|March 2002 · Vol. 14, No. 3
Incision decisions: which ones for which procedures?
Incision selection plays an important role in gynecologic surgery, especially with regard to adequate pelvic access and preservation of abdominal wall function. Here, a guideline to the advantages and disadvantages of commonly used longitudinal and transverse incisions and the procedures for which they are best suited.
Dr. Meeks is professor of OBG and the Winfred L. Wiser Chair for Gynecologic Surgery and Dr. Trenhaile is assistant professor of OBG, department of OBG, at the University of Mississippi Medical Center in Jackson.
The incision should be considered as a second surgical procedure, which temporarily interferes with normal abdominal wall function.
The midline incision provides excellent exposure to all areas of the abdomen and retroperitoneum, which can be accessed with minimal risk of significant vascular or nerve injury.
Transverse incisions create less tension on the opposing skin edges because the incision follows Langer’s lines. The incidence of incisional hernias and wound dehiscence has been reported to be lower, but these studies are not randomized.
An abdominal incision often is given little thought other than as an access site through which a surgical procedure is performed. In reality, the incision is a second surgical procedure, which interferes—at least temporarily—with normal abdominal wall function.
While most physicians concur that the essential elements of a well-planned incision include adequate access to anticipated pathology, extensibility, and security of closure, many may not consider preservation of abdominal wall function as a key factor in their decision-making. Additional considerations include certainty of diagnosis, speed of entry, body habitus, presence of previous scars, potential for problems with hemostasis, and cosmetic outcome. These factors are the key determinants of whether the incision will be longitudinal (midline or paramedian) or transverse (Pfannenstiel’s, Cherney’s, or Maylard’s). For most gynecologic procedures confined to the pelvis, either option may be considered. The exceptions are patients with uncertain diagnoses or when access to the upper abdomen is indicated.