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January 1996, Volume 46, Issue 1

Original Article

Subcostal Gridiron Incision for Biliary Surgery

Mahmud Aurangzeb  ( Surgical “A” Unit. Hayat Shaheed Teaching Hospital. Pcshawar. )
Mushtaq Ahmad  ( Surgical “A” Unit. Hayat Shaheed Teaching Hospital. Pcshawar. )
Muhanmad Kabir  ( Surgical “A” Unit. Hayat Shaheed Teaching Hospital. Pcshawar. )


This r, ctive study audited all the extrahepatic biliary operations performed through a subcostal muscle splitting incision between January, 1979 and June, 1995. Of the 400 patients subjected to biliary surgery 340 (85%) were females and 60 (15%) males. One hundred and eighty (45%) patients presented with symptoms of acute and 220 (55%) with chronic cholecystitis. Most (95%) of the operations were performed electively. Simple cholecystectomy was performed in 320 (80%) patients and 72 (18%) had common bile duct exploration for stones. Of these 67 had choledochoduodenostomy and 5 a polythene tube drainage of common bile duct. The overall morbidity of the procedure was 13.5% of which 3.5% were procedure related complications and 10.0% general complications. Only two deaths occured during the studygiving a mortality of 0.5%. This technique has greatlyreduced the hospital stay, the amount of blood loss during operation and post operative pain. No patient had incisional hernia or wound dehiscence and all the patients were back to work early. The results of this study suggest that this incision may be used with advantage elsewhere (JPMA 46:7, 1996).


Several incisions have been described for biliary sur­gery. Of them the most commonly used are right paramedian and Kocker’s subcostal incision. Improvements have been made in the technique which enable procedures to be performed through smaller incisions and minimal trauma1. Laparoscopic surgery and mini laparotomy cholecystectomy are the recent advances but these procedures need surgical expertise, special equipments and proper case selection.
Biliary operations are one of the most frequently performed surgical procedures on the upper abdomen in Pakistan A rapid and safe approach to the biliary tract which causes minimal post operative discomfort and early discharge from hospital are features of importance in a country where a rapid surgical turnover is the biliary tract is described which may reduce both the length of operation and the amount of bleeding which is, normally encountered in biliary surgery.

Patients and Methods

All the records of 400 patients having undergone extra-hepatic biliai surgery through a muscle splitting incision, between 1979 and 1995, were studied. Investigations performed, pre-operative state of health, operation notes, post-operative medications and complications and their con­dition at discharge was reviewed. All patients attended the out-patient clinic after 4 weeks of operation. Majority (70%) of them had responded and their complaints were noted.
The subcostal Gridiron incision was performed under general anaesthesia with muscle relaxation. A 3-4 inch right subcostal incision was made one and half inch below the subcostal margin proceeding laterally from the outerborderof the right rectus sheath. The skin edges were retracted and the external oblique was divided along the line of fibres. The internal oblique and tranversus abdominus were split in the line of their fibres. The peritonium was opened transversely and deep retractors used to aid exposure.
Closure of the incision was by continuous 2’O chroniic catgut suture for the peritonium. Internal oblique and trnnsver­sus abdominus were approximated with interrupted Chrornici catgut sutures followed by interrupted catgut closure of external oblique aponeurosis.


Of the 400 cases, 340 (85%) were female and 60 (15%) males. The mean age was 52 years and 18% were over 65 years. One hundred aild eighty (45%) presented with symp­toms of acute and 220 (55%) with chronic cholecystitis. Almost all the cases were operated electively. 380 (95%) patients had cholecystectomies during the same hospital stay.
Three hundred and twenty (80%) had simple cholecys­tectomy and 72 (18%) cholecystectomy with CBD explora­tion. Of these choledochoduodenostomy was performed in 67 and polythene tube was inserted for biliaiy drainage after
exploration m cases. Choledochoduodenostomy for caret­noma head of pancreas was done in 8 patients.
No difficulties were encountered when choledo­chotomy or choledochoduodenostomy was required, a proce­dure which is being increasingly used in jaundiced patients with choledocholithiasis or obstructive jaundice due to any other cause.
During the study lateral border of rectus required forceful retraction in 50 (12.5%) patients and in 10 the rectus muscle had to be divided. Assessment of blood loss at operation indicated losses of between 40-280 ml. Duration of stay after operation ranged 3-20 days (mean 5.2 days).
The post-operative complications noted during the study were wound sepsis in 4 (1%) cases, 2 after choledo­choduodenostomy and 2 after exploration of CBD and insertion of polythene tube, haematorna of the wound in 6 (1.5%) patients which rapidly resolved without further inter­vention, 4 patients had re- exploration, the first two with a sub-hepatic abscesses requiring drainage. Two patients devel­oped biliary leak requiring drainage. No difficulties were faced using the original incision for reoperation. None of the patients operated upon, developed dehiscence of the wound or incisional hernia. All this gives a procedure related morbidil of 3 .5%.
The general morbidity noted was 10% (40 complica­tions) which included 20 cases of lower respiratory tract infection, 10 cases of atelectasis, one of cardiac arrythmia, one of ventricular fibrillation, one of angina pectoris, 2 of urinary tract infection and two cases of urinary retention. The combined general and procedure related morbidity was 13.5%.
Only two deaths occured during the study, both due to myocardial infarction, 3 and 7 days respectively after the operation giving an overall mortality of 0.5%.


The surgical removal of the gall bladder has been the gold standard for the treatment of symptomatic gall stones2. The standard Kocker’s incision is usually preferred to paramedian approach because the exposure is placed directly over the gallbladder. Furthermore, the subcostal incision heals more rapidly and with less discomfort probably because it is in the line of the normal skin crease3. This inciaion is preferred because of lower incidence of pulmonary and abdominal complications’ and less pain than vertical paramedian inci­sions4.
Surgical wound does contribute to morbidity and mortality. therefore, attempts have been made to make the trauma minimal. First mini-laparotomy cholecystectomy was introduced and then the laparoscopic method. The results of mini-lap cholecystectomy were so good that it can be compared even to the laparoscopic surgery2.
The present procedure has further decreased the mor­bidity and rnortality withthe mortality inthis study bei9 0.5% as compared to 1.2% in muscle cutting open procedure5. This is better because in muscle cutting there may be considerable bleeding from the Cut edges. a complication which is time consuming and potentially dangerous. In this study, the ease of access that a subcostal incision affords was combined with One in which bleeding is reduced to minimum. An additional advantage of this technique is that-intercostal nerve damage is minimal. Most patients requiring biliary operations in this unit have a wide costal angle which makes this procedure particularly suitable.
This technique is suitable for cholecystectomy, chole­dochotomy and choledochoduodenostomy. The approach is usually without complications and wound sepsis occured in patients having bile duct surgery. because the bile is com­monly infected6. The duration of hospital stay has also been reduced using the muscle splitting incision as compared with aKocker’s incision.
In view of the satisfactoiy results this technique could have a wider application in biiiary tract surgery. The direct approach, combined with minimal bleeding and few post-op­erative complications, makes this an ideal procedure for cholecystectomy or choledochotomy.


1. O’Dwyer, P.J.. Morhphy, J.J and O’Higgins Cholecystectomy, through a 5cm subcostal incision. Br. J. Surg.. 1990,77:11 89- 1190.
2 .Douglcs, 0., Oslen Mini-Lap Cholecystectomy. Am. J. Surg., 1993;165:440-443.
3. Thorbjarnoarson, B. and Glenn. F. Complications of biltary tract surgery Surg. Clin. North Am., 1964;44:43 1 -448.
4. Amstrong, P.J. and Burges, R.W. Choice of incision and pain following gall bladder surgery Br. J. Surg, 1990,77:746-747
5. Charles, KM. Sherry. Open cholecystectomy. Am. J. Surg.. 1993;165:435-438
6. Keighley, M.R.B. and Graham, N.G. Infective cholecystitis. JR. Coil. Surg. Edin., 1973~18:213-220.

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