Chapter 6

The impact that the planning, execution, and closure of an incision has on the outcome of an abdominal operation should not be underestimated. The high combined incidence of surgical site infection (SSI), wound dehiscence, and hernia formation suggests a dominant contribution of wound complications to surgical morbidity. Moreover, the quality of exposure provided by an incision influences the ease and safety with which an operation can be undertaken and the outcome in ways which defy easy quantification.

An incision must provide access to the site of abdominal pathology and allow easy extension if greater exposure than originally anticipated is required. Indeed, the adequacy of an incision is determined above all else by the safety with which an operation can be undertaken. Nothing should compromise this and a larger incision or even, on occasion, a second incision should be created without hesitation if exposure is inadequate. Notwithstanding this, the incision should be executed in a fashion that anticipates a secure wound closure and interferes as little as possible with the function and cosmesis of the abdominal wall. These principles apply to both open and laparoscopic incisions. While the vertical midline incision remains most popular, and is, perhaps the most flexible, a variety of other incisions may have distinct advantages in specific settings.

### Choice of Incision

Abdominal incisions can be vertically, transversely, or obliquely oriented. The avascular linea alba affords the vertical midline its superior flexibility. Indeed, when optimal exposure of the abdominal cavity is necessary (eg, exploration for abdominal trauma), the vertical midline incision is preferred and can be extended superiorly to the xiphoid process and inferiorly to the symphysis pubis. Alternatively, vertical incisions may be placed in a paramedian position, an approach that was previously more popular than it is today but continues to have its proponents. Transverse and oblique incisions can be placed in any of the four quadrants of the abdomen depending on the site of pathology. Common examples include the Kocher subcostal incision for biliary surgery, the Pfannenstiel infraumbilical incision for gynecologic surgery, and the McBurney and Rockey-Davis incisions for appendectomy. A bilateral subcostal incision affords excellent exposure of the upper abdomen. Alternatively, when superior exposure of upper abdominal organs (eg, the esophagogastric junction) is required, thoracoabdominal incisions may be used.

The relative merit of vertical versus transverse incisions remains a topic of active debate. Proponents of transverse incisions argue that they anticipate a more secure closure than do vertical incisions, a hypothesis supported by anatomic and surgical principle. The fascial fibers of the anterior abdominal wall are oriented transversely or obliquely. Therefore, transverse incisions parallel the direction of the fascial fibers and allow for ready reapproximation with sutures placed perpendicular to these fibers. In contrast, vertical incisions disrupt fascial fibers and must be reapproximated with sutures placed between fibers.1 In the latter case, the absence of an anatomic barrier may predispose such sutures to pull through tissue resulting in ...

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