3. Indications and Contraindications of Surgery, Surgical Incisions

I. Indications for Surgery

• Surgical indication: Reason why surgery is justified
• Principle: Expected benefit > operative/anesthetic risk
• Decision depends on: Urgency, therapeutic alternatives, therapeutic aim, patient condition, consent

1. Considering the Urgency of Surgery

• Vital indication: Life-threatening condition → Immediate surgery is necessary

• No time for full preparation if delay kills
• Ex: Obstruction of blood supply, ruptured aortic aneurysm, spleen rupture, uncontrolled bleeding, perforation

• Acute indication: Urgent surgery within a few hours

• Resuscitation + basic preparation if possible
• Ex: Ileus, acute appendicitis

• Planned / elective indication: Operation can be scheduled → Time for optimization

• Ex: Hernia, benign tumor, elective cholecystectomy

2. Considering Therapeutic Possibilities

• Absolute indication: Disease can only be treated adequately by surgery

• Ex: Malignant tumor, incarcerated hernia, ruptured appendicitis, perforation

• Relative indication: Non-surgical treatment or observation is also possible

• Delay does not threaten life expectancy
• Decision: Symptoms, progression, risk-benefit ratio, patient preference
• Ex: Benign tumor, asymptomatic hernia, aesthetic operation

3. Considering Therapeutic Aim

• Diagnostic: Establish diagnosis → Biopsy, diagnostic laparoscopy, lymph node excision
• Curative / ablative: Removal of pathological tissue → Complete healing if possible
• Reconstructive / restorative: Restore anatomy, function or appearance
• Corrective: Reconstruction of congenital abnormalities
• Palliative: Relieve symptoms in incurable disease → Improve QOL
• Preventive / prophylactic: Prevent future disease in high-risk patient

• Ex: Appendectomy, tumor resection, hernia repair, breast reconstruction, bowel bypass/stoma, prophylactic colectomy in FAP

II. Contraindications to Surgery

• Contraindication: Surgery is not justified or must be delayed → Risk exceeds benefit
• Many contraindications are relative → Correct reversible problems before elective surgery

1. Absolute Contraindications

• Moribund patient: Operation cannot change outcome
• Therapy-resistant cardiomyopathy / end-stage organ failure: No realistic recovery or benefit
• Shock: Contraindication to elective surgery

• Exception: Surgery is the solution → Bleeding, perforation, ischemic bowel/source control

• Uncontrolled bleeding disorder: Especially if operation is not immediately lifesaving

2. Relative Contraindications

• No consent: Patient refuses surgery

• Exception: Life-threatening emergency + patient cannot consent → Surgery may proceed

• Inoperability of patient: General condition not appropriate for operation

• Factors: Age, frailty, comorbidities, cardiopulmonary compromise

• Correctable high-risk state: Malnutrition, severe anemia, hypovolemia, electrolyte disorder, uncontrolled diabetes/hypertension, active infection
• Disease not suitable for surgery: Irresectable cancer or diffuse metastases without useful palliation
• No meaningful improvement expected after operation

III. Surgical Incisions

• Choice depends on: Target organ, exposure, urgency, previous scars, body habitus, cosmesis, wound complication risk
• Good incision → Adequate exposure, extendable, preserves blood supply/nerves, allows secure closure

Abdominal Incisions / Laparotomies

1. Longitudinal Laparotomies

• Upper median: Sternum/xiphoid → Umbilicus through linea alba
• Middle median: Above and below umbilicus through linea alba
• Lower median: Umbilicus → Pubic bone in the midline
• Paramedian: Vertical incision lateral and parallel to midline, through anterior rectus sheath
• Transrectus: Following/splitting fibers of rectus abdominis
• Pararectus: Lateral to rectus sheath

• Midline advantage: Fast, little bleeding, no muscle cutting, easily extendable → Good emergency laparotomy

2. Transverse and Oblique Laparotomies

• Pfannenstiel: Curved transverse suprapubic incision → Gynecologic/urologic surgery, cesarean section
• Subcostal / Kocher: Oblique incision below costal margin → Open cholecystectomy, biliary/liver or splenic exposure
• Chevron / rooftop: Bilateral subcostal incision → Wide upper abdominal exposure, liver transplantation
• McBurney / gridiron: Oblique right lower quadrant muscle-splitting incision → Open appendectomy

3. Laparoscopic Port Incisions

• Small incisions for trocar placement, usually 5-12 mm
• Port placement depends on target organ and triangulation

Thoracic Incisions

• Posterolateral thoracotomy: Lateral position, parallel to ribs → Wide thoracic exposure
• Anterolateral thoracotomy: Lateral/anterior chest → Trauma/emergency or selected thoracic access
• Axillary thoracotomy: Lateral position from lateral edge of pectoralis major → Muscle-sparing, limited exposure
• Median sternotomy: Midline sternum incision + sternum division → Cardiac/mediastinal surgery