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Incisions for open abdominal surgery

Incisions for open abdominal surgery
Literature review current through: Jan 2024.
This topic last updated: Nov 11, 2022.

INTRODUCTION — The success of any open surgical procedure requires, in part, a wisely chosen incision based upon sound anatomic principles.

Incisions for open abdominal surgery will be reviewed here. Closure of the abdominal wall and complications of abdominal wall incisions are discussed separately. (See "Principles of abdominal wall closure" and "Complications of abdominal surgical incisions".)

BASIC PRINCIPLES

Choice of incision — The most important goal when choosing an abdominal incision is to provide adequate exposure for the anticipated procedure while taking into account the possibility that the planned procedure may change depending upon intraoperative findings or complications. The incision should interfere minimally with abdominal wall function by preserving important abdominal structures and heal with adequate strength to reduce the risk of wound disruption and subsequent incisional hernia. (See "Anatomy of the abdominal wall" and "Complications of abdominal surgical incisions".)

Additional considerations in selecting the type of incision include:

Need for rapid entry

Certainty of the diagnosis

Body habitus

Location of previous scars

Potential for significant bleeding

Minimizing postoperative pain

Cosmetic outcome

An appropriately placed incision of adequate length is enhanced by minimal tissue trauma, complete hemostasis, adept use of retractors and packs, correct positioning of the patient on the operating table, and efficient illumination [1].

There are generally two main types of incision: transverse/oblique and longitudinal. Transverse/oblique incisions may have a lower incidence of adhesion formation and postoperative bowel obstruction compared with longitudinal incisions [2,3]. Transverse/oblique incisions may also be less painful and have less impact on pulmonary function compared with a longitudinal, midline incision, particularly in the early postoperative period. However, a systematic review comparing transverse/oblique incisions with longitudinal, midline incisions found no significant differences in the incidence of early or late postoperative complications, and recovery times were also similar [4,5]. Other studies have found that transverse incisions appear to be associated with a lower incidence of incisional hernias [4,6,7], but some report a higher incidence of wound infection [4,7]. Due to the fact that data strongly supporting one incision over another are lacking, the choice of incision remains the preference of the surgeon.

Skin incision — Controversy persists regarding the choice of scalpel or electrosurgery for making abdominal wall incisions. A systematic review and meta-analysis identified 11 trials comparing the outcomes of abdominal incisions using cold scalpel or diathermy involving a total of 3122 patients [8]. A pooled analysis found no significant differences in the rate of postoperative wound infection. The blood loss and time required to make the incision were significantly greater in the scalpel group, but the differences were small (15 mL blood, 67 seconds) and probably not clinically relevant. Postoperative pain scores (visual analog scale) were significantly lower for the diathermy group in the early postoperative period (<24 hours). A later meta-analysis of 14 trials reported similar results and also found no significant differences in wound complication rates [9]. In light of these findings, we feel that neither scalpel nor electrosurgery holds a significant benefit over the other and that electrosurgery is acceptable and may lower postoperative analgesic requirements.

Once the incision site is chosen, we prefer to use a sharp scalpel to make a single incision through the skin and into the subcutaneous tissues. Some surgeons use a second scalpel for the subcutaneous tissue; however, this practice is unnecessary given that no difference in the rate of wound infection has been identified for a one-scalpel versus two-scalpel technique [10]. During sharp incision, care should be taken to make as few blade strokes as possible in the subcutaneous tissues. Multiple strokes result in greater tissue damage and increase the susceptibility to infection.

Control of superficial bleeding — Small subcutaneous vessels that are divided during the course of making the incision will constrict, minimizing blood loss. Persistently bleeding vessels can be managed with electrocautery, taking care to limit excessive cauterization, which can cause needless tissue destruction. The control of larger vessels (eg, inferior epigastric artery) is best accomplished by isolating the vessel through dissection, clamping it with a hemostat, and suture ligating it.

Measures to control surgical site infection — Measures to control surgical site infection include skin antisepsis, prophylactic antibiotics, proper hand hygiene, and surgical technique. These are discussed in detail elsewhere. (See "Overview of control measures for prevention of surgical site infection in adults".)

Prophylactic antibiotics are generally indicated prior to open abdominal surgery. General considerations for antibiotic prophylaxis are discussed elsewhere, and antibiotic selection for specific procedures is discussed in separate procedural reviews (eg, open cholecystectomy). (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Antimicrobial prophylaxis' and "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal procedures in adults".)

LONGITUDINAL INCISIONS — Longitudinal incisions are almost always placed in the midline (figure 1A-B). Paramedian and pararectus incisions are uncommonly used.

Midline incision — The midline abdominal incisions take advantage of the fact that only terminal branches of the abdominal wall blood vessels and nerves are located at the linea alba, thereby limiting the potential for bleeding or nerve injury (figure 2). A systematic review comparing midline with transverse incisions found that analgesia use, pulmonary compromise, and wound dehiscence may be increased with midline incisions [5].

One of the main indications for a midline incision is an exploratory laparotomy (eg, trauma, abdominal sepsis). The midline incision provides the most rapid entry, which is especially important if the patient is hypotensive due to bleeding or septic shock. Additionally, the midline incision provides the greatest abdominal exposure, which may be required in a seriously ill patient for whom the diagnosis or location of bleeding is uncertain. It also can be extended superiorly to the xiphoid (or to median sternotomy), inferiorly to the pubic tubercle. Additionally, transverse or oblique extensions to a midline incision can be added if lateral exposure is needed.

The midline incision provides ready access to the abdominal viscera, liver, spleen, inferior vena cava, aorta, renal pedicles, kidneys, pelvic organs, and vasculature. However, exposure of the posterolateral retroperitoneum, including the posterior renal hilum and retrohepatic vena cava, can be more difficult to achieve.

The incision is made in the skin with a scalpel and carried through the subcutaneous fat sharply or using electrocautery. The midline fascia can be identified as the point where the fibers of each anterior rectus sheath join each other.

The entire length of fascia may be divided; alternatively, some surgeons prefer to open a limited amount of fascia and complete the fascial incision after the peritoneal cavity has been entered. The preperitoneal fat is bluntly dissected from the peritoneum by sweeping the index finger or using a blunt Kelly clamp. Once identified, the peritoneum is brought up into the fascial incision with forceps or a hemostat. The elevated peritoneum is opened sharply in a longitudinal manner by incising the peritoneum adjacent to the forceps or, alternatively, by dividing the elevated peritoneum between two hemostats. Electrocautery should not be used to divide the peritoneum, due to the risk for thermal injury to underlying bowel. Once a small opening is created, air enters the peritoneal cavity and breaks the surface tension, which allows the bowel to fall further away. The index finger is used to explore for adhesions prior to extending the incision. When identified, adhesions should not be bluntly dissected using the finger; rather, purposeful adhesiolysis with a scalpel or electrocautery will prevent tearing the serosa of any involved bowel.

The incision is extended superiorly and inferiorly, the length of which depends upon the indication. When extending superiorly, the ligamentum teres is encountered and can be taken between clamps, divided, and ligated if exposure to the liver is needed. Alternatively, the incision can be deviated slightly to the left to leave the ligamentum teres intact. However, if retractors are placed into the left upper quadrant, division of the ligamentum teres prevents avulsion.

When entering the abdominal cavity inferior to the umbilicus, care should be taken to incise the peritoneum slightly off the midline since the bladder is highest in the midline and the urachus may communicate with it (figure 3). This will reduce the risk of bladder injury, eliminate the risk of urine leaking from an incised persistent urachus, and provide better exposure. Alternatively, the urachus can be divided and ligated [11]. The bladder can be identified because of its opaqueness and markedly increased vascularity. The Foley balloon can also be pulled up to identify the upper extent of the bladder.

Paramedian incision — A paramedian incision is made 2 to 5 cm to the left or right of the midline (figure 4).

The anterior rectus sheath is incised vertically, and the rectus muscle is dissected from the medial fascial edge. The muscle is retracted laterally, exposing the posterior sheath, which is incised vertically along with the peritoneum. Lateral paramedian incisions are placed at the junction of the outer one-third and inner two-thirds of the rectus muscle. In this location, the anterior rectus sheath often consists of two layers. In order to expose the posterior rectus sheath, the rectus muscle is separated vertically.

Paramedian incisions can be extended into the upper abdomen without the difficulties of curving around the umbilicus. The paramedian incision may decrease the risk of dehiscence or hernia as compared with midline incisions, although conflicting data have been reported [12,13]. These incisions take longer to perform, restrict access to the contralateral pelvis, and risk injury to the epigastric vessels. In addition, nerve injury may result in rectus paralysis. The closure of paramedian incisions is similar to the closure of midline longitudinal incisions, although mass closure may be more difficult.

Pararectus incision — A pararectus incision (also known as Battle's incision) is placed at the lateral border of the rectus muscle, which is retracted medially. This infrequently utilized incision was used primarily for appendectomy or drainage of pelvic abscesses [14]. It causes denervation of the rectus, resulting in paralysis and, ultimately, muscle atrophy. The length of this incision must be restricted to no more than two dermatomes to prevent weakness of the abdominal wall.

OBLIQUE INCISIONS — Several oblique incisions are used for specific anatomic exposures (figure 5).

McBurney's incision — McBurney's incision is an oblique muscle-splitting incision located one-third of the way from the iliac spine to the umbilicus (figure 6) [15]. It is commonly used for an open appendectomy or surgeries in which exposure to the right or left lower quadrant is required. An oblique incision is made in the skin along Langer's lines. The fibers of the external oblique, internal oblique, and transversus abdominis are sequentially separated along their fibers (figure 7). The peritoneum and transversalis fascia are exposed and incised parallel to the skin incision.

Retractors may be used to stretch the incision for better exposure. If exposure is still not adequate, the incision may be first expanded laterally and upward, and then medially if necessary. Lateral extension may be made following the fibers of the external oblique muscle. Further medial access can be obtained by incising the anterior rectus sheath and rectus muscle. The epigastric vessels should be identified and possibly ligated to avoid bleeding.

Although the muscles will reapproximate by contraction, closure of the muscle fascia is performed. The transverse abdominis and internal oblique muscles can be loosely reapproximated with interrupted or continuous absorbable sutures (figure 8). The aponeurosis of the external oblique is also closed with either interrupted or continuous absorbable suture.

McBurney's incision provides excellent access to the ipsilateral lower quadrant, making it ideal for appendectomy. The incision may be placed lower for extraperitoneal drainage of a pelvic abscess. It is easily expanded, and cosmesis is excellent [16].

Subcostal — The subcostal and bilateral subcostal (chevron) incisions are used to access the upper abdomen and flank and can be used for open cholecystectomy, bile duct surgery, liver resection, liver transplant, duodenal surgery, adrenalectomy, and open nephrectomy, among other surgeries. The subcostal or chevron incision can also be extended to a sternotomy incision (also known as the Mercedes-Benz incision) when cardiopulmonary bypass or liver mobilization is needed.

The skin incision is placed approximately 3 cm below and parallel to the costal margin. The fascia of the rectus muscle and the external oblique muscles are initially divided. Next, the rectus muscle and the external oblique, internal oblique, and transversalis muscles are divided. When dividing the rectus muscle, the superior epigastric vessels should be identified and divided between clamps and ligated.

Disadvantages of a subcostal approach include poor cosmesis and increased postoperative pain, particularly with bilateral subcostal incisions. For this reason, some surgeons prefer epidural for postoperative analgesia, which can reduce the discomfort.

Thoracoabdominal — The thoracoabdominal approach is a transthoracic intra- or extraperitoneal approach that provides exposure to the kidney, adrenal, lung, and inferior vena cava (IVC; right) and aorta (left). It is the preferred approach for open thoracoabdominal aortic surgery and for intravenous tumor thrombus extending into the IVC since it allows mobilization of the liver and complete IVC exposure up to the heart. The disadvantages of the thoracoabdominal approach include the potential for thoracic complications (hernia, phrenic nerve injury, pneumothorax), postoperative chest tube requirement, and a prolonged operative time.

For this approach, the patient is placed in semi-lateral position, with both hips on the operating table. The thorax ipsilateral to the operated side is rotated 45 degrees over a rolled towel, and the ipsilateral arm is placed over an arm support. The incision is performed over the 9th or 10th rib and extended to the midline for an intra-abdominal approach (inverted hockey stick incision), to the contralateral subcostal region, or to between the umbilicus and pubis for a retroperitoneal approach (figure 5).

After the incision is cut down to the selected rib, the rib and the cartilage are exposed, and the intercostal muscles are incised with cautery followed by division of the pleura. Care is taken to avoid injury to the lung. The external oblique, internal oblique, transverse, and rectus muscles are divided with cautery. The rectus muscle can usually be spared with a retroperitoneal approach. If a transperitoneal approach is selected, the peritoneum is opened between clamps, whereas care is taken to preserve the peritoneum for a retroperitoneal approach by reflecting it medially off Gerota's fascia. If the peritoneum is inadvertently divided, it can be repaired with absorbable suture to prevent herniation of the intestines into the operative field. The cartilage above the selected rib is cut with heavy Mayo scissors, and the diaphragm is divided medially, avoiding the phrenic nerves (figure 9). Following completion of the procedure, the diaphragm is closed with a 0-prolene running suture. The ribs are reapproximated with absorbable suture after a chest tube is positioned in the thorax at a location several intercostal spaces above the level of the incision in the midaxillary line.

TRANSVERSE INCISIONS — Transverse incisions were initially developed to minimize likelihood of fascial dehiscence and incisional hernias. However, a study evaluating only gynecologic surgery patients found no difference in fascial dehiscence between transverse (Pfannenstiel) and vertical incisions [17]. Since these incisions follow Langer's lines (figure 10), less tension exists across transverse incisions, and the cosmetic result is enhanced.

Abdominal — Transverse incisions above or below the umbilicus are occasionally used in adults to access the abdominal organs but are more commonly used in the pediatric population. A transverse extension of a midline incision may also be used to gain additional exposure. (See 'Midline incision' above.)

Rockey-Davis or Elliot incision — Modified from the McBurney's incision, the Rockey-Davis or Elliot incision is a transverse incision that is centered at the McBurney's point (the junction of the lower and middle third of a line from the superior anterior iliac spine to the umbilicus) (figure 5). Medially, the incision extends to the lateral border of the rectus abdominis muscle; laterally, the incision extends an equal distance as it does medially. The aponeurotic layers are opened in a fashion similar to McBurney's incision. This incision is thought to be cosmetically superior to the McBurney's incision, and indications for its use are like those of McBurney's incision. Additionally, the incision may be made on the left or the lower abdomen to gain better access to a pelvic abscess. Exposure to the ipsilateral lower quadrant is excellent.

Flank — The flank incision is a retroperitoneal approach that provides good exposure to the retroperitoneal structures without the need to open the peritoneum and is an excellent approach for radical, simple, and partial nephrectomy. It is useful for avoiding contamination of the peritoneum when active infection of the kidney is present (eg, emphysematous pyelonephritis).

The advantages of the flank approach include the relatively small size of the incision, direct access to the kidney, no need to mobilize the colon, and a retroperitoneal-only dissection, which minimizes postoperative ileus.

Disadvantages include poor access to the inferior vena cava and aorta and limited exposure of the upper pole of the kidney, particularly on the left side. Given the proximity of the pleura, pneumothorax or other thoracic complications can occur.

The patient is placed in full lateral position with the ipsilateral arm placed overhead on an arm support. An axillary roll is placed under the patient's thorax to decrease pressure on the dependent shoulder and axilla, and the contralateral leg is bent at the hip and knee while the ipsilateral leg is kept straight. The table is then flexed to stretch the flank. A kidney rest can be used to temporarily elevate and further flex the patient; however, it should not be used for more than four hours, particularly in patients with obesity, due to the potential for compression. Rhabdomyolysis has been reported after prolonged use [18].

The flank incision is performed at the superior margin of the 10th, 11th, or 12th rib and extended toward the midline. The latissimus dorsi, intercostal, external oblique, internal oblique, and transversalis muscles are divided using electrocautery. The peritoneum is then reflected medially off Gerota's fascia exposing the retroperitoneum.

Lumbotomy — Lumbotomy is used mainly for nephrectomy involving small nonfunctional kidneys and for pediatric pyeloplasty. A transverse incision is placed between the 12th rib and the iliac crest perpendicular to the sacrospinalis muscle. After the incision of the lumbodorsal fascia, the sacrospinalis and quadratus muscles are retracted medially, the transversalis fascia is opened, and Gerota's fascia is entered. The main advantages of the lumbotomy include avoidance of muscle, decreased postoperative pain, and direct access to the renal pelvis and ureter. Disadvantages include poor access to the renal vessels and difficult dissection in the face of renal masses.

Incisions for pelvic operations — The greatest disadvantages of transverse incisions are the limited exposure provided to the upper abdomen, limited extensibility, increased surgical time, and relatively larger blood loss. Low transverse incisions can also be problematic if the pannus is large. However, when a planned operation is likely going to be confined to the pelvis, low transverse incisions are often used.

All of the incisions described below begin with a transverse skin incision centered above the symphysis pubis. The different incisions are distinguished by their distance above the symphysis. They may be straight or have a gentle curve with cephalic concavity. Several vertical marks can be placed across the incision line to aid in symmetrical reapproximation. This is especially helpful if the incision is curved. Placing the incisions in the pubic hair line or in a natural skin crease may enhance the cosmetic result. However, the incision should not be placed in a deep skin fold of a large panniculus where maceration of the skin can increase the risk of infection. (See "Complications of abdominal surgical incisions", section on 'Obesity'.)

Transverse incisions for pelvic surgery are of four types (figure 11):

Pfannenstiel's incision, a muscle-separating operation (most common)

Cherney's incision, a tendon-detaching operation

Maylard's incision, a true muscle-cutting incision

Küstner's incision, a median incision using a transverse skin incision

Turner-Warwick's incision, a low midline incision for retropubic exposure

The Pfannenstiel incision and the Maylard incision have been compared directly with Caesarean delivery and were judged to be comparable [19]. (See 'Pfannenstiel's incision' below.)

Pfannenstiel's incision — Pfannenstiel's incision, the most popular transverse incision for pelvic surgery, is placed 2 to 5 cm above the pubic symphysis and usually is 10 to 15 cm in length (figure 12) [11]. After the skin is entered, the incision is carried through the subcutaneous tissue to the anterior rectus sheath, which is incised transversely. The upper and lower fascial edges are grasped with a heavy toothed clamp, such as a Kocher, elevated, and dissected bluntly and sharply off the underlying rectus muscle from the umbilicus to the symphysis. The rectus muscle is separated along the midline raphe, exposing the transversalis fascia (and the posterior rectus sheath above the arcuate line). These layers and the peritoneum are incised vertically.

Closure of Pfannenstiel's incision may include loose reapproximation of the peritoneum and rectus muscles at the midline, if diastasis is present. Otherwise, the rectus muscles reapproximate themselves. The anterior rectus sheath is closed with absorbable or nonabsorbable suture in an interrupted or continuous fashion.

Pfannenstiel's incision provides excellent strength and cosmesis, and exposure is adequate for procedures limited to the pelvis; however, there is minimal opportunity to extend the incision if wider exposure is desired. This incision is used only when pathology is confined to the pelvis. However, the Pfannenstiel incision may be modified in a Cherney manner for improved exposure. (See 'Cherney's incision' below.)

Like all other incisions, the Pfannenstiel does have its limitations, however. Since several tissue planes must be opened, speed of entry is restricted and the risk of seroma, hematoma, and wound infection may be increased. Because of these considerations, this incision is relatively contraindicated in the presence of active abdominal infection or if speed is of the essence. Additionally, the rectus muscle is not routinely divided, so exposure is more limited than in the Maylard or Cherney incisions.

Dissection of the lower rectus sheath has been standard practice in performing a Pfannenstiel incision for Caesarean section. The need to separate the rectus sheath from the rectus muscles has been evaluated. A randomized trial found a significant reduction in postoperative pain and reduced blood loss in patients who did not undergo dissection of the rectus sheath compared with those who did [20].

The incidence of inguinal hernia with the Pfannenstiel incision, at least in men, may be greater when the incision is close to the external inguinal ring [12]. If the incision is extended beyond the rectus muscle, the iliohypogastric and ilioinguinal nerves may be encountered. Neuromas can occur if these nerves are traumatized, and some patients will experience chronic pain severe enough to limit daily activities.

Significant predictors of chronic pain following Caesarean section include numbness after a primary incision, repeat Pfannenstiel incision, and emergency procedure [21]. In this study, over one-half of the patients with moderate-to-severe pain had evidence of nerve entrapment.

Cherney's incision — Cherney's incision is similar to the Pfannenstiel incision, except it involves incising the rectus tendons and is placed slightly lower on the abdomen (figure 13). Like Pfannenstiel's incision, the anterior rectus sheath is incised in transverse fashion and may be dissected from the muscle superiorly and inferiorly. The tendons of the rectus and pyramidalis muscles are incised at their insertion to the symphysis following blunt separation from the underlying bladder and adventitial tissue. A half-centimeter segment of tendon is left on the symphysis for reattachment. The muscles and tendons are retracted caudad, and the peritoneum is incised longitudinally.

Closure of Cherney's incision requires reattachment of the muscle tendons to their insertions. This is usually accomplished using permanent horizontal mattress sutures. Alternatively, the tendons may be attached to the lower rectus sheath.

Cherney's incision provides excellent exposure to the retropubic space of Retzius, making it a good choice for retropubic urethropexy. A Pfannenstiel incision may be converted to a Cherney incision to enhance exposure.

Maylard's incision — Maylard's incision (also known as the Mackenrodt incision) is a transverse incision through all layers of the abdominal wall, usually at the level of the anterior iliac spine (figure 14). Following wide transverse incision in the aponeurosis, the rectus muscles are incised transversely with a scalpel, electrosurgery, or surgical stapler.

Prior to transection of the muscles, the deep inferior epigastric vessels are identified on their lateral undersurface. The vessels are isolated, clamped, transected, and ligated. During transection of the rectus muscles, dissection from the anterior rectus sheath should be avoided in order to limit retraction of the muscles. In addition, the cut edge of the muscle may be secured to the anterior sheath with 0-caliber absorbable mattress sutures to further prevent retraction.

The Maylard incision can provide adequate abdominal and pelvic exposure for complex gynecologic surgery [22]. As with other transverse incisions, the Maylard incision can limit access to the upper abdomen depending on the patient's body habitus, and delayed bleeding from the cut edge of the rectus muscle or deep epigastric vessels can occur.

A serious and often unanticipated complication of the Maylard incision can occur in patients with significant aortoiliac occlusion (eg, aortic atherosclerosis or coarctation). These patients depend upon collateral flow from the epigastric vessels for perfusion of the lower extremities (figure 2). The ligation of these epigastrics during a Maylard incision may cause worsening symptoms of lower extremity ischemia, such as claudication and even acute leg ischemia. (See "Clinical features and diagnosis of acute lower extremity ischemia".)

Küstner's incision — This incision is uncommonly used. Küstner's incision is begun with a transverse skin incision approximately 5 cm above the symphysis and just below the anterior iliac spine (figure 15) [23]. Subcutaneous adipose is then separated from the rectus sheath in a vertical plane to reveal the linea alba. Numerous small branches of the superficial epigastric plexus of vessels may be encountered and must be ligated to prevent excess oozing. Because of the need for extensive hemostasis, this incision tends to be very time consuming. Care must be taken to dissect only enough to expose the linea alba and not to separate the subcutaneous tissue too far laterally. A vertical midline incision is then made in the linea alba. The procedure for the midline incision is subsequently followed. (See 'Midline incision' above.)

Küstner's incision combines the disadvantages of both midline and transverse incisions and therefore has limited utility. Collection of blood and serum increases the risk of infection and may necessitate drainage. The incision affords less exposure than the Pfannenstiel and almost no extensibility. It was developed to reduce the risk of evisceration; however, the incidence of herniation is similar to that of midline incisions.

Turner-Warwick's incision — Turner-Warwick's incision is centered 2 to 3 cm above the symphysis and placed within the lateral borders of the rectus muscles (figure 16) [24]. The lower pole of the rectus muscles from below the symphysis is separated from the overlying sheath. The aponeurosis incision is usually 2 cm below the symphysis and 4 cm across. The rectus sheath incision is angled upward to the lateral border of the rectus but remains medial to the internal oblique and transversus abdominis muscle bellies. A Kocher clamp can be placed on the aponeurosis for traction as it is separated from the muscle by blunt and sharp dissection. The pyramidalis muscles usually remain attached to the aponeurosis. The rectus muscles are separated from the transversalis fascia, and the peritoneum is incised in the midline.

The Turner-Warwick incision provides excellent exposure to the retropubic space, but upper pelvis and abdominal exposure is severely limited.

REENTRY INCISIONS — For patients who have had prior surgery at the same planned incision site, it is preferable to make the incision through the previous scar since the placement of parallel incisions may result in an intervening bridge of ischemic tissue, even if the incisions are performed many years apart [25]. Skin ischemia and necrosis may also occur at points of intersection where incisions cross each other.

If the prior scar is cosmetically unacceptable, it may be excised at the beginning or end of the procedure. This is easily accomplished by elevating the old scar with Allis clamps and making an elliptical incision around the old scar.

As noted above, it is usually preferable to extend the skin and fascial incision a few centimeters above the previous incision so the peritoneum can be opened where it is relatively free of adhesions.

In a single-center comparative study of relaparotomy versus primary laparotomy, relaparotomy required a longer time to gain abdominal access (23.5 versus 8.8 minutes), and the peritoneal adhesion index was higher (10.8 vs. 0.4) [26]. Inadvertent enterotomies were more common with relaparotomy (0.3 versus 0.0). However, the rate of overall complications, surgical site infections, wound dehiscence with evisceration, and long-term incisional hernias was not different between the two groups.

SPECIAL CONSIDERATIONS FOR PATIENTS WITH OBESITY — Incisions should not be placed within the overlapping fold of a panniculus, due to the anaerobic bacterial load [27]. Several strategies have been described to avoid incision placement in this area. (See "Complications of abdominal surgical incisions", section on 'Obesity'.)

The panniculus can be grasped with towel clamps and pulled down. The skin incision is then placed in a paramedian or midline location extending above the umbilicus. Although the topography of the abdomen is distorted, the fascial anatomy is not. A protocol utilizing this technique has been shown to lower the rate of wound infection from 42 to 3 percent [28].

PANNICULECTOMY — An alternative approach is surgical removal of the panniculus (ie, a panniculectomy) [29]. The advantage of this procedure is that by removing the panniculus, the depth of the surgical field is significantly reduced [30]. Surgeons are increasingly either including a panniculectomy in the operation on patients who are clinically obese or, in elective cases, requiring that the patient undergo and recover from the panniculectomy prior to the abdominal surgery. Unfortunately, complication rates of panniculectomy are high, with wound healing problems occurring in 40 to 50 percent of patients [31].

The simplest approach to panniculectomy is a pair of curvilinear transverse incisions across the abdomen, widest apart at the midline and tapering to meet laterally over the iliac spines, creating a pointed oval (ie, "football") piece of tissue, which will be removed (figure 17). The incisions should be placed in existing skin creases if possible. Typically, the lower incision is made first and located several centimeters superior to the pubic symphysis at the midline (overlaps a Pfannenstiel incision centrally). Once the lower incision has been made, the skin and subcutaneous fat are elevated off the muscular fascia. The tissue is undermined to the level of the xyphoid centrally and the lower costal margins laterally. Undermining is taken superior to the level of skin/subcutaneous resection to allow the skin to be redraped into its new position. Once the undermining is completed, the location of the upper incision is determined by the skin tension that will result on closure.

Many surgeons are adding a second wedge resection perpendicular to the transverse one, using a "fleur-de-lis" incision [31,32]. A "fleur-de-lis" incision removes tissue and skin laxity in a vertical dimension as well as a horizontal one (figure 18).

The surgeon can preserve the umbilicus by separately dissecting a cone of tissue around it to be brought out from a new site in the abdominal skin, maintaining its position relative to the pubic symphysis. However, for very large panniculi, the umbilicus may need to be sacrificed.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Abdominal incisions and closure".)

SUMMARY AND RECOMMENDATIONS

Skin incision – The initial incision can be made using a scalpel or electrosurgery wand. During sharp incision of the subcutaneous tissues, care should be taken to make as few strokes as possible. (See 'Skin incision' above.)

Choice of incisions – The most important factor in choosing an incision is ensuring that it will provide adequate exposure for the anticipated procedure while taking into account the possibility that the extent of the procedure may change depending upon intraoperative findings. Other factors to consider include speed, blood loss, cosmetic appearance, and the presence of comorbid conditions. (See 'Choice of incision' above.)

Midline incisions – The midline incision is the most versatile longitudinal incision. It provides the quickest entry and the best exposure and extensibility. It is a good choice for patients who are anticoagulated, have enlarged epigastric vessels that may be injured, have intra-abdominal infection, or may need an extended incision. (See 'Midline incision' above.)

Transverse incisions – The major advantage of transverse incisions is cosmetic. Disadvantages include the limited exposure provided to the upper abdomen, limited extensibility, increased surgical time, and potentially larger blood loss. Low transverse incisions can also be problematic if the pannus is large. (See 'Transverse incisions' above.)

Reentry incisions – Reentry incisions should be performed through the previous incision whenever possible. Adhesions are expected at the site of the prior incision. (See 'Reentry incisions' above.)

Incisions for patients with obesity – Incisions should not be placed in the overlapping fold of a large pannus. Panniculectomy may facilitate surgery in the patient with class 3 obesity and reduce the risk of wound infection. (See 'Special considerations for patients with obesity' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Dr. Keith Garret Wolter, who contributed to this review.

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Topic 2 Version 22.0

References

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