The Makuuchi or J incision completely exposes the liver and right-sided retroperitoneal organs. The modified Makuuchi incision also achieves a superb en face view of critical structures, including the hepatocaval junction and the esophageal hiatus, but does not divide the intercostal muscles, thus reducing muscle atrophy and postoperative pain. This incision also offers significant advantages over other incisions commonly used in foregut surgery. We describe herein the use of the modified Makuuchi incision for foregut procedures, with particular emphasis on strategic retractor placement.
Figure 1. The modified Makuuchi incision. A, The modified incision is used for liver and right-sided abdominal surgery. This incision begins cephalad to the xiphoid, extends to 1 cm above the umbilicus, and then extends laterally to the right. B, The L incision is used for gastric, pancreatic, and left-sided abdominal surgery. This incision is a mirror image of the modified Makuuchi incision.
Figure 2. Placement of retractors for liver surgery. The oncology Thompson retractor system (Thompson Surgical Instruments, Inc, Traverse City, Michigan) is used. The obesity bar is placed between the posts cephalad and the ends of the sidebars caudad. The right sidebar is set with the short end on the post and the long end pointing upward and caudad. The left sidebar is set with the long end on the post and the short end pointing in the lateral direction. Five retractors are used. The first 2 are placed on the cephalad obesity bar: the rightmost retracts the abdominal flap, and the left one is placed in the apex of the vertical portion of the incision. The third retractor is set on the right sidebar and retracts the abdominal wall to the right and toward the floor. The fourth retractor, set on the caudad bar, retracts the lower abdominal wall. The fifth retractor is a fan retractor set on the caudad bar and is used to retract the bowel.
Figure 3. Closure of the abdomen.
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