What is a Pfannenstiel (lower abdominal) incision?

Pfannenstiel Incision: Definition and Clinical Applications

A Pfannenstiel incision is a transverse infraumbilical incision used for access to the lower abdomen, characterized by a curved skin incision above the pubic symphysis with a separate transverse fascial incision. 1

Anatomical Characteristics

• The Pfannenstiel incision involves a slightly curved transverse skin incision made approximately 2-3 cm above the pubic symphysis 1
• It includes a transverse incision through the skin and subcutaneous tissue, followed by incision of the anterior rectus sheath transversely 1
• Originally described for gynecological procedures, the classical approach involved transverse dissection of the rectus abdominis muscles, though modern techniques often use longitudinal fascial incisions (modified Pfannenstiel approach) 2

Clinical Applications

• Commonly used for cesarean sections and gynecological procedures 3, 4
• Utilized for access to the lower abdomen and pelvis in various surgical specialties 2, 5
• Can be modified for specimen extraction after retroperitoneal laparoscopic procedures 5
• Suitable for surgical management of pelvic ring injuries, particularly symphyseal plating 2

Advantages

• Lower incidence of incisional hernia compared to midline incisions 1
• Reduced negative impact on pulmonary function compared to midline laparotomy 1
• Lower rates of wound dehiscence and burst abdomen 1
• Decreased postoperative pain compared to midline approaches 1
• Superior cosmetic results due to placement in the natural skin lines of the lower abdomen 4

Comparison to Other Incisions

• The Joel-Cohen (modified Misgav-Ladach) incision has been shown to be superior to the Pfannenstiel incision in reducing postoperative pain 1
• Contrary to traditional belief, research suggests that Pfannenstiel incisions may not be significantly stronger than lower abdominal vertical incisions in preventing fascial dehiscence 6
• Transverse incisions generally have better outcomes than midline incisions regarding wound complications and postoperative pain 1

Potential Complications

• Wound infection is the most significant risk factor for fascial dehiscence, regardless of incision type 6
• Rare long-term complications include scar endometriosis after cesarean section 3
• Incisional hernias can occur but are less common than with midline incisions 3, 1

Surgical Considerations

• For cesarean deliveries with suspected placenta accreta spectrum, while many surgeons employ vertical incisions for better access, Pfannenstiel incisions are reasonable alternatives 1
• The choice between continuous and interrupted sutures for fascial closure shows no significant difference in incisional hernia or dehiscence rates 1
• In emergency settings, while midline laparotomy provides faster and better access to all peritoneal organs, a transverse incision like Pfannenstiel may be preferred when the site of pathology is clearly identified 1

Modern Adaptations

• The term "modified Pfannenstiel approach" is increasingly used to describe the contemporary technique that employs a longitudinal fascial incision rather than the traditional transverse fascial incision 2
• Modifications can be made to accommodate specific surgical needs, such as combining with a longitudinal midline incision in the upper rectus sheath for removal of large masses 4