Overview
The success of a gynaecologic procedure performed through an abdominal incision depends on careful selection of the incision site and proper closure of the wound. The surgeon needs to consider multiple factors before making an abdominal incision.
These factors include the disease process, body habitus, operative exposure, simplicity, previous scars, cosmesis, and the need for quick entry into the abdominal cavity. The most important factor is adequate exposure to the operative field.
Complications during surgery can occur because of inadequate exposure, which is often due to the unwillingness of the surgeon to extend the incision. Incision location is particularly important when the patient has a gynecologic malignancy.
These patients may need a colostomy, urinary diversion, or extraperitoneal lymph node dissection to satisfactorily manage the clinical situation. This article reviews pertinent abdominal wall anatomy, discusses various options for abdominal incisions, and examines various sutures available to surgeons.
Types of Abdominal Incisions
Vertical incision
Several types of vertical abdominal incisions have been used in gynecologic surgery, including midline, paramedian, and wide paramedian incisions. A midline incision is almost exclusively the type of vertical incision used in gynecologic oncology surgery.
The midline incision is the easiest and most versatile vertical incision for performing gynecologic cancer surgery. This incision allows quick entry into the abdominal cavity with little blood loss, and it is easily extended in length to accommodate the operative findings.
The presumed disadvantages of a midline incision, compared with a transverse incision, include an increased risk of wound dehiscence and hernia formation.
Most studies that support this idea are retrospective or lack proper statistical design. Recent studies have challenged this dictum and advocate that little difference exists in dehiscence rates between properly closed midline incisions and transverse incisions.
For a midline abdominal incision, the skin and subcutaneous fat are incised to the level of the fascia. The scalpel or electrocautery can be used to incise this tissue. Some surgeons believe the infection rate is higher with the use of electrocautery.
Using either instrument, the principle is to make long smooth strokes through the subcutaneous fat to the fascia. The subcutaneous fat should not be dissected from the fascia because this creates unnecessary dead space.
Next, the fascia is incised, and the rectus muscles are separated vertically in the midline. The midline may not be evident in patients with previous abdominal surgery. Identifying where the rectus muscles diverge around the umbilicus or locating the pyramidalis muscles assists in identifying the midline.
Once the rectus muscles are divided, the peritoneum is grasped between 2 hemostats, opened with a scalpel, and extended the length of the incision.
If the operative findings necessitate extending the incision above the umbilicus, avoid cutting through the umbilicus. Postoperative wound infections may be increased due to bacterial colonization of the umbilicus. Extension of the incision should pass to the left of the umbilicus to avoid cutting through the ligamentum teres.
Closure of the midline incision has evolved over the last two decades. Layered closure using interrupted sutures was previously the choice of many surgeons. Today, most surgeons prefer to close the abdominal wall with a continuous running suture using delayed absorbable sutures.
The use of a continuous suture to close the fascia is faster, with dehiscence rates comparable to those of interrupted closures. Two basic techniques are used to close the abdomen with continuous suture, the single-layer mass closure and the internal mass closure.
The single-layer mass closure involves using a heavy monofilament delayed-absorbable or permanent suture. Fascial closure involves penetrating the fascia 1.5 cm from the edge with the suture. The suture should also include the underlying muscle and peritoneum.
Some surgeons close the wound using the internal mass closure technique advocated by Smead-Jones. This is a far-far, near-near suturing technique. The anterior fascia is included in the near-near bite. The initial stitch is similar to the single-layer mass closure.
The second bite only includes the anterior rectus fascia, approximately 0.5 cm from the fascial edge. Either technique requires starting from each end of the incision. Securing the suture with 5 knots at each end is sufficient. In patients who are slender, burying the knot is helpful.
A retrospective study by Spencer et al indicated that in patients with ovarian cancer who undergo primary laparotomy with midline incision, risk factors for incisional hernia development by 1 year postoperatively include poor nutritional status (with an albumin level below 3 g/dL) and less-than-ideal cytoreductive surgery results (with 1 cm or more of residual tumor remaining).
Patient age of 65 years or above was associated with incisional hernia development by 2 years postoperatively.
Transverse incision
Several useful transverse abdominal incisions are available to the surgeon performing gynecologic cancer surgery. Historically, the obstetrician-gynecologist has preferred this type of incision.
Reported advantages include better cosmetic results, less pain, and low incidence of hernia formation. Gynecologic oncologists have embraced certain types of transverse incisions for specific gynecologic cancer operations. Several disadvantages of these incisions exist.
Transverse incisions limit exploration of the upper abdomen, they are associated with greater blood loss, and they are more prone to hematoma formation when compared with a midline incision. Nerve injury, which can result in paresthesia of the overlying skin, is more frequent in a transverse incision compared with a midline incision.
Pfannenstiel incision
The Pfannenstiel incision results in good exposure to the central pelvis but limits exposure to the lateral pelvis and upper abdomen. These factors limit the usefulness of this incision for gynecologic cancer surgery. If the patient is thin and has a gynecoid or platypelloid pelvis, this incision can be used for a radical hysterectomy and pelvic lymph node dissection.
The incision is usually made 1-2 fingerbreadths above the pubic crest. Use of a marking pen is helpful to keep the incision symmetric. An incision length of 10-14 cm is sufficient.
Increasing the length of the skin incision usually does not improve exposure due to the rectus muscles. The incision is made through the subcutaneous fat to the fascia. The superficial epigastric vessels are often near the lateral edges of the incision.
The anterior fascia is incised in the midline with a scalpel or electrocautery. Using curved scissors or electrocautery, the fascia is incised in a curvilinear fashion 1-2 cm lateral to the rectus muscle. The upper edge of the fascia is grasped with 2 Kocher clamps on either side of the midline.
Using electrocautery, the rectus muscle is dissected free from the fascia. Electrocautery allows coagulation of multiple small vessels that perforate the rectus muscle to the fascia.
The rectus muscles are mobilized off the fascia to the level of the umbilicus. Next, the lower fascial edge is grasped with Kocher clamps. Electrocautery is used again to dissect the rectus muscles and the pyramidalis muscle from the fascia. The rectus muscles are separated. The peritoneum is opened and incised vertically to complete a Pfannenstiel incision.
Closure of the Pfannenstiel incision is straightforward. The peritoneum does not need to be closed separately as re-epithelization occurs within 48 hours. Closure of the peritoneum does not add to the strength of the incision.
A Cochrane review of peritoneal closure in nonobstetrical operations reaffirms of peritoneal closure with transverse incisions offers no short-term or long-term advantages.
The rectus muscles should be thoroughly irrigated with water or saline, and any bleeding areas should be cauterized or ligated. Bleeding from small perforating vessels through the rectus muscle is the most common source of subfascial hematoma.
The fascia is approximated with a delayed absorbable suture. Usually, a separate suture is started at each end of the fascial incision, and all layers of the anterior rectus sheath are incorporated.
Unless a large area of dead space exists between the fascia and the skin, closure of the Scarpa fascia is not needed. Placement of a closed drainage system, like a Jackson-Pratt drain, may be needed if a large amount of fluid collection is anticipated.
Various studies have assessed the optimal closure technique of the skin after a Pfannenstiel incision with conflicting results. Most studies have not been in the specialty of obstetrics and gynecology.
The advantage of staples compared with suture incision closure has yielded no conclusive advantages for either technique. Staple closure is faster, but rates of wound infection/disruption, cosmesis, pain, and cost-effectiveness appear to be no different between staples and suture.
A 2013 Cochrane Review found no conclusive difference between outcomes of incisional closure with staples and sutures after cesarean delivery. The authors found that if staples are removed after 72 hours, incidence of skin separation increased. Figueroa and colleagues reported their experience with incision closure after cesarean delivery in 400 patients.
The primary outcome was the incidence of wound disruption and wound infection 4-6 weeks after surgery. The authors reported a 14.5% rate of wound disruption/infection with staples compared with 5.9% in the suture group. Suture closure added 10 minutes to the surgery compared to staples. Interesting, staples were removed on postoperatively day 3 or 4. The evidence suggests wound closure with either staples or suture is acceptable, with similar outcomes.
Maylard incision
In an effort to improve surgical exposure to the lateral pelvic sidewall with a transverse incision, Maylard proposed a transverse muscle-splitting incision. This incision usually refers to a subumbilical transverse incision. For gynecologic surgery, the incision is made 3-8 cm superior to the pubis symphysis. The anterior rectus sheath is cut transversely.
The inferior epigastric vessels are identified under the lateral edge of each rectus muscle and then are ligated. Patients with significant peripheral arterial disease may experience ischemia from ligation of the inferior epigastric vessels.
These patients may have collateral flow from the epigastric vessels to the lower extremities. After ligation of the inferior epigastric vessels, electrocautery is used to transversely cut the rectus muscle. The peritoneum is opened and cut laterally.
To facilitate closure of a Maylard incision, flex the operating table. Close the peritoneum with an absorbable suture. Next, inspect the ties placed on each inferior epigastric vessel, and irrigate with water.
Examine the cut edges of the rectus muscles for any bleeding areas. The fascia and underlying rectus muscle can be closed with a monofilament absorbable suture.
Cherney incision
Cherney described a transverse incision that allows excellent surgical exposure to the space of Retzius and the pelvic sidewall. The skin and fascia are cut in a manner similar to a Maylard incision. The rectus muscles are separated to the pubis symphysis and separated from the pyramidalis muscles. A plane is developed between the fibrous tendons of the rectus muscle and the underlying transversalis fascia. Using electrocautery, the rectus tendons are cut from the pubic bone. The rectus muscles are retracted and the peritoneum opened.
Closing a Cherney incision begins with closure of the peritoneum. Attach the cut ends of the rectus muscle to the distal end of the anterior rectus sheath with interrupted nonabsorbable sutures. Fixing the rectus muscle to the pubis symphysis can result in osteomyelitis. Next, the fascia is closed with 2, running, continuous, delayed-absorbable sutures.
Several types of incisions facilitate extraperitoneal para-aortic lymph node dissection. An upper abdominal transverse incision, which is a high Maylard incision, is made approximately 2 cm above the umbilicus. The incision is extended laterally and caudad to the anterior superior iliac spines. The fascia and rectus muscles are incised transversely, usually requiring ligation of the inferior and superior epigastric vessels.
Next, the transversus abdominis muscle is cut, exposing the peritoneum. Using blunt dissection, the peritoneal sac is dissected caudad to cephalad to expose the psoas muscle, the aorta, and the common iliac vessels. Often, a drain needs to be placed in the area of the lymph node dissection.
Modified Gibson incision
Some gynecologic oncologists perform an extraperitoneal lymph node dissection using a modification of the Gibson incision. This incision can be made on each side of the midline, but often, the skin is cut only on the left.
The incision is started 3 cm superior and parallel to the inguinal ligament. Extension is made vertically 3 cm medial to the anterior superior iliac spine to the level of the umbilicus. The fascia is cut and the peritoneum bluntly dissected, as described above.
The round ligament and the inferior epigastric vessels are ligated to facilitate surgical exposure. Care is needed when exposing the lymph nodes using only a left-sided incision. Too much traction on the peritoneum can result in avulsion of the inferior mesenteric vessels.
Incisions in Patients Who are Obese
Surgery in patients who are obese and morbidly obese represents a challenge for every surgeon. Wound complication rates are uniformly higher in patients who are obese, regardless of the type of incision. Obtaining adequate surgical exposure requires patience, understanding of changes in anatomical landmarks, and proper surgical equipment.
The abdominal wall landmarks are distorted in patients who are obese, particularly in the presence of a large panniculus. The umbilicus is located caudad to its normal position. If a vertical incision is needed, first pull the panniculus downward.
A periumbilical incision is made and the fascia incised to the symphysis. Care is needed not to buttonhole the skin under the panniculus. Use of a ring retractor, such as the Bookwalter, optimizes surgical exposure.
The site of a transverse incision in patients who are obese should never be made under the fold of the panniculus. Wound complications are invariably higher compared with an incision made away from the panniculus. Ideally, a paraumbilical midline incision should be made.
In some patients, this will not allow for adequate exposure to the pelvic organs. The surgeon may find the distance to the pelvic structures exceeds the length of the surgical instruments and the retractors. In this scenario, a panniculectomy should be performed.
A panniculectomy allows the fascial incision to be within several centimeters of the pubis symphysis, allowing easier access to the pelvic organs. Large suction drains should be placed above the fascial closure with a panniculectomy, and kept in place until the drainage is less than 25 mL in 24 hours.