Modified Makuuchi Incision for Foregut Procedures
Executive Summary
The modified Makuuchi incision is a specialized surgical approach designed to optimize exposure for complex foregut and retroperitoneal procedures, including hepatic resection, esophagectomy, gastrectomy, and pancreatectomy. By modifying the original "J" incision described by Masatoshi Makuuchi, this technique offers a superior en face view of critical structures such as the hepatocaval junction and the esophageal hiatus.
Crucially, the modified approach focuses on preserving the integrity of the abdominal wall by sparing intercostal muscles and following the natural dermatomal distribution of nerves. Clinical data from M. D. Anderson Cancer Center indicates that this technique is particularly effective in obese patients and for large tumors, providing excellent surgical access while maintaining a manageable rate of postoperative complications.
Overview of the Modified Technique
The modified Makuuchi incision is an evolution of the traditional "J" incision used for hepatic resections. While the original version curves cephalad and divides intercostal muscles, the modified version adopts an "L" or "reverse L" configuration to reduce patient morbidity.
Comparison of Incision Structures
Anatomical and Clinical Advantages
The modified Makuuchi incision offers several distinct advantages over traditional incisions like the inverted-T (Mercedes), bilateral subcostal (chevron), and subcostal (Kocher/Kehr) incisions.
1. Superior Exposure and Access
Direct View: Provides a superb en face view of the esophageal hiatus and hepatocaval junction.
Midline Efficiency: The midline portion allows for easy left-sided retraction without needing to extend the incision across the midline, unlike chevron or Mercedes incisions.
Versatility: The "L" shape can be used for right-sided surgery (liver/retroperitoneum), while its mirror image is suitable for left-sided surgery (gastric/pancreatic).
2. Physiological Preservation
Vascular Integrity: The horizontal limb is placed in the mid-abdominal wall to leverage the abundant blood supply of the periumbilical region.
Neurovascular Sparing: By running parallel to the dermatomal distribution, the incision preserves neurovascular structures, reducing skin numbness and long-term muscle atrophy.
Reduced Complications: Unlike the Mercedes incision, which has a higher risk of incisional hernia at the "trifurcation point" due to ischemia, the modified Makuuchi keeps nerves and vessels on the opposite side of the midline intact.
3. Reduced Postoperative Morbidity
Pain Management: Sparing the intercostal muscles and nerves significantly reduces postoperative pain.
Pulmonary Function: Lower pain levels lead to reduced pulmonary compromise in the immediate postoperative period.
Operative Methodology
Opening Procedure
Skin Incision: Begins cephalad to the xiphoid and extends vertically to the umbilicus before extending laterally.
Tissue Division: Subcutaneous tissue, fascia, and muscle are divided via electrocautery.
Xiphoid Excision: The xiphoid process is exposed, its diaphragmatic attachments are divided, and it is excised to optimize upper midline access.
Ligament Manipulation: The falciform ligament is identified, divided, and ligated. The hepatic stump is utilized as a handle for liver manipulation.
Strategic Retractor Placement
The use of the oncology Thompson retractor system is critical for maximizing the exposure provided by this incision:
Obesity Bar: Placed between posts cephalad to the incision.
Right Sidebar: Angled laterally and toward the floor to retract the abdominal wall flap posteriorly, maximizing exposure of the right liver and retroperitoneum.
Blade Configuration: Bladder blades are used for cephalad retraction, while a small Richardson blade is used for lateral retraction. A fan retractor is used to manage the bowel.
Closure and Reconstruction
The closure follows specific anatomic reconstruction principles to reinforce the abdominal wall:
Stay Sutures: Three 0 polyglycolic acid (PGA) interrupted sutures are placed at the superior midline (near the resected xiphoid).
Alignment: Three stay sutures are placed at the corner of the incision, and one at the lateral edge of the right rectus to align the abdominal wall.
Internal Retention: These sutures serve as internal retention sutures and allow for atraumatic retraction during the placement of running stitches, preventing crush injuries to the fascia.
Layered Closure: The transverse portion is closed in two layers (Layer 1: transverse muscles and posterior rectus sheath; Layer 2: oblique muscles and anterior rectus sheath) using a looped size 1 polydioxanone suture.
Clinical Results and Observations
A study of 137 laparotomies performed at M. D. Anderson Cancer Center (2005–2008) provides a benchmark for the efficacy of this incision.
Patient Demographics: The majority of patients underwent hepatic resection (109 patients), with others undergoing resections for pancreatic (6), gastric (11), and soft tissue (11) malignancies.
Obesity Factor: 61% of hepatic resection patients had a BMI ≥ 25, highlighting the incision's utility in patients with significant body habitus.
Wound Complications: The rate of wound infections or seromas was 8.8% (12 patients).
Incisional Hernia: The rate was 10.9% (15 patients). While higher than some previous reports, this is attributed to the relative obesity of the patient population studied.
Conclusion
The modified Makuuchi incision is a robust surgical approach for foregut procedures. It balances the need for extensive surgical exposure—particularly in cases involving large tumors or high-BMI patients—with the necessity of preserving abdominal wall function. By avoiding the division of intercostal muscles and protecting the periumbilical blood supply, the technique minimizes postoperative pain and promotes anatomical recovery.
