Errors in Surgery of the Biliary Tract*

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The Incision

IT has been said by generations of surgical teachers that abdominal wounds heal from side to side and not from end to end. The implication is that it makes no difference how long the incision is, so long as it gives adequate exposure.

Any abdominal incision, if long enough, affords good exposure. But is it really true that the length of the incision makes no difference to the convalescence of the patient? By reductio ad absurdum it is obvious that an incision 1 inch long would give less chance of wound disruption, hernia, hematoma, and infection than one 18 inches long. How long an incision can one make without increasing the incidence of these complications? Statistics on the subject are not available, but it is amazing and a little frightening to see the high incidence of hernias in the scars of upper abdominal operations. Since hernias are incomplete wound disruptions, the incidence of complete disruptions with their attendant mortality must also be significant.

The first consideration in all surgery is exposure, and no one will argue that this prerequisite of an accurate operation should be jeopardized by a keyhole incision. On the other hand, both the exposure afforded and the strength of the closure depend as much on the type of incision made as on its length. Most gallbladders lie fairly far lateral, away from the line of a right rectus incision. Adequate exposure of the gallbladder can be obtained by retraction, if the incision is long enough, but through . . .



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