal appendectomy incision with minimal muscle derangement. Surg Gyneco! Obstet 136: 451, 1973.
Volume 132, July 1976
127
Incision for Appendectomy
Harry M. Delany, MD, FACS, Bronx, New York Nino J. Carnevale, MD, FACS, Bronx, New York
As modern advertising continues to glorify the blemish-free face and body, an exposed abdominal scar is viewed as most objectionable. For women the appeal of the “bikini,” with its wide areas of exposed abdomen, has been sustained since its introduction by designer Jacques Hyme. As a result, general surgeons should consider the cosmetic effects of abdominal incisions, especially if this consideration does not lead to increased morbidity or significant prolongation of abdominal surgical procedures. Appendectomy is usually performed through the incision introduced by McBurney [I] in 1894. The efficiency of this incision is well established. It has a low complication rate and provides excellent access to the cecum. The common and continued use of this incision attests to its value as a surgicalcontribution. However, several alternative incisions exist and have gained popular use. The Rockey-Davis and paramedian incisions are adequate for appendectomy and lower abdominal exploration. The dual requirement for appropriate access to the abdominal cavity and the simultaneous preservation of the integrity of the exposed abdominal wall skin favor the use of incisions that avoid unsightly scars. The strong desire of women to avoid abdominal scars has encouraged many surgeons to use a variety of incisions that are hidden from exposure. Incisions in the pubic hair line and transverse incisions of very short length have been used. The Pfannenstiel incision is an example of this approach. With the advent of the bikini bathing suit and considering the common permanent blemish produced by the standard approach to simple appendectomy, an incision has been designed to achieve access to the appendix and at the same time assure preservation of the normal contour and appearance of the lower abdomen. A short skin flap is required that would widen the area of wound infection in the presence of marked suppuration; therefore, this “bikini” incision is for use in patients with simple, nonperforated appendicitis. It is also not
From the Department of Surgery, Montefiore Hospital and Medical Center. Montefiore-Morrisania Affiliate, Albert Einstein College of Medicine, Src+w, New York. Reprint requests should be addressed to Harry M. Delany, MD. Morris&a City Hospital, 1230 Gerard Avenue, Bronx, New York 10452.
recommended in complicated diagnostic circumstances or when a very wide exploration of the abdomen is indicated. Technic
The “bikini” incision is in the lateral low transverse position located below the pubic hair line. It extends from approximately 2 to 3 cm below the anterior superior spine medially across the inguinal ligament to approximately 1 cm from the midline. The incision is carried down to the aponeurosis of the external oblique muscle. (Figure 1.) A flap is then developed on the aponeurosis of the external oblique upward to the level of the line extending from the anterior spine to the umbilicus. This is the level of the standard McBurney incision in the aponeurosis of the external oblique muscle. (Figure 2.) From this point the sequence of steps are exactly the same as for the classic McBurney incision. (Figure 3.) An alternative approach is to primarily incise the anterior rectus sheath at its lateral border using the technic of Jelenko and Davis [2]. (Figure 4.) The rectus muscle can then be retracted medially and the peritoneal cavity entered through the transversalis fascia and peritoneum. The aponeurosis of the oblique and transverse muscle can be incised as part of the incision or to enlarge a lateral muscle-splitting incision. The only unusual requirement for the incision is upward retraction on the skin and subcutaneous fat to allow access to the aponeurosis of the external oblique or rectus fascia. To achieve this the skin incision must be longer than the standard McBurney oblique incision. The completed incision is located below the level of most bathing suit wear including the bikini. The skin should then be closed in a technic that minimizes scar formation. A running subcuticular wire or absorbable suture with tape approximation of the skin has been our standard technic. The ultimate cosmetic effect is quite satisfactory. (Figures 5A and 5B.) The clinical experience so far has been satisfactory. The incision has been used in twelve patients. There have been no wound infections or other untoward complications. Some tenderness and pain has been noted postoperatively at the site of upper retraction on the flap; however, this tenderness subsides within three to four days postoperatively. TheAmerkan
Journal of Surgery
AppendectomyIncision
Figure 1. The in&don extends trom 2103cmbeknvtheante~qerior qlne nmdtaliy to approximately one centimeter tram the mkiline. Figure 2. Up’ward retraction on the sk~nandaubcutaneoustlssueisused to approach the area to be entered. Figure 3. A muscte-sptftting inc&lon is used for access to the perttoneai cav/ty aHer upward retraction on the skin flap. Figure 4. An alternatlve rectus retr&ting a#m#ach can be used for
%
I’
Figure 5A. The completed /n&ion is below the upper edge of the pubic hak line. Figure 581.Thepatlent can wear “biklni” bafhhg auif wfthout exposlw the appendectomy scar.
Summary
References
An incision is described for adaptation to the young female requiring an appendectomy. The incision is designed to allow the use of brief bathing suits and to preserve the normal contoured appearante of the abdominal wall.
1. McBurney C: The incision made in the abdominal wall in cases of appendicitis with a description of the method of operation. Ann Surg 20: 38, 1894. 2. Jelenko C, Davis L: A transverse lower abdominal appendectomy incision with minimal muscle derangement. Surg Gyneco! Obstet 136: 451, 1973.
Volume 132, July 1976
127