Abdominal Incisions

Christopher Morosky, MD, FACOG Developed in association with

Assistant Professor
Department of Obstetrics and Gynecology
University of Connecticut Health Center

Joel Sorosky, MD, FACOG, FACS

Chair, Abington Memorial Hospital
Reaffirmed 2/2021
 Abdominal Wall Muscles

Berek, J. Berek and Novak’s Gynecology. Lippincott Williams & Wilkins, 2011: figure 5.17 p 95.
NB: All Figures to be numbered, made consistent, and finalized. Permission granted 4/1/15.
Transverse Section of the Rectus Abdominis
The aponeurosis of the
external and internal oblique
and the transversus
abdominis from the rectus
abdominis
A. above the arcuate line
B. below the arcuate line

Berek and Novak figure 5.18 page 97 chapter 5

 Incisions: Open to Close
• Antibiotics • Irrigation
• Skin Preparation • Drains
• Incision Types • Subcutaneous Closure
• Incision Technique • Skin Closure
• Peritoneal Closure • Skin Dressing
• Fascial Closure
• Suture Technique
 Antibiotics

• A single dose of intravenous antibiotics one hour

prior to incision reduces the incidence of surgical site
infections
– 2 grams of cefazolin
• Penicillin allergy
– Metronidazole and aminoglycoside
– Vancomycin
 Skin Preparation

• Hair
– Avoid removal if possible
– Use of clippers rather than straight razor decreases
wound infection
• Prep solution
– Iodine versus chlorhexidine +/- alcohol equivalent
– Alcohol preps must be allowed to dry prior to
surgery due to an increased fire risk
 Incision Types:
Transverse and Vertical
Transverse Vertical
• Pfannenstiel • Midline
• Cherney • Paramedian
• Maylard
• Küstner
 Transverse Incisions

• Pfannenstiel
• Cherney
• Maylard
• Küstner

Mann/Stovall Gynecologic Surgery pg. 136 fig 8-12.

 Pfannenstiel Incision

The Pfannenstiel incision is a transverse skin incision, two finger-breadths above the
symphysis pubis, which is extended in the direction of the anterior superior iliac spine
(ASIS) and ends 2–3 cm medial to ASIS on both sides.

Advantages
• More cosmetic
o Scar is almost imperceptible
o Hidden in the pubic hairline
o Obscured by a skin crease
• Less painful
• Less pulmonary depression
• Excellent postoperative strength

Disadvantages
• No upper abdominal exposure
• Possible increased hematoma rate
 Separate Fascia

Fascia is
separated from
rectus muscle
superiorly and
inferiorly.

Mann/Stovall Gynecologic Surgery pg. 137 Figure 8-13 B

 Entering Peritoneum

The rectus
muscle is
separated in the
midline and the
peritoneum is
incised
longitudinally.

Mann/Stovall Gynecologic Surgery pg. 137 Figure 8-13C.

 Rectus Muscle Reapproximation

Sutures may be
placed in the
rectus muscle to
close a rectus
diastasis.

Muscle
reapproximation
is not routine.

Mann/Stovall Gynecologic Surgery pg. 138 Figure 8-13 D.

 Pfannenstiel Incision: Closing
Sheath is closed with
continuous suture. Skin is
approximated with a
subcuticular (SC) suture.

Fascia is closed with

continuous delayed-
absorbable suture.

Subcutanous tissue closure

if > 2 cm depth

Skin is approximated with

subcuticular, absorbable Mann/Stovall Gynecologic Surgery pg. 138 Figure 8-13 E
monofilament suture
 Cherney Incision
The Cherney incision is similar to the Pfannenstiel incision,
except it involves incising the rectus tendons and is placed
slightly lower on the abdomen.

Advantages
• Excellent pelvic exposure
• Dehiscence, hernia rare
• Incision of choice to “extend” Pfannenstiel

Disadvantages
• Limited upper abdominal exposure
 Cherney Incision: Opening
Transverse
incision of
rectus sheath.

Mann/Stovall pg 139-140 fig 8-14 A.

 Cherney Incision: Opening
Lower sheath is
separated from
rectus muscles.
Tendons are
exposed and incised
1.5 cm above
periosteum
of symphysis.

Mann/Stovall pg 139-140 fig 8-14 B.

 Cherney Incision: Closing
Tendons are
sutured to
lower rectus
sheath above
symphysis.

Mann/Stovall pg 140 fig 8-14 C.

 Maylard Incision
Advantages
• Excellent exposure, including upper abdomen
• Dehiscence, hernia rare

Disadvantages
• Risk of femoral nerve injury from retractor
• Risk of subfascial hematoma
• Poor choice for patients with extensive vascular
disease
 Maylard Incision: Opening

Incision of rectus
sheath is extended
laterally to iliac spine
to expose rectus
muscle. Rectus
muscles are cut
transversely.

Mann/Stovall pg 141 fig 8-15 A.

 Maylard Incision: Opening

Cut edges of muscles are

sutured to the rectus
sheath. Ligated epigastric
vessels and exposed
transversalis fascia.
Transversalis fascia and
peritoneum are incised
transversely. Urachus is
ligated.

Mann/Stovall pg 141 fig 8-15B.

 Küstner Incision
The Küstner incision is not commonly used.

Advantages
• More cosmetic
• Increased exposure versus Pfannenstiel

Disadvantages
• Visible erythema in area of fat dissection postoperatively
• Unable to extend around the umbilicus
• More painful than transverse fascial incision
 Küstner Incision
Transverse
incisions to sheath,
subcutaneous
tissue separated
from linea alba.

Mann/Stovall pg 142 Fig 8-16.

 Vertical Incisions
• Midline
• Paramedian

Mann/Stovall Gynecologic Surgery pg. 133 fig 8-9.

 Vertical Midline Incision
Advantages
• Versatile, rapid,
low blood loss
• Excellent exposure

Disadvantages
• More painful,
increased
pulmonary
depression
• Less
Mann/Stovall Gynecologic Surgery pg. 133 fig 8-9.
cosmetic
 Vertical Midline Incision
The line alba is
incised and muscles
separated in the
midline. The
peritoneum is
opened at cephalic
pole of incision. The
peritoneal incision is
expanded
longitudinally,
slightly off midline to
Mann/Stovall Gynecologic Surgery pg. 134 fig 8-10.
avoid urachus.
 Paramedian Incision
Advantages
• Theoretical decreased risk of herniation
• Improved lateral exposure

Disadvantages
• More likely to encounter the inferior epigastric
vessels vs. midline incision
• Less cosmetic
 Paramedian Incision
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.

Mann/Stovall Gynecologic Surgery pg. 135 fig 8-11 A

 Paramedian Incision
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.

Mann/Stovall Gynecologic Surgery pg. 135 fig 8-11 B

 Vertical Versus Transverse Incision

• Multiple prospective randomized trials

o No difference between vertical and transverse
incisions in fascial disruption
 Scalpel: One is Enough
• No difference in wound infection rate
• Skin knife is usually sterile
• Knife blade is not a vehicle for bacterial contamination
• No bacteriological evidence to justify the use of different
blades
 Electrocautery Versus Scalpel

• Inflammation/infection rates equal

• No differences in pain or wound healing
• Less blood loss with electrocautery
• More rapid incision with scalpel
 Peritoneal Closure

• Peritoneal reformation results from transformation of

subperitoneal fibroblasts
• Surgical closure prevents autolysis of early fibrinous
attachments
• Even minimally reactive sutures increase tissue necrosis
and foreign body reaction
• OB Cochrane review recommends against this
 Peritoneal Closure

• Edges do not need to be closed to enhance healing

• No increase in infectious complications
• No influence on wound integrity
• Avoiding closure decreases adhesion formation, including
bowel
• Not closing decreases surgical time, and may shorten hospital
stay
 Abdominal Closure: Variables
• Obesity
• Diabetes
• Cancer
• Radiation therapy
• Malnutrition
• Immunosuppression (steroids)
• Pulmonary disease
• Active infection
• Postoperative wound infection
• Ileus
 Risks
• Hernia
o 2-5% of benign surgeries
o 10-20% of malignant surgeries
• Evisceration
o Less than 1%
 Fascial Closure
• Continuous vs. interrupted
• Absorbable vs. permanent
• Suture placement
• Significant decrease in incisional hernia with continuous
sutures (OR 0.73, 95% CI 0.55-0.99)
• No difference in wound infection or dehiscence rate
• Continuous suture more rapid, less risk to staff, less
expensive
• Suture to wound length ratio should be ≥ 4
 Fascial Closure

• Absorbable suture associated with higher incidence of

incisional hernia (OR 0.68, 95% CI 0.52-0.87)
• No difference in wound infection or dehiscence rate
• Permanent suture associated with higher incidence of
wound pain and suture sinuses
 Suture Choice: Size Matters

• Suture diameter and cross-sectional area differ markedly

despite same gauge
• Permanent sutures have greater tensile strength but higher
incidence of stitch sinus and incision pain
• Monofilament sutures have lower incidence of infection
 Suture Technique

• Large bites, loosely tied is stronger

• Square knot strongest
• Surgeon’s knot decreases breaking strength
• Surgeons use too many throws
o 4 or less is sufficient for silk or braded
o 6 or less is sufficient for monofilament
 Irrigation:
The Solution To Pollution Is Dilution
• Antibiotic solutions have no effect on non-contaminated
wounds
• Volume, volume, volume
• Recommend omitting intraabdominal irrigation (in CD)
and perform subcutaneous irrigation
 Drains

• Controversial with conflicting data

• If used:
o Closed-suction system
o Separate exit wound
• See JAMA article by Tuuli et al., 2020: Effect of
prophylactic negative pressure wound therapy
versus standard wound dressing on surgical-site
infection in obese women after cesarean delivery.
 Subcutaneous Closure

• In obese patients (> 2 cm of subcutaneous fat), closure of

subcutaneous fat at cesarean section decreased superficial
wound disruption by 35%
• If performed, use fine absorbable suture in continuous
fashion
 Drains and Subcutaneous Closure

• Multicenter randomized trial of women undergoing

Cesarean Section
o Greater than 4 cm of subcutaneous fat
 Suture closure: 17% wound morbidity
 Suture closure plus drain: 22% wound morbidity

• Addition of a drain to subcutaneous closure does not

prevent would complications
Staples May Be Worse Than Subcuticular
In a prospective randomized study of 416 women who
underwent Cesarean Section, the wound separation rate was
significantly higher at 17% in the staple group, compared with
5% in the suture group.
 New and Potentially Exciting

Staple closure was an independent risk factor for wound

separation after controlling for gestational age, repeat CD,
obstetric complications, maternal co-morbidities, BMI >30,
incision type, OR time, and insurance.
 Facts

• Staple closure required more scheduled and unscheduled

office visits for wound care
• Mean GA of 38 weeks
• Mean age of 29 years
• 70% white
• 60% BMI > 30
 Closure

• Stainless steel staples in 197 women versus 4-0

absorbable monofilament on a PS2 needle in 219 women
• Adhesive closure strips placed after removing staples and
at SC closure
• SC closure in both if > 2 cm
• Composite wound complication rate was 22% in stapled
versus 9% in suture
• Composite rate included would separation, wound infection
or need for antibiotics, follow-up visits for wound, and
hospital admission for wound
 Skin Dressing
• Dry adherent dressing traditional
• Wound healing facilitated by moist environment
(semi-occlusive dressing)
o Faster healing, less pain, less scarring
o No increase in infection rate
o Leave on for 24-48 hours
 Summary
• Choose appropriate incision
• Au natural
• One knife or knife and electrocautery
• Meticulous surgical technique
• Do no close peritoneum
• Close fascia with running, non-locked, mass closure
using monofilament delayed-absorbable suture
• Use smallest suture gauge appropriate
 Summary
• Wide bites, loosely tied in a square knot with appropriate
number of throws
• Irrigate subcutaneous tissue copiously with saline
• Drain deep wounds with closed-suction system via
separate exit wound
• Avoid staples
• Semi-occlusive dressing for 24 – 28 hours
 Bibliography
Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of subcutaneous fat and wound disruption after
cesarean delivery: a meta-analysis. Obstet Gynecol 2004;103:974-80.
Dahlke, et al. The Case for Standardizing Cesarean Delivery Technique. Obstet and Gyneco Nov 2020; pp. 972-
980.
Duffy DM, diZerega GS. Is peritoneal closure necessary? Obstet Gynecol Surv 1994;49:817-22.
Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure: a meta-
analysis. Ann Surg 2000;231:436-42.
Meeks GR. Clinical anatomy of incisions. In: Mann WJ Jr, Stovall TG, editors. Gynecologic surgery. New York
(NY): Churchill Livingstone; 1996. p. 121-68.
Ramsey PS, White AM, Guinn DA, Lu GC, Ramin SM, Davies JK, et al. Subcutaneous tissue reapproximation,
alone or in combination with drain, in obese women undergoing cesarean delivery. Obstet Gynecol
2005;105:967-73.
Sokol ER, Genadry R, Anderson JR. Anatomy and embryology. In: Berek JS, editor. Berek & Novak's gynecology.
15th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2012. p. 62-111.
Tuuli, M. G., Liu, J., Tita, A. T., Longo, S., Trudell, A., Carter, E. B., ... & Harper, L. (2020). Effect of prophylactic
negative pressure wound therapy vs standard wound dressing on surgical-site infection in obese women after
cesarean delivery: A randomized clinical trial. Jama, 324(12), 1180-1189.