What is the name and description of the midline suprapubic (infra‑umbilical) incision?

Midline Suprapubic (Infraumbilical) Incision

The midline suprapubic incision is a vertical incision made below the umbilicus through the skin, subcutaneous tissue, linea alba, and peritoneum, providing direct access to the lower abdomen and pelvis. 1

Anatomical Description

The infraumbilical midline incision has the following characteristics:

• Vertical orientation extending from below the umbilicus toward the pubic symphysis 1
• Passes through multiple layers sequentially: skin → subcutaneous tissue → linea alba → peritoneum 1
• Located in the avascular midline at the linea alba, which has a paucity of peritoneal fat and adherent peritoneum 2
• The infraumbilical ring serves as a key anatomical landmark where the peritoneum is closely adherent and the rectus muscle can be avoided 2

Technical Considerations for Identification

When performing this incision, surgeons should note:

• The median umbilical ligament attachments provide a reliable method for identifying the true linea alba in infraumbilical incisions 3
• Traditional visual identification can be unreliable in the infraumbilical region, making anatomical landmarks critical 3
• Proper identification prevents inadvertent muscle incision and facilitates wound closure 3

Clinical Context and Alternatives

This incision type carries significant disadvantages compared to transverse approaches:

• Higher incisional hernia rates compared to transverse incisions like the Pfannenstiel, based on high-certainty evidence from multiple randomized trials 1, 4
• Greater negative impact on pulmonary function than transverse approaches 1
• Increased rates of wound dehiscence and burst abdomen compared to non-midline incisions 1
• More postoperative pain than transverse or oblique approaches 1

The World Society of Emergency Surgery recommends against midline incisions when alternatives are feasible, particularly for laparoscopic extraction sites (Grade 1A recommendation) 1

When This Incision Remains Appropriate

Despite its disadvantages, the infraumbilical midline incision is justified in specific scenarios:

• Emergency trauma settings requiring rapid, unlimited abdominal access in hemodynamically unstable patients 1
• Uncertain diagnoses requiring exploratory access to multiple abdominal quadrants 5
• Preperitoneal pelvic packing for hemorrhage control in pelvic fractures, where a separate suprapubic midline incision allows direct retroperitoneal approach to the space of Retzius 1

Preferred Alternative: Pfannenstiel Incision

For planned infraumbilical access to the lower abdomen and pelvis:

• The Pfannenstiel incision is a slightly curved transverse skin incision made approximately 2-3 cm above the pubic symphysis 6
• Significantly lower incisional hernia rates compared to midline approaches 6, 4
• Reduced pulmonary complications, wound dehiscence, and postoperative pain 6, 4
• Considered a reasonable alternative for most lower abdominal procedures when the surgical site is clearly identified preoperatively 6, 5