Modified Stewart Incision for Upper Abdominal Surgery
What is the Modified Stewart Incision?
The Modified Stewart incision is a supracostal transverse or oblique incision that provides excellent exposure to upper abdominal organs while potentially reducing postoperative complications compared to traditional midline approaches 1, 2.
Primary Recommendation
For patients with previous abdominal surgeries and comorbidities requiring upper abdominal surgery, a transverse or oblique incision (Modified Stewart approach) should be strongly considered over midline incision, as it significantly reduces incisional hernia rates (2% vs 14%, P=0.017) and postoperative pain without increasing operative complications 3.
Key Advantages Over Midline Incision
Reduced Hernia Risk
- Incisional hernia occurs in only 2% of transverse incisions versus 14% with midline incisions in upper abdominal surgery 3
- This advantage is particularly critical in patients with diabetes, as these patients have impaired wound healing and higher baseline hernia risk 3
Improved Pain Control
- Significantly less pain on postoperative days 1,2, and 3 compared to midline incisions 3
- Reduced impact on pulmonary function in the early postoperative period 4
- This is especially important in patients with heart disease or hypertension who may have compromised cardiopulmonary reserve 4
Cosmetic and Functional Benefits
- Transverse incisions are significantly shorter than midline incisions for equivalent exposure 3
- More pleasing cosmetic appearance 3
- Lower rates of partial wound dehiscence (only 3/915 cases in one large series) 1
Specific Technical Considerations
Exposure Capabilities
The supracostal transverse incision (inverted U configuration) provides excellent access to 1, 2:
- Gastroesophageal junction and stomach
- Liver and hepatic structures
- Pancreas (particularly distal pancreas via left approach)
- Spleen
- Upper retroperitoneal structures
Patient-Specific Factors
For patients with diabetes:
- The 7-fold reduction in hernia risk with transverse incision is particularly valuable given impaired wound healing 3
- Consider prophylactic subfascial mesh reinforcement if midline incision is unavoidable, though this increases seroma risk 5
For patients with hypertension or heart disease:
- Reduced pulmonary compromise with transverse incision benefits patients with limited cardiopulmonary reserve 4
- ASA class 3-4 patients have 20-39% delirium risk; minimizing pain and pulmonary complications is critical 6
For patients with previous abdominal surgeries:
- Surgery must occur within 12-24 hours if acute abdomen is suspected to optimize outcomes 6, 7
- Laparoscopic exploration should be attempted first if hemodynamically stable 6, 7
- Lower threshold for surgical exploration when radiological findings are inconclusive 6, 7
Critical Pitfalls to Avoid
Do Not Default to Midline "Out of Habit"
- The evidence clearly favors transverse incisions for upper abdominal surgery when technically feasible 3
- Midline incision should be reserved for situations requiring rapid access or when transverse approach is anatomically impossible 4
Avoid These Technical Errors with Transverse Incisions
- Splenic injury during diaphragm division (most common complication) 2
- Phrenic nerve injury causing diaphragmatic dysfunction 2
- Inadequate fixation of costal cartilage leading to clicking sensation and nonunion 2
Do Not Delay Surgery in High-Risk Patients
- Tachycardia ≥110 bpm, fever ≥38°C, and respiratory distress are alarming signs requiring immediate intervention 6
- In patients with previous abdominal surgery presenting with acute symptoms, delaying surgical exploration increases mortality 8
- Surgery is mandatory within 12-24 hours of presentation with surgical abdomen 6, 7
When Midline Incision May Be Necessary
Consider midline approach only when 4, 2:
- Emergency surgery requiring fastest possible access
- Need for extensive exploration of multiple abdominal quadrants
- Severe hemodynamic instability requiring damage control surgery 6
- Anatomic constraints (severe kyphoscoliosis, previous thoracotomy with dense adhesions)
If midline incision is unavoidable in high-risk patients (diabetes, obesity, previous surgeries), strongly consider prophylactic subfascial polypropylene mesh reinforcement to reduce hernia risk from 15% to 5% 5.
Postoperative Monitoring Priorities
Early Warning Signs (First 24-72 Hours)
- Tachycardia ≥110 bpm is often the earliest sign of complications 6, 8
- Fever with leukocytosis suggests anastomotic leak or infection 8
- Persistent vomiting/nausea may indicate internal complications 6