kocher's incision layers kocher's incision layers

This information is intended for medical education, and does not create any doctor-patient relationship, and should not be used as a substitute for professional diagnosis and treatment. Two modifications and extensions of the Kocher incision are possible: Whilst open procedures that come with inherent drawbacks, all these subcoastal incisions provide the surgeon with good exposure to the abdominal viscera and tend to heal well. Previous abdominal operation. Using SOCRATES in History Taking | OSCE | Communication Skills, Abdominal Surgical Incisions and the Rectus Sheath. Primary Low Transverse Cesarean Section Operative Sample Report - Introduction 00:00 The goal is approximation of tissue edges to allow scar formation. . Last updated: August 23, 2022 8.1 and 8.2 show the vascular and nervous supply to the abdominal wall muscles. The skin is the largest and heaviest organ of the body. [QxMD MEDLINE Link]. This method uses 3 to 4 very small incisions. The lateral (Kocher) approach can be used to access the radial head and the tip of the coronoid. A collection of communication skills guides, for common OSCE scenarios, including history taking and information giving. [29], In the past, abdominal midline surgical wound dehiscence rates as high as 10% were reported A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. In liver surgery, the Kocher subcostal incision, i.e., the right subcostal oblique incision, is often used, which has the advantages of hepatic mobilization and vascular control. Many planned approaches are extensile but . - Geeky Medics OSCE App: https://geekymedics.com/geeky-medics-app/ The two primary methods of skin closure are with suture or staples. Br J Surg. Abdominal incisions: techniques and postoperative complications 317 over,exposureoftheabdomenisexcellent.Exten-sions,whenrequired,caneasilybemadesuperiorly [QxMD MEDLINE Link]. [1] ; for this reason, the ensuing discussion of abdominal closure focuses on this incision. Am J Surg. The operation was performed (Figure 2 and Figure 3) - Exacerbating & relieving factors 05:12 New York: McGraw-Hill; 2020. Right Kocher's incision: a feasible and effective incision for right However, a few studies have reported surgical treatment for TAMH, and the optimal surgical procedure remains controversial. Finally, class III (contaminated) and IV (dirty) wounds should not be closed and should be left open to heal by secondary intention, [QxMD MEDLINE Link]. The Kocher incision is not to be confused with the Kocher Maneuver, which describes the mobilization of the second and third portion of the duodenum and the pancreatic head. Medical Dictionary for the Health Professions and Nursing Farlex 2012 Kocher, E. Theodor, Swiss surgeon and Nobel laureate, 1841-1917. Surgical incisions are planned based on the expected extent of exposure needed for the specific operation planned. In continuous fascial closure, two Kocher clamps are clamped to the fascial layer midway through the incision and then retracted by the assistant. [QxMD MEDLINE Link]. Midline incision, Paramedian incision, Kocher incision, Rooftop modification and Mercedes Benz modification. Int Surg J. Emil Theodor Kocher LITFL Medical Eponym Library J Surg Res. Kocher incision: subcostal incision made parallel to the costal margin, starting below the xiphoid and extending laterally; used to access the gall bladder; these subcoastal incisions provide good abdominal viscera exposure and good healing. If you'd like to support us and get something great in return, check out our awesome products: You don't need to tell us which article this feedback relates to, as we automatically capture that information for you. 1987 Aug. 74 (8):738-41. Diagnosis was made of a 6.2 cm 5 cm bowel-contain-ing RUQ posterior rectus sheath hernia with intact rectus muscle. 2019 Mar. It is mainly used to gain access for gall bladder and/or biliary tree pathology. Kocher himself, however, recognized the logic behind utilizing as small an incision as possible and is quoted as saying thyroidectomy incisions should be "as small as possible, as big as necessary," therefore perhaps qualifying him as the first minimally invasive surgeon. Abdominal Incisions PRIYA ANUSHA DSOUZA. (Kocher approach) to access to the radial head and the disrupted LCL. The most commonly documented postoperative complication is incisional hernia, which occurs in approximately 9-20% of patients after an abdominal closure. Staple or suture removal should occur at approximately 7-14 days. It can achieve the same standards of tumor resection and surgical field accessibility as the midline approach, while reducing postoperative recovery. Examples of such circumstances include the following: Various methods and materials are used to accomplish temporary closure (eg, sterile intravenous bag, fish-shaped viscera retainer, or abdominal vacuum pack). Nobel Laureate in Medicine 1909 "for his work on the physiology, pathology and surgery of the thyroid gland" (Courtesy of Nobelprize.org) Full size image. An oblique incision made in the right lower quadrant of the abdomen, classically used for. There is no posterior sheath above the level of the costal margin, as the recti remain covered anteriorly by the external oblique aponeurosis and insert directly onto the underlying costal cartilages. [17] The use of prophylactic mesh in high-risk patients, in comparison with primary suture closure of the midline incision, yielded a significant reduction in the incisional hernia rate. [25, 26]. Wound dehiscence following midline laparotomy is a particularly distressing event for the patient, whereby classically a serosanguinous discharge is noted from the wound 7-10 days postoperatively, and a day or so later the whole wound may burst open and spill the patients intestines into their lap. A Kocher incision (no. 2003 Feb. 109 (2):130-7. Advise the patient should be advised to seek advice if any signs of infection or wound dehiscence. Am J Surg. [1] ; however, a few consensus techniques are generally used. Temporary abdominal closure with polytetrafluoroethylene prosthetic mesh in critically ill non-trauma patients. Transverse incisions are felt to have more intrinsic strength than their vertical counterparts because the abdominal fascia fibers are transversely oriented, causing sutures to be placed perpendicular to the fiber direction (see the image below). Surgical Incisions Their Anatomical Basis Section: Thoracic Incisions: H. J. Pfannenstiel. Check out our NEW & IMPROVED quiz platform at geekyquiz.com, To be the first to know about our latest videos, subscribe to our YouTube channel . Am J Surg. The authors' analysis led them to conclude that the particular technique used for interrupted suturing is critically important to the outcome. After medical optimization, the patient was sched - uled for a laparoscopic incisional hernia repair with mesh. Small tissue bites and wound strength: an experimental study. Management strategy for dirty abdominal incisions: primary or delayed primary closure? This cookie is set by GDPR Cookie Consent plugin. Medscape Education, Invasive Group A Streptococcus Outbreaks Associated With Home Healthcare, England, 20182019, encoded search term (Abdominal Closure) and Abdominal Closure, Pressure Injuries (Pressure Ulcers) and Wound Care. BMC Surg. 2014 Aug. 76 (4):270-6. Standring S, ed. Surgical Incision is a cut made through the skin to facilitate an operation or precedure. 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. Membranes are ruptured by toothed or Kocher's forceps. Wound infection occurred in 12 group A patients and 10 group B patients, wound dehiscence in two group A patients and no group B patients. Avoid dissection distal to the annular ligament or strenuous retraction because the posterior interosseous nerve, lying within the supinator muscle, is at risk. The intercostal nerves emerge from below the costal margin and run between the layers of the internal oblique and transversus abdominis muscles. Thus, excellent cosmesis can usually be achieved with the Pfannenstiel, Maylard . [Full Text]. Bursting open of a wound. Abdominal Incisions and Anatomy of the Abdominal Wall This field is for validation purposes and should be left unchanged. DO NOT perform any examination or procedure on patients based purely on the content of these videos. The technique of fascial closure is highly variable among surgeons; however, the various approaches may be grouped into two primary methods as follows Vol 2: 1549-66. Open Cholecystectomy Technique: Approach Considerations, Open Carney MJ, Weissler JM, Fox JP, Tecce MG, Hsu JY, Fischer JP. Kirk RM, Ribbans WJ, eds. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. Midline incision hi-res stock photography and images - Alamy Some common incision sites are discussed below. - Timing 03:23 [QxMD MEDLINE Link]. This incision is also commonly utilised by vascular surgeons for elective and emergency repair of abdominal aortic aneurysms. A Kocher incision is made parallel to the subcostal margin to access the underlying liver and biliary tree. This classically corresponds to the area of maximal tenderness on clinical examination when the appendix has become sufficiently inflamed to cause localised peritonitis. Subcostal Also called upper oblique, Kocher's incision Gallbladder and biliary tract surgery Paramedian Upper R side (biliary tract, gallbladder) Upper L side (splenectomy, gastrectomy) Lower R side (small bowel resection) Lower L side (sigmoid colon resection) Midline Upper and lower abdominal incision Abdominal surgeries . Named after Emil Theodor Kocher. This article discusses the anatomy of the abdominal wall, anatomy of the rectus sheath and common abdominal surgical incision types (midline, paramedian, pararectal, Gridiron, Lanz, Pfannenstiel, transverse, Kocher). A number of randomized, controlled trials have showed no benefit to peritoneal closure; thus, refraining from closing the peritoneum is a commonly accepted practice. Incise the subcutaneous tissue in line with the incision and raise flaps to expose the fascia over the muscles. Late postoperative complications included . generic complications of surgery vs those specific to the operation, and presenting as immediate, early or late complications. [Full Text]. According to Novitsky's description [], shown in Rosen's atlas of abdominal wall reconstruction [], the non-viable Musculo-fascial tissue was debrided.Tension at the wound edges was assessed by applying the Kocher's clamps over the tissues, checking for sutures cutting through the tissues, and . Gupta H, Srivastava A, Menon GR, Agrawal CS, Chumber S, Kumar S. Comparison of interrupted versus continuous closure in abdominal wound repair: a meta-analysis of 23 trials. Incisions through the anterolateral wall will, therefore, breach the following structures: As the fibres of the lateral abdominal wall muscles progress medially they give rise to fibrous sheets of tissue known as aponeuroses, allowing a far wider area of insertion than would be achievable with the typically round tendons seen on muscles of the appendicular skeleton. Ranaboldo CJ, Rowe-Jones DC. A prospective randomised study. It was originally used to access much of the lateral viscera, such as the kidneys, the spleen, and the adrenal glands. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. To repair the lateral thigh dermal tissue area, a local skin flap was obtained, and a blade thick skin graft was used. A modification was introduced by Nyhus which used a transverse (oblique) skin incision 3cm above the inguinal ligament and a transverse incision (oblique) to divide the anterior rectus sheath. Gallbladder, biliary tract and certain liver operations can be suited for a Kocher's incision. The subcostal or Kocher incision is an oblique incision that follows the profile of the costal margin and is directed in a medio-proximal direction. Cesarean section (LSCS): Operative procedure - MedchromeTube Ellis H, Heddle R. Does the peritoneum need to be closed at laparotomy?. Exposure of the fascia is often enhanced with the use of S-shaped retractors. This can be accomplished as either a layered or a mass closure (see the image below). The subcostal incision is also used for access to the liver for wedge resections; for the adrenal gland on either side; and the spleen if on the left side. 3. [QxMD MEDLINE Link]. Right Kocher's incision: a feasible and effective incision for right (For more information, seeTemporary Abdominal Closure Techniques.). New York: McGraw-Hill; 2019. Cochrane Database Syst Rev. The Kocher's incision group had a significantly shorter hospital stay (median time 5 vs 8 days). 2. In a randomized controlled trial from 2020 (N = 80), Sharma et al evaluated the efficacy and safety of two commonly applied abdominal-wall closure strategiescontinuous suture (group A; n = 40) and interrupted X suture (group B; n = 40)in gynecologic patients undergoing primary emergency midline laparotomy. [QxMD MEDLINE Link]. It provides good exposure for biliary and bariatric surgery and can be extended bilaterally if needed. Close the capsule with resorbable sutures (3/0). These cookies will be stored in your browser only with your consent. : a strong forceps for controlling bleeding in surgery having serrated blades with interlocking teeth at the tips. Incisions that are most useful for obstetric patients include the midline (vertical) incision and the Pfannenstiel, Maylard, Cherney, and supraumbilical (transverse) incisions ( Fig. Gray's Anatomy: The Anatomical Basis of Clinical Practice. Divide the annular ligament, if intact, in line with the muscle interval. most common type of incision associated with wound dehiscence followed by Kocher's incision (18%) and Mcburney's incision (10%). 9:8. On examination, the patient may have a palpable lump close to the lateral border of the rectus sheath, commonly at the level of Douglas. The anterior rectus sheath is separated and moved laterally, before the excision is continued through the posterior rectus sheath (if above the arcuate line) and the transversalis fascia, reaching the peritoneum and abdominal cavity. Access to the radiohumeral articulation has been . APPROACHESMidline incisionThis is the main approach for major abdominal surgery, central vascular (aortic), and abdominal trauma surgery. If you log out, you will be required to enter your username and password the next time you visit. [45] Some have reported good results with the use of expanded polytetrafluoroethylene (ePTFE) mesh for temporary abdominal closure in critically ill nontrauma patients. . Kocher incision hi-res stock photography and images - Alamy This produces a distinct ridge in the midline on increasing intra-abdominal pressure that is often mistaken for an epigastric hernia. The rectus muscle was then pulled medially. The. Evidence-based recommendations have been developed for the use of negative-pressure wound therapy (NPWT) in the setting of the open abdomen. A midline incision will thus encounter the following layers of tissue: The scar of a paramedian incision may be seen running parallel to the midline in a limited number of patients but has fallen from common practice in favour of the midline incision due to its complexity and poor cosmesis. 2015 Apr. 41 (3):57-60. In general, re-entry into the . The cookie is used to store the user consent for the cookies in the category "Analytics". [Full Text]. BackgroundIn focal congenital hyperinsulinism (CHI), surgery is the gold standard of treatment, even for lesions localized in the head of the pancreas. 2015 Dec 4. [Full Text]. In pediatrics the most common use of this approach is open reduction of radial head/neck fractures. - 700+ OSCE Stations: https://geekymedics.com/osce-stations/ Closure of subcutaneous fat: a prospective randomized trial. [36]. Results: Both dermal tissue and local skin . Reattach the muscles and fascia with resorbable sutures (2/0 or 3/0). It is appropriate for certain operations on the liver, gallbladder and biliary tract. Neth J Surg. Am J Surg. Edinburgh: Churchill Livingstone; 2004. Structures within the transpyloric plane: Complications are best considered in terms of specificity and chronicity; i.e. This approach is commonly used for procedures requiring emergency laparotomy, such as in faecal peritonitis secondary to malignant intestinal perforation or in cases of ischaemic bowel. Superficial to the external oblique lies Scarpas membranous fascia, Campers subcutaneous fatty layer, and the skin. [19] Subcutaneous closure may be accomplished with absorbable suture in an interrupted or continuous fashion. If you do not agree to the foregoing terms and conditions, you should not enter this site. Closure of the uterine incision is done in 3 layers. There is no evidence that mass closure is associated with an increased incidence of hernia formation or wound dehiscence. Of these, transverse incisions follow Langer lines of skin tension. Wound infection. Layers of abdomen, from interior to exterior: peritoneum, extraperitoneal fascia, muscle, deep fascia, superficial fascia, subcutaneous tissue, and skin. Nr. 1975 Oct. 62 (10):823-9. Transverse incision might be preferred over a midline incision regarding the incidence of incisional hernias when adequate exposure can be obtainedSpecial attention is paid to the following hazards you may encounter during this Abdominal Wall Incision - Kocher procedure:- Wound closure difficulties due to incision too close to the costal arch- Superior epigastric vessels injuryWith the following tips you might perform this Abdominal Wall Incision - Kocher procedure even better:- Extension of the incision- Opening of the peritoneum- Abdominal muscle transection- Wound closure in case of peritonitis Surgical Approaches in Total Knee Arthroplasty: Standard and MIS A collection of surgery revision notes covering key surgical topics. The Lanzincision is a transverse incision, whilst theGridiron incision is oblique (superolateral to inferomedial). Webster C, Neumayer L, Smout R, Horn S, Daley J, Henderson W, et al. 1996 Feb. 162 (2):125-9. The intent of this chapter is to provide an overview of body tissues, surgical incisions, and surgical site closure. This may be used for oesophagectomy, gastrectomy, bilateral adrenalectomy, hepatic resections, or liver transplantation, This may be used for the same indications as the Chevron incision, however classically seen in liver transplantation, A surgical incision is an aperture into the body to permit the work of the operation to proceed, The specific surgical incision will depend on the underlying pathology, site, patient factors, and the surgeons preference and experience, Incisions should try to follow Langers lines and muscles should be split and not cut, The wound can be covered in a protective dressing once closed. [18, 43] : Retention sutures are placed outside of the primary suture line through all layers of the abdominal wall, including the skin; a large-bore suture material, usually nonabsorbable, is employed. Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Kao LS, et al, eds. Maingot's Abdominal Operations. Incisions and Closures | Obgyn Key The effect is to alleviate the tension on the primary suture line. The Pfannenstiel incision is a transverse suprapubic incision, placed approximately 5 cm superior to the pubic symphysis (see the image below). 1981 Apr. 1231 patients were treated with the classical Kocher's incision, whereas in 125 cases the minimal cer vical access was. Franz MG. Control the damage: morbidity and mortality after emergent trauma laparotomy. [15] The results of this study underscore the necessity of carrying out further randomized, controlled trials to facilitate the development of a consensus on the best method of abdominal closure. Theyinvolve passing through all of the abdominal muscles, transversalis fascia, and then the peritoneum, before entering the abdominal cavity. Front Surg. O'Meara L, Ahmad SB, Glaser J, Diaz JJ, Bruns BR. Some incisions avoid the muscles entirely, some split or separate them to avoid them, and some cut through layers of muscle. Surgical Incisions. Application of Autogenous Dermis Combined With Local Flap This incision may be modified to follow the horizontal Langers lines for improved cosmesis. Suture closure is generally performed with 3-0 or 4-0 absorbable suture in a running subcuticular fashion or with nylon running or interrupted transdermal suture. (D) Two PDS ends meeting in middle of incision, tied together, and cut. 2000 Dec. 166 (12):932-7. Between 2009 and 2013, an estimated 2 million patients per year underwent an open surgical intervention in the United States. 2016 Jul. 167-92. 249 (4):576-82. PDF Posterior Rectus Sheath Hernia Gislason H, Viste A. Closure of burst abdomen after major gastrointestinal operations--comparison of different surgical techniques and later development of incisional hernia. [Full Text]. 1977 Oct. 64 (10):733-6. Systematic review and meta-analysis of cutting diathermy versus scalpel for skin incision. The Joel-Cohen incision is widely used by obstetricians. Mkel JT, Kiviniemi H, Juvonen T, Laitinen S. Factors influencing wound dehiscence after midline laparotomy. - Character 02:14 (B) Looping of 0 polydioxanone (PDS) at vertex. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. - Associated symptoms 03:04 Learn the principles of clinical research online, Follow us and get notifications on new publications. Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. Perioperative Antirheumatic Drug Guideline Contains Caveats, 8-Week TB Treatment Strategy Shows Potential, Physicians of the Year 2022: Best and Worst, Clinical Approach to Chronic Wound Management in Older Adults. ) is a subcostal incision used to gain access for the gall bladder the biliary tree. 1995 Oct. 170 (4):387-90. In general surgery, the routinely usedincisions include the Lanz incision and midline incision. Use the information in this article to help you with the answers. Hernia (bulging of the organ through belly openings) Scarring. Can Skin Care Aid Use of Diabetes Devices? Due to its continuation with Langers lines, the Lanz incision produces much more aesthetically pleasing results with reduced scarring. [QxMD MEDLINE Link]. Open Access Surg. Numerous trials and meta-analyses found continuous mass closure to be the superior closure method. The incision runs 2-5cm lateral to the midline, cutting through the skin, subcutaneous tissue, and the anterior rectus sheath. This incision is just inferior and parallel to the subcostal margin. Kocher's studies on one of his patients, who was operated on in 1874, led to an early discovery. Share cases and questions with Physicians on Medscape consult. 2009 Nov. 144 (11):1056-9. Goligher JC, Irvin TT, Johnston D, De Dombal FT, Hill GL, Horrocks JC. It is commonly used for open cholecystectomy. Generic early complications declare themselves in the hours and days following the operation and may include atelectasis, postoperative pneumonia, urinary tract infection, oliguria, bedsores and deep vein thromboses. The Kocher's incision approach for right- sided colon cancer is technically feasible, safe and overall very well tolerated. [4] Continuous absorbable suture may be used. DONT FORGET these 3 key components of the cardiovascular exam for your upcoming OSCEs Save this video to watch later and dont forget to follow Geeky Medics! Interrupted abdominal closure prevents burst: randomized controlled trial comparing interrupted-x and conventional continuous closures in surgical and gynecological patients. 2001 Apr. Rucinski J, Margolis M, Panagopoulos G, Wise L. Closure of the abdominal midline fascia: meta-analysis delineates the optimal technique. In some cases, there will be anastomotic branches of the superior and inferior epigastric vessels crossing from either side, but the incision generally avoids major neurovascular bundles. [7, 18, 4, 3]. For most closures, the authors prefer to use looped 0 polydioxanone (PDS) suture. Abdominal Wall Closure in Elective Midline Laparotomy: The Current Recommendations. Kocher extensile approach: the skin incision runs from the supracondylar ridge of the humerus (ca. There are two modifications of Kocher's incision that include: Chevron/rooftop incision: It is the extension of a Kocher's incision to the other side of the abdomen. Once you've finished editing, click 'Submit for Review', and your changes will be reviewed by our team before publishing on the site. Suture material is chosen. [Full Text]. The pyramidalis muscles are typically left attached to the aponeurosis. Occasionally, circumstances may dictate that permanent closure of the abdomen is contraindicated. Br J Surg. Wound healing. The duration of the surgery for the Kocher's incision group was significantly shorter (median time 70 vs 85 min, p < 0.001). Abdominal Wall Incision - Kocher - How to approach the - YouTube The elbow is an unforgiving articulation with significant bony congruity and a . Abdominal Wall Incision - Kocher - How to approach the abdominal cavity using a Kocher incision 2,005 views Oct 18, 2021 55 Dislike Incision 6.82K subscribers Notice You're signed out of. It is an optimal way for emergencies, as opening the abdomen should not take longer than 40-60 seconds. The great advantage of the midline incision is the limited risk of bleeding as the incision is made along the avascular linea alba. 4-1 ). Within each region of the body, several incisions are common. The Kocher incision is a subcostal incision on the right side of the abdomen used for open exposure of the gallbladder and biliary tree. With a Rockey-Davis incision, some benefit to closing the peritoneum has been shown. 2. Often, having the assistant cross the. 1977 Aug 6. Volkovich-Kocher sign - Sign of acute appendicitis: pain, initially arising in the epigastric region (sometimes immediately below the xiphoid process), after a few hours localized in the right illiac fossa Biography Born on December 9, 1858, Horodnia, Ukraine 1888 - Doctor of Medical Sciences 1908 - Head of the Kiev Surgical Society The Lanz and Gridiron incisions are two incisions that can be used to access the appendix, predominantly for appendicetomy. The sheath overlying the rectus muscles at the symphysis pubis is released, 4cm transversely, and the incision angled up to the lateral borders of the rectus muscles. (Volkmann's) Sammlung klinischer Vortrge, Leipzig, 1900, n F. 268 (Gynk. Medicina | Free Full-Text | A Traumatic Neuroma Formation Following ) is used for a wide array of abdominal surgery, as it allows the majority of the abdominal viscera to be accessed. The median length of the midline incision was slightly longer (12 vs. 10 cm, p < 0.05). We report the video of the pylorus-preserving pancreatoduodenectomy performed in a five-month-old child with focal CHI.Operative techniqueBaby was placed in the supine position with both arms outstretched to the up. A controlled clinical trial of three methods of closure of laparotomy wounds. [23, 24, 4] Incisional hernia is two to five times more common in vertical incisions than in transverse incisions. JCM | Free Full-Text | Strategic Approach to Aberrant Hepatic Arterial The key principles of making surgical incisions are: Once the operation is over, surgical excisions can be closedby sutures, staples, steri-strips, tissue glue, or a combination of these agents. Risk factors for wound dehiscence can be: Late complications include the development of an incisional hernia, where the underlying peritoneum and associated contents protrude through residual defects in the abdominal wall, and the formation of dense fibrotic intra-abdominal band adhesions. This step of the incision is usually time consuming and is one of the limitations associated. It is useful for biliary tract surgery. [QxMD MEDLINE Link]. Either a posterior skin incision with a lateral skin flap or a lateral skin incision can be used. Identify the incisions A. right upper paramedial incision surgical technique, site and orientation of incision, intra-operative contamination, lengthy procedure).