Midline incision

1. Divide skin in midline, divide subcutaneous tissue
2. Divide linea alba for full length of skin incision
3. Pick up peritoneum between clips, confirm no bowel adherent, nick peritoneum between clips
4. Insert finger beneath wound to ensure no underlying adhesions, then divide peritoneum with scissors for full lenght of incision
5. Ensure no adherent viscera, avoid bladder in lower midline

Exploratory laparotomy

• Oesophageal hiatus > stomach > duodenum
• Palpate liver, GB, Rt kidney
• Right colon > caecum
• Pelvis
• Sigmoid > ascending colon, spleen, left kidney
• Transverse colon, pancreas, aorta
• Small bowel, (from ligament of Treitz) to jejunum, ileum and caecum

Closure of Midline Laparotomy

Jenkin's rule: decreases the risk of dehiscence

• Mass closure technique (include peritoneum + rectus sheath in closure)
• Continous suture (0 or 1 loop PDS) on a blunt needle
• Suture should be FOUR times the lenght of the incision and bites should be taken 1cm from the wound edge at 1cm intervals

1. Incise skin 4cm from midline (over rectus)
2. Incise anterior rectus sheath
3. Divide sheath from muscle at points of intersections
4. Reflect rectus laterally to expose posterior sheath
5. Incise posterior sheath for full length of wound and then divide peritoneum

 Closure of Paramedian incision

• Close peritoneum using over and over technique
• Anterior rectus sheath closed as for midline incision (applying Jenkins' rule) 

1. Keep parallel + 2cm from costal margin
2. Divide anterior rectus sheath
3. Pass long forceps underneath meuscle to emerge in midline
4. Pull swab back under muscle to protect underlying structures from cutting diathermy (superior epigastric artery br. int thoracic) as muscle is being divided
5. Small incision made into peritoneum, allows protection of viscera as transversus abdominis muscle is divided