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Incision decisions: which ones for which procedures?

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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.


 

References

Key points
  • 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.

Regardless of the type of incision selected, the skin should be incised with a single, clean stroke of a sharp scalpel. However, when it comes to dissecting the underlying subcutaneous tissues, the debate continues over whether a scalpel or electrosurgery is best. While I recently have switched to the latter, here is a look at what the data say: Johnson and Serpell demonstrated that electrosurgery is associated with faster hemostasis, with no difference in the incidence of wound infection.1 Similarly, a recent randomized trial by Kearns et al found electro-surgery causes less blood loss and does not increase the risk of wound infections or fascial dehiscence.2 In contrast, a large prospective study by Cruse et al suggested that the use of diathermy is associated with twice the wound infection rate.3

This controversy also involves patients with gynecologic malignancies. Kolb et al found that electrosurgery was an independent risk factor for wound complications following surgery for ovarian cancer.4 However, Franchi and colleagues reported no difference in the rate of wound complications between scalpel and diathermy in patients who underwent mid-line abdominal incisions for the treatment of uterine cancer.5

Use the midline when the diagnosis and the extent of surgery are uncertain.

The inconsistencies in the data may reflect differences in electrosurgical technique. Non-modulated (cutting) current concentrates energy, vaporizing the tissue with little heat injury to surrounding areas. Conversely, modulated (coagulating) current coagulates the tissue with heat-producing char over a large area, and tissue injury often extends beyond the char. This effect is magnified if the electrode comes in direct contact with the tissue. Use the arc, rather than direct contact, to prevent excessive devitalization of tissue.

This article will review the techniques for, as well as the rationale and disadvantages of, common incisions—both longitudinal and transverse—to help the gynecologic surgeon minimize morbidity and maximize outcomes.

Longitudinal incisions

The longitudinal incisions that will be reviewed here are the midline (median) and paramedian. Classically, it was thought that longitudinal incisions were at greater risk of dehiscence than transverse incisions.6 However, it is difficult to make legitimate comparisons since longitudinal incisions are more likely to be performed in cases of hemorrhage, trauma, sepsis, multiorgan disease, previous surgery, previous radiation therapy, and malignancy—all of which increase the likelihood of postoperative complications. Furthermore, prospective and randomized studies have shown little, if any, difference in the incidence of dehiscence and hernias between longitudinal and transverse incisions.6-8

MidlineTechnique. Initiate the midline as a low abdominal incision (approximately 2 cm above the pubic symphysis), cutting along the linea alba. To extend the incision, if necessary, continue the dissection to the left of the umbilicus to avoid the ligamentum teres. Open the peritoneum at the cephalad pole of the incision (Figure 1). Expand this cut slightly off midline to avoid the urachus yet adequately expose the peritoneal cavity (Figure 2).

Rationale. While this incision can be used for any surgical procedure, it is especially appropriate when the diagnosis is uncertain and the exact procedure or extent of surgery is unclear. It is an excellent choice when access to the upper abdomen may be necessary, e.g., patients with gynecologic malignancies who may need assessment of the diaphragm, liver biopsy, para-aortic node biopsy, omentectomy, or debulking procedures. Patients with benign gynecologic conditions also may benefit from a midline incision. For example, when pelvic anatomy is distorted, as with severe endometriosis or sepsis, recognizable anatomy may be found only above the pelvic brim.

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