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.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Surgery editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 8
Customize your page view by dragging & repositioning the boxes below.
More Listings atJAMACareerCenter.com >
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.