3. Indications and Contraindications of Surgery, Surgical Incisions

I. Indication for Surgery

• Surgical indication: Reason why an operation is justified because expected benefit is greater than risk
• Decision depends on → Diagnosis, urgency, therapeutic alternatives, patient condition, consent, expected quality of life
• Basic question → Does surgery save life, cure disease, diagnose disease, relieve symptoms, restore function or prevent future disease?

Classification by Urgency

1. Vital / Emergency Indication

• Immediate life-threatening condition → Operation cannot be delayed
• No time for full preparation if delay would kill the patient
• Goal → Save life / limb / organ function
• Examples → Ruptured aortic aneurysm, ruptured spleen with shock, perforated hollow viscus with peritonitis, acute limb ischemia, uncontrolled bleeding

2. Acute / Urgent Indication

• Operation needed within hours or short time frame
• There is time for basic resuscitation, labs, imaging, antibiotic prophylaxis and anesthesia preparation
• Delay increases risk of complication
• Examples → Acute appendicitis, ileus, strangulated/incarcerated hernia, acute cholecystitis after indication, abscess needing drainage

3. Planned / Elective Indication

• Operation can be scheduled safely
• Patient can be optimized before surgery
• Examples → Uncomplicated hernia, benign tumor, elective cholecystectomy, planned cancer resection after staging

Classification by Therapeutic Possibility

1. Absolute Indication

• Disease can only be treated definitively by surgery, or non-operative treatment would be inadequate/dangerous
• Examples → Perforated appendicitis with peritonitis, incarcerated/strangulated hernia, resectable malignant tumor, traumatic internal bleeding, bowel perforation

2. Relative Indication

• Disease may also be treated conservatively or observed
• Delay does not immediately endanger life expectancy
• Decision depends on symptoms, progression, patient preference and risk-benefit ratio
• Examples → Asymptomatic hernia, benign tumor, gallstones without complications, aesthetic operation

Classification by Therapeutic Aim

II. Contraindications to Surgery

• Contraindication: Condition where operation is not justified or must be delayed because risk is excessive compared with benefit
• Always separate contraindication to surgery from contraindication to anesthesia
• Many contraindications are relative → Optimize first, then operate if benefit remains

Absolute Contraindications

• Patient refuses operation / no informed consent

• Exception → Life-threatening emergency when patient cannot consent and delay would cause death/serious harm

• Moribund patient if operation cannot change outcome
• End-stage organ failure with no realistic chance of recovery or benefit from surgery
• Uncorrectable / uncontrolled bleeding disorder when operation is not immediately lifesaving
• Therapy-resistant severe cardiopulmonary failure where anesthesia/surgery would be fatal and benefit is absent
• Shock is a contraindication to elective surgery

• Exception → If surgery is the source-control solution, e.g. bleeding, perforation, ischemic bowel

Relative Contraindications

• Poor general condition / high operative risk
• Advanced age with frailty and comorbidities
• Cardiopulmonary compromise
• Poor nutritional status, cachexia, severe anemia
• Uncontrolled diabetes mellitus or hypertension
• Active infection, especially infection at surgical site
• Anticoagulation or correctable coagulopathy
• Pregnancy for non-obstetric elective surgery unless benefit justifies risk
• Disease is technically not suitable for surgery → Irresectable cancer, diffuse metastases without useful palliation
• No meaningful improvement expected after operation

Preoperative Optimization

1. Confirm diagnosis and indication
2. Assess operative/anesthetic risk → ASA, comorbidities, functional status
3. Correct reversible problems → Shock, hypovolemia, anemia, electrolyte disorder, glucose, BP, coagulopathy
4. Treat infection / give antibiotics when indicated
5. Nutrition optimization if elective and malnourished
6. Discuss informed consent → Procedure, alternatives, risks, benefits, no-treatment option

III. Surgical Incisions

• Choice of incision depends on → Target organ, required exposure, urgency, previous scars, body habitus, cosmesis, risk of wound complications
• Good incision should give adequate exposure, allow extension, preserve blood supply and nerves, and permit secure closure
• Main abdominal principle → Incision should be large enough for safe surgery, not only cosmetically small

Abdominal Incisions / Laparotomies

1. Longitudinal Incisions

• Upper midline laparotomy → From xiphoid/sternum region to umbilicus through linea alba
• Lower midline laparotomy → From umbilicus to pubic symphysis through linea alba
• Full midline laparotomy → Xiphoid to pubis if maximal abdominal access is needed
• Middle median / periumbilical extension → Around/above and below umbilicus through linea alba

• Advantages of midline → Fast, little bleeding, no muscle cutting, easy extension, good emergency access
• Disadvantages → Higher risk of wound dehiscence/incisional hernia than some transverse/oblique incisions

• Paramedian incision → Vertical incision lateral and parallel to midline, through anterior rectus sheath
• Transrectus incision → Through rectus abdominis muscle fibers
• Pararectus incision → Along lateral edge of rectus sheath

• Paramedian/pararectus incisions are less common now because midline and minimally invasive access are usually preferred

2. Transverse and Oblique Incisions

• Transverse abdominal incision → Follows skin tension lines; good cosmetic result and less pain in selected operations
• Kocher / right subcostal incision → Oblique incision below right costal margin

• Use → Open cholecystectomy, biliary surgery, liver exposure

• Left subcostal incision → Below left costal margin

• Use → Splenic surgery, left upper abdominal exposure

• Chevron / rooftop incision → Bilateral subcostal incision forming inverted V/roof shape

• Use → Wide upper abdominal exposure, liver transplantation, major hepatobiliary surgery

• Mercedes-Benz incision → Chevron + vertical midline extension
• McBurney / gridiron incision → Oblique right lower quadrant muscle-splitting incision at McBurney point

• Use → Open appendectomy

• Lanz incision → Transverse right lower quadrant incision for appendectomy, better cosmetic result
• Pfannenstiel incision → Curved transverse suprapubic incision

• Use → Cesarean section, gynecologic and urologic surgery

• Inguinal incision → Parallel to inguinal ligament

• Use → Open inguinal hernia repair, femoral/vascular access depending on position

3. Laparoscopic Port Incisions

• Small skin incisions for trocar placement, usually 5-12 mm
• Advantages → Less pain, faster recovery, lower wound infection risk, better cosmesis
• Limitations → Requires pneumoperitoneum, equipment, training; conversion may be needed
• Port placement depends on target organ and triangulation

Thoracic Incisions

Thoracotomies

• Posterolateral thoracotomy → Patient in lateral position; incision from posterior axillary/scapular region toward anterior chest, usually along intercostal space

• Classic wide access to lung, esophagus, thoracic cavity
• Can divide latissimus dorsi ± serratus anterior depending on technique

• Anterolateral thoracotomy → Incision on anterior/lateral chest, usually below breast along intercostal space

• Use → Emergency thoracotomy, trauma, selected cardiac/thoracic access

• Axillary thoracotomy → Incision in axillary region between pectoralis major and latissimus dorsi borders

• Muscle-sparing, better cosmetic result, limited exposure

• Median sternotomy → Vertical midline incision over sternum + division of sternum

• Use → Cardiac surgery, mediastinal surgery, bilateral anterior thoracic access

Incision Complications

• Bleeding / hematoma
• Wound infection / surgical site infection
• Seroma
• Wound dehiscence / burst abdomen
• Incisional hernia
• Nerve injury → Sensory loss, chronic pain, muscle denervation
• Poor cosmetic scar, hypertrophic scar, keloid
• Adhesions and difficult reoperation after laparotomy