Incisions For Open Abdominal Surgery

19/5/2020 Incisions for open abdominal surgery - UpToDate
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Incisions for open abdominal surgery

Author: Jason S Mizell, MD, FACS
Section Editor: Michael Rosen, MD
Deputy Editor: Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2020. | This topic last updated: Apr 29, 2019.
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
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● 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 obese patients, 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 'Morbid 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. 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. One study found that
the extent of anterior abdominal wall adhesions at secondary cytoreductive surgery were minimal
with this incision [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
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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 are 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.
SPECIAL CONSIDERATIONS FOR OBESE PATIENTS

Incisions should not be placed within the overlapping fold of a panniculus due to the anaerobic
bacterial load [26]. Several strategies have been described to avoid incision placement in this
area. (See "Complications of abdominal surgical incisions", section on 'Morbid 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 [27].
PANNICULECTOMY
An alternative approach is surgical removal of the panniculus (ie, a panniculectomy) [28]. The
advantage of this procedure is that by removing the panniculus, the depth of the surgical field is
significantly reduced [29]. 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 [30].
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 [30,31]. 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
● 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.)
● 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.)
● 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.)
● 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 should be performed through the previous incision whenever possible.
Adhesions are expected at the site of the prior incision. (See 'Reentry incisions' above.)
● Incisions should not be placed in the overlapping fold of a large pannus. Panniculectomy may
facilitate surgery in the very obese patient and reduce the risk of wound infection. (See
'Special considerations for obese patients' above.)
ACKNOWLEDGMENT
The editorial staff at UpToDate would like to acknowledge Dr. Keith Garret Wolter, who contributed
to this review.
Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES
1. Meeks GR, Trenhaile TR. Management of abdominal incisions. J Pel Surg 2002; 6:295.
2. Inaba T, Okinaga K, Fukushima R, et al. Prospective randomized study of two laparotomy

incisions for gastrectomy: midline incision versus transverse incision. Gastric Cancer 2004;
7:167.
3. Levrant SG, Bieber E, Barnes R. Risk of Anterior Abdominal Wall Adhesions Increases with
Number and Type of Previous Laparotomy. J Am Assoc Gynecol Laparosc 1994; 1:S19.
4. Bickenbach KA, Karanicolas PJ, Ammori JB, et al. Up and down or side to side? A
systematic review and meta-analysis examining the impact of incision on outcomes after
abdominal surgery. Am J Surg 2013; 206:400.
5. Brown SR, Goodfellow PB. Transverse verses midline incisions for abdominal surgery.
Cochrane Database Syst Rev 2005; :CD005199.
6. Fassiadis N, Roidl M, Hennig M, et al. Randomized clinical trial of vertical or transverse

laparotomy for abdominal aortic aneurysm repair. Br J Surg 2005; 92:1208.
7. Seiler CM, Deckert A, Diener MK, et al. Midline versus transverse incision in major
abdominal surgery: a randomized, double-blind equivalence trial (POVATI:
ISRCTN60734227). Ann Surg 2009; 249:913.
8. Ahmad NZ, Ahmed A. Meta-analysis of the effectiveness of surgical scalpel or diathermy in

making abdominal skin incisions. Ann Surg 2011; 253:8.
9. Ly J, Mittal A, Windsor J. Systematic review and meta-analysis of cutting diathermy versus

scalpel for skin incision. Br J Surg 2012; 99:613.
10. Hasselgren PO, Hagberg E, Malmer H, et al. One instead of two knives for surgical incision.
Does it increase the risk of postoperative wound infection? Arch Surg 1984; 119:917.
11. EVERETT HS, MATTINGLY RF. Urinary tract injuries resulting from pelvic surgery. Am J
Obstet Gynecol 1956; 71:502.
12. Cox PJ, Ausobsky JR, Ellis H, Pollock AV. Towards no incisional hernias: lateral paramedian
versus midline incisions. J R Soc Med 1986; 79:711.
13. Guillou PJ, Hall TJ, Donaldson DR, et al. Vertical abdominal incisions--a choice? Br J Surg
1980; 67:395.

14. Yamada M, Maruta K, Shiojiri Y, et al. Atrophy of the abdominal wall muscles after
extraperitoneal approach to the aorta. J Vasc Surg 2003; 38:346.
15. McBurney C. IV. The Incision Made in the Abdominal Wall in Cases of Appendicitis, with a
Description of a New Method of Operating. Ann Surg 1894; 20:38.
16. Delany HM, Carnevale NJ. A "Bikini" incision for appendectomy. Am J Surg 1976; 132:126.
17. Hendrix SL, Schimp V, Martin J, et al. The legendary superior strength of the Pfannenstiel
incision: a myth? Am J Obstet Gynecol 2000; 182:1446.
18. Akhavan A, Gainsburg DM, Stock JA. Complications associated with patient positioning in
urologic surgery. Urology 2010; 76:1309.
19. Giacalone PL, Daures JP, Vignal J, et al. Pfannenstiel versus Maylard incision for cesarean
delivery: A randomized controlled trial. Obstet Gynecol 2002; 99:745.
20. Kadir RA, Khan A, Wilcock F, Chapman L. Is inferior dissection of the rectus sheath
necessary during Pfannenstiel incision for lower segment Caesarean section? A randomised
controlled trial. Eur J Obstet Gynecol Reprod Biol 2006; 128:262.
21. Loos MJ, Scheltinga MR, Mulders LG, Roumen RM. The Pfannenstiel incision as a source of
chronic pain. Obstet Gynecol 2008; 111:839.
22. Fanning J, Pruett A, Flora RF. Feasibility of the Maylard transverse incision for ovarian
cancer cytoreductive surgery. J Minim Invasive Gynecol 2007; 14:352.
23. Küstner O. Der suprasymphysare kreuzscnitt, eine methode der coeliotomie bei wenig
umfanglichen affektioen der weiblichen beckenorgane. Monatsschr Geburtsh Gynäkol 1986;
4:197.
24. Warwick RT, Worth P, Milroy E, Duckett J. The suprapubic V-incision. Br J Urol 1974; 46:39.
25. Nygaard IE, Squatrito RC. Abdominal incisions from creation to closure. Obstet Gynecol
Surv 1996; 51:429.
26. Alexander CI, Liston WA. Operating on the obese woman--A review. BJOG 2006; 113:1167.
27. Gallup DG. Modifications of celiotomy techniques to decrease morbidity in obese

gynecologic patients. Am J Obstet Gynecol 1984; 150:171.
28. Hopkins MP, Shriner AM, Parker MG, Scott L. Panniculectomy at the time of gynecologic
surgery in morbidly obese patients. Am J Obstet Gynecol 2000; 182:1502.
29. Olejek A, Manka G. Panniculectomy in gynecologic cancer surgical procedures by using a

harmonic scalpel. Acta Obstet Gynecol Scand 2005; 84:690.
30. Cooper JM, Paige KT, Beshlian KM, et al. Abdominal panniculectomies: high patient
satisfaction despite significant complication rates. Ann Plast Surg 2008; 61:188.
31. O'Brien JA, Broderick GB, Hurwitz ZM, et al. Fleur-de-lis panniculectomy after bariatric
surgery: our experience. Ann Plast Surg 2012; 68:74.
Topic 2 Version 17.0

GRAPHICS
Vertical skin incisions of the abdominal wall
Courtesy of William J Mann, Jr, MD.
Graphic 63560 Version 4.0

Midline incision of the abdominal wall
The linea alba is incised and muscles separated in the midline. The peritoneum is opened
at the cephalic pole of the incision. The peritoneal incision is expanded longitudinally,
slightly off midline to avoid the urachus.

Blood vessels of the anterior abdominal wall
The superior and inferior epigastric arteries provide a rich arcade, arising from the internal
thoracic artery superiorly and the external iliac artery inferiorly. The musculophrenic artery,
deep circumflex iliac artery, and subcostal arteries supply the lateral abdominal wall. The
superficial epigastric veins and the superficial iliac veins can arise from the great saphenous
vein.

Anomalies of the urachus

Paramedian incision of the abdominal wall
(A) The anterior rectus sheath is opened for the full length of the incision 2 to 3
cm from the midline. The rectus muscle is retracted laterally and the posterior
sheath is incised longitudinally under the muscle bed. (B) The lateral paramedian
incision is placed near the lateral border of the rectus. When the muscle is
retracted laterally, the inferior deep epigastric artery is seen. Finally, the
posterior sheath is closed.

Oblique abdominal incisions

McBurney incision 1
(A) Incision through McBurney's point. (B) Fibers of external oblique separated.
Internal oblique muscle split.

McBurney incision 2
(C) Peritoneum and transversalis fascia incised. (D) Fibers of internal oblique reapproximated.

McBurney incision 3
(E) External oblique closed with running suture. (F) Delayed closure of skin.

Surfaces of the diaphragm

Langers lines of the abdomen
Langer's lines are lines of skin tension. Because these lines are predominantly
horizontal in the abdomen, transverse incisions generate less tension in the skin.

Transverse incisions of the abdominal wall

Pfannenstiel incision
(A) "Low" Pfannenstiel: the skin incision is placed lower for cosmetic reasons. The
subcutaneous tissues are dissected to allow standard placement of rectus sheath
incision. (B) Fascia is separated from rectus muscle superiorly and inferiorly. (C) The
rectus muscle is separated in the midline and the peritoneum is incised
longitudinally. (D) Sutures may be placed in the rectus muscle to close a rectus
diastasis. (E) Sheath is closed with continuous suture. Skin is approximated with a
subcuticular suture.

Cherney incision
(A) Transverse incision of rectus sheath.

(B) Lower sheath is separated from rectus muscles. Tendons are exposed and incised 0.5 cm
above periosteum of symphysis.
(C) Tendons are sutured to lower rectus sheath above symphysis with permanent suture
material.
(D) Sheath is closed in a continuous manner.

Maylard incision
Transverse muscle-cutting incision. (A) Incision of rectus sheath is extended

laterally to iliac spine to expose rectus muscle. Rectus muscles are cut
transversly. (B) Cut edges of muscles are sutured to the rectus sheath. Ligated
epigastric vessels and exposed transversalis fascia are shown. Transversalis
fascia and peritoneum are incised transversely. Urachus is ligated.

Küstner incision
Transverse incision to sheath, subcutaneous tissue separated from linea alba.

Midline incision in linea alba.

Turner-Warwick incision
Transverse skin incision. Subcutaneous tissue is dissected from the anterior sheath to a point at
least 2 cm below the pubis. The sheath is incised 2 cm below the pubis and at least 4 cm in
length. The incision is extended cephalad along the borders of the rectus muscles. Peritoneum is
incised longitudinally.

Panniculectomy
An elliptical transverse incision is made extending from one flank to the other below the
umbilicus.

Fleur-de-lis incision

Contributor Disclosures
Jason S Mizell, MD, FACS Consultant/Advisory Boards: Applied Medical [Laparoscopic colorectal surgery
(Laparoscopic hand access device, transanal access platform)]. Michael Rosen, MD Employment: Medical
Director of AHSQC (Americas Hernia Society Quality Collaborative). Grant/Research/Clinical Trial Support:
Intuitive Surgical [Inguinal hernia (Surgical robot)]; Pacira [Ventral hernia repair (Bupivacaine)].
Consultant/Advisory Boards: Artiste Medical [Mesh (Mesh)]. Wenliang Chen, MD, PhD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
Conflict of interest policy

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Official reprint from UpToDate®

Additional considerations in selecting the type of incision include:

● Need for rapid entry

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An appropriately placed incision of adequate length is enhanced by minimal tissue trauma,

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McBurney's incision — McBurney's incision is an oblique muscle-splitting incision located one

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Thoracoabdominal — The thoracoabdominal approach is a transthoracic intra- or extraperitoneal

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Lumbotomy — Lumbotomy is used mainly for nephrectomy involving small nonfunctional

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

Cherney's incision — Cherney's incision is similar to the Pfannenstiel incision, except it

Maylard's incision — Maylard's incision (also known as the Mackenrodt incision) is a

Turner-Warwick's incision — Turner-Warwick's incision is centered 2 to 3 cm above the

SPECIAL CONSIDERATIONS FOR OBESE PATIENTS

SOCIETY GUIDELINE LINKS

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SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

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2. Inaba T, Okinaga K, Fukushima R, et al. Prospective randomized study of two laparotomy

6. Fassiadis N, Roidl M, Hennig M, et al. Randomized clinical trial of vertical or transverse

8. Ahmad NZ, Ahmed A. Meta-analysis of the effectiveness of surgical scalpel or diathermy in

9. Ly J, Mittal A, Windsor J. Systematic review and meta-analysis of cutting diathermy versus

https://bibvirtual.upch.edu.pe:2050/contents/incisions-for-open-abdominal-surgery/print?search=Incisions for open abdominal surgery&source=… 14/36

27. Gallup DG. Modifications of celiotomy techniques to decrease morbidity in obese

29. Olejek A, Manka G. Panniculectomy in gynecologic cancer surgical procedures by using a

Topic 2 Version 17.0

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Vertical skin incisions of the abdominal wall

Courtesy of William J Mann, Jr, MD.

Graphic 63560 Version 4.0

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Midline incision of the abdominal wall

Courtesy of William J Mann, Jr, MD.

Graphic 59682 Version 3.0

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Blood vessels of the anterior abdominal wall

Graphic 81343 Version 5.0

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Anomalies of the urachus

Graphic 79324 Version 3.0

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Paramedian incision of the abdominal wall

Courtesy of William J Mann, Jr, MD.

Graphic 78609 Version 3.0

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Oblique abdominal incisions

Graphic 58517 Version 3.0

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Graphic 76933 Version 6.0

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Graphic 63567 Version 4.0

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Graphic 70883 Version 3.0

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Surfaces of the diaphragm