Incisions in Hepatobiliopancreatic Surgery: Surgical Anatomy and its Influence to Open and Close the Abdomen

Abstract

Incisions performed for hepato-pancreatic-biliary (HPB) surgery are diverse, and can be a challenge both to perform correctly as well as to be properly closed. The anatomy of the region overlaps muscular layers and has a rich vascular and nervous supply. These structures are fundamental for the correct functionality of the abdominal wall. When performing certain types of incisions, damage to the muscular or neurovascular component of the abdominal wall, as well as an inadequate closure technique may influence in the development of long-term complications as incisional hernias (IH) or bulging. Considering that both may impair quality of life and that are complex to repair, prevention becomes essential during these procedures. With the currently available evidence, there is no clear recommendation on which is the better incision or what is the best method of closure. Despite the lack of sufficient data, the following review aims to correlate the anatomical knowledge learned from posterior component separation with the incisions performed in hepato-pancreatic-biliary (HPB) surgery and their consequences on incisional hernia formation. Overall, there is data that suggests some key points to perform these incisions: avoid vertical components and very lateral extensions, subcostal should be incised at least 2 cm from costal margin, multilayered suturing using small bites technique and consider the use of a prophylactic mesh in high-risk patients. Nevertheless, the lack of evidence prevents from the possibility of making any strong recommendations.

Incisional hernia repair following pancreatic surgery—open vs laparoscopic approach

“…The percentage of lateral (15.4%) and combined (17.4%) incisional hernias after pancreatic surgery is 32.8% (Table 1 ). Lateral and combined incisional hernias are considered complex and their treatment more difficult [ 8 ]. In addition, larger defects occur more frequently after pancreatic surgery than after other previous surgeries.…”

“…Different access techniques are used in open pancreatic surgery. This variability results from the strategy, which must be aligned with the goal of the operation [ 8 ]. Often, surgery is performed via a transverse approach, which should be guided with a 2 cm distance from the costal arch [ 8 ].…”

“…This variability results from the strategy, which must be aligned with the goal of the operation [ 8 ]. Often, surgery is performed via a transverse approach, which should be guided with a 2 cm distance from the costal arch [ 8 ]. In general, there is a lower risk of developing an incisional hernia after performing a transverse laparotomy [ 8 , 9 ].…”

“…Often, surgery is performed via a transverse approach, which should be guided with a 2 cm distance from the costal arch [ 8 ]. In general, there is a lower risk of developing an incisional hernia after performing a transverse laparotomy [ 8 , 9 ]. However, if a hernia does occur permanent correction is difficult [ 10 ].…”

“…Compared with medial incisional hernias, lateral incisional hernias are at significantly higher risk of recurrence [ 11 ]. To prevent incisional hernia, the combination of medial and transverse laparotomy should be avoided [ 8 ]. The use of mesh augmentation for closure of lateral incisions may reduce the incidence of incisional hernias [ 12 ].…”