Abdominal Surgical Incisions: Types and Nomenclature
I cannot provide an actual image, but I can describe the major types of abdominal surgical incisions with their anatomical locations and characteristics.
Primary Incision Types
Vertical Incisions
Midline incision: A vertical incision along the linea alba from xiphoid process toward symphysis pubis, providing rapid access and easy extensibility, making it the incision of choice for trauma, uncertain diagnoses, or when unlimited abdominal access is required 1, 2, 3
Paramedian incision: A vertical incision lateral to the midline through the rectus muscle, with the lateral paramedian variant showing 0% incisional hernia rates in all comparative trials versus midline approaches 4
Transverse Incisions
Pfannenstiel incision: A slightly curved transverse skin incision made approximately 2-3 cm above the pubic symphysis, involving transverse incision through skin, subcutaneous tissue, and anterior rectus sheath 5
Transverse upper abdominal incision: A horizontal incision across the upper abdomen, typically used for biliary or gastric procedures 2, 3
Transverse lower abdominal incision: Similar to Pfannenstiel but may be placed higher in the lower abdomen 4, 2
Oblique Incisions
Subcostal (Kocher) incision: An oblique incision parallel to and below the costal margin, typically used for hepatobiliary procedures 4, 3
McBurney/Gridiron incision: An oblique incision in the right lower quadrant for appendectomy 6
Specialized Incisions
Thoracoabdominal incision: A contiguous abdominal and thoracic incision through the eighth intercostal space, used for esophagogastric procedures 1
Loop colostomy/ileostomy sites: Specific locations chosen based on planned definitive treatment, with right-sided transverse colostomy preferred for mobility and future anastomotic protection 1
Clinical Performance Comparison
Incisional Hernia Rates
Transverse, oblique, and paramedian incisions cause significantly fewer incisional hernias than midline incisions 4, 2
The pooled odds ratio for incisional hernia after vertical versus transverse incision is 1.68 (95% CI 1.10-2.57, p=0.02) 2
Lateral paramedian incisions demonstrate 0% incisional hernia rates across all comparative studies 4
Wound Dehiscence and Burst Abdomen
Transverse incisions result in lower rates of wound dehiscence and burst abdomen compared to midline approaches 5, 2
The pooled odds ratio for burst abdomen in vertical incision groups is 2.86 (95% CI 1.72-4.73, p=0.0001) 2
Postoperative Pain and Pulmonary Function
Transverse and oblique incisions produce significantly less postoperative pain and fewer pulmonary complications than midline incisions, particularly in the early postoperative period 5, 2, 3
The Pfannenstiel incision specifically reduces negative impact on pulmonary function compared to midline laparotomy 5
Wound Infection
Selection Algorithm
Emergency Settings
Midline incision remains the choice for trauma or uncertain diagnosis due to rapid entry capability and easy extension 2, 6
When the pathology site is clearly identified in emergency settings, transverse incisions like Pfannenstiel may be preferred 5
Elective Surgery
Paramedian incision should be used for major elective laparotomies given superior hernia outcomes 4
Transverse or oblique incisions should be preferred for small unilateral operations 4, 2
For cesarean deliveries with suspected placenta accreta spectrum, Pfannenstiel incisions are considered reasonable alternatives 5
Specific Anatomical Considerations
Right colectomy benefits from easier hepatic flexure mobilization and optimal blood supply for ileo-colic anastomosis 1
Rectal procedures requiring future stomas should have emergency stoma type and location planned to correspond with definitive stoma placement 1
Critical Technical Considerations
The primary rule is choosing an incision large enough to operate comfortably and effectively 7, 6
Operating time is shorter with vertical incisions, but this does not offset the clinical advantages of transverse approaches 2
Mass closure techniques have greatly decreased disruption rates regardless of incision type 7
Avoidance of subcutaneous sutures decreases wound infection rates 7