Kocher Incision: Purpose and Technique
The Kocher incision is a right subcostal (right upper quadrant) transverse or slightly oblique incision used primarily for biliary tract surgery, providing direct access to the gallbladder, common bile duct, and duodenum while offering lower rates of wound complications compared to midline approaches. 1, 2
Primary Indications
- Biliary tract procedures: The Kocher incision is the traditional approach for open cholecystectomy and bile duct exploration, allowing direct visualization and repair of bile duct injuries under direct vision with T-tube drainage placement 1, 2
- Duodenal access: Provides excellent exposure for duodenal procedures and pancreatic head pathology 1
- Pregnancy considerations: In pregnant patients (second and third trimester) requiring cholecystectomy, the Kocher incision is preferred over laparoscopic approaches due to uterine size limitations and safety concerns 3
Surgical Technique
Incision Placement and Execution
- Location: The incision is made in the right upper quadrant, running parallel to and approximately 2-3 cm below the right costal margin 2, 3
- Direction: Extends from the midline laterally toward the anterior axillary line, following the natural skin creases 2
- Layers: Sequential division through skin, subcutaneous tissue, anterior rectus sheath (transversely), rectus muscle (retracted or divided), and peritoneum 2
Closure Considerations
- Peritoneal closure is NOT recommended: Strong evidence demonstrates that omitting peritoneal closure during Kocher incision closure shows no adverse effects on wound complications, infection rates, dehiscence, or incisional hernia formation 2
- Fascial closure technique: Use continuous suturing with a suture-to-wound length ratio of at least 4:1, employing slowly absorbable sutures 1
- Common extensor fascia: When used for orthopedic elbow approaches, the common extensor fascia must be firmly sutured as it provides significant lateral elbow stabilization 4
Clinical Advantages Over Midline Incisions
- Lower hernia rates: Transverse incisions like the Kocher demonstrate significantly lower incisional hernia incidence compared to midline laparotomy 5, 6
- Reduced pulmonary impact: Less negative effect on postoperative pulmonary function compared to vertical midline approaches 5, 6
- Decreased wound dehiscence: Lower rates of burst abdomen and wound breakdown 5
- Less postoperative pain: Transverse incisions produce significantly less pain, particularly in the early postoperative period 6
Critical Surgical Principles for Bile Duct Injury Repair
When the Kocher incision is used for bile duct injury management:
- Simple injuries: For Type I bile duct injuries (pancreatic segmental bile duct), perform repair under direct vision through Kocher incision with T-tube drainage of the common bile duct 1
- Severe injuries: When encountering transection of the common bile duct, proceed with choledochojejunostomy 1
- Timing considerations: Intraoperative or early postoperative injuries without inflammation should undergo primary repair; infected cases require staged operations with initial drainage followed by definitive reconstruction 4-6 weeks later 1
Important Caveats
- Vascular considerations: The subcostal scar from a Kocher incision may jeopardize blood supply to abdominal wall flaps in subsequent procedures (such as abdominoplasty), requiring delayed flap techniques 7
- Emergency settings: When urgent unlimited abdominal access is required or diagnosis is uncertain, midline laparotomy remains superior to the Kocher incision due to faster access and extensibility 6
- Extraction site: Avoid using the midline as an extraction site when laparoscopic procedures are performed; the Kocher approach provides a better alternative for specimen extraction 1