What is a large incision in the abdominal wall called?

Pfannenstiel Incision

This incision is made transversely in a manner similar to the Maylard incision, although some surgeons may prefer to curve the incision upward toward the anterior superior iliac spine to gain more exposure (the “smile” incision) (Fig. 9.9A and B). The cut traverses the skin, the fat, Scarpa’s fascia, and the rectus sheath (i.e., to the lateral margin of the rectus sheath). Typically, the incision through the fascia is superficial and therefore is unlikely to impinge on the inferior epigastric vessels (Fig. 9.10A). The sheath is clamped and elevated to allow dissection of the sheath cranially and to free it from the underlying rectus abdominis muscles (Fig. 9.10B and C). This plane can be accentuated by the operator’s spread fingers, creating countertraction via pressure on the rectus muscles (Fig. 9.11). The dissection is continued upward for several centimeters (Fig. 9.12) and may be continued to the level of the umbilicus (Fig. 9.13). The rectus muscles are separated vertically in the midline, and the peritoneum is entered. The properitoneum and peritoneum are opened together vertically in the midline (Fig. 9.14). The pyramidalis muscles are similarly cut in the midline down to the level of the symphysis pubis (Fig. 9.15A to C). The peritoneum is carefully dissected inferiorly to the level of the bladder reflection (Fig. 9.16).

Pfannenstiel Incision

This incision is utilized by both adult and pediatric urologists and may be suitable for both extraperitoneal and intraperitoneal pelvic surgeries. It also serves well as a specimen-extraction site postnephrectomy (Matin and Gill, 2003) and may have lower rates of morbidity and incisional hernias than a midline or extension of a port site approach (Binsaleh et al., 2015;Lee et al., 2017).

A transverse semilunar incision is made two fingerbreadths above the pubic bone (Fig. 9.4). The anterior rectus sheath is opened transversely, and the muscle above and below either side of the midline is bluntly separated from the sheath. Using cautery or scissors, the linea alba attachment to the anterior sheath is taken down both inferiorly and superiorly. The midline is then opened to either expand into the extraperitoneal space (Space of Retzius) or enter the peritoneum. The incision can be extended laterally for more exposure and can be extended into a Gibson incision if one needs more access to the lower ureter, for example. For specimen extraction, it can be modified slightly toward the side of surgery (Matin and Gill, 2003). For closure, the peritoneum and muscle are reapproximated, and the fascia is closed with a running or figure-of-eight absorbable suture.

Incorrect Choice of the Pfannenstiel Incision

Abdominal Skin Incision and Abdominal Entry

In general, universally accepted good surgical techniques aimed at avoiding excessive blood loss and tissue trauma should be used. Compared with sharp needles, the use of blunt needles during CD is associated with a decrease in the rate of surgeon glove perforation but also with a decrease in surgeon satisfaction.47

The surgeon has a choice of a transverse or vertical skin incision, with the transverse Pfannenstiel being the most common incision type employed in the United States (Fig. 19.2).Factors that influence the type of incision include the urgency of the delivery, placental disorders such as anterior complete placenta previa and placenta accreta, prior incision type, significant maternal obesity with pannus, and the potential need to explore the upper abdomen for nonobstetric pathology. Although some still prefer a vertical incision in emergency situations, a Pfannenstiel incision actually adds only 1 minute of extra operative time in primary and 2 minutes in repeat cesareans, differences that are not associated with improved neonatal outcome compared with that of a vertical incision.48 Vertical incisions have been performed very rarely in the United States and Europe for routine CDs since the 1980s. A survey of obstetricians in the United Kingdom found that more than 80% use the Pfannenstiel abdominal entry.49 The remaining 20% use the incision and abdominal entry described by Joel-Cohen.50 In brief, this incision is performed 1.5 to 2 cm above the level of the Pfannenstiel incision or 4 to 5 cm above the pubic symphysis. A survey of obstetric residents in the United States found that 77% use a horizontal skin incision for urgent or emergency CD.51 Overall, the Pfannenstiel incision is currently the preferred technique around the world and is used for more than 90% of CDs in the United States. By contrast to the Pfannenstiel incision that was described for bladder surgical procedure, the Joel-Cohen incision was described for gynecologic surgical procedures such as abdominal hysterectomy. It allows access to the pelvis and lower abdomen similar to a vertical incision, is less painful postoperatively, and is associated with risks of long-term complications similar to the Pfannensteil incision. In the early 1990s, the Joel-Cohen incision (Video 19.1) was integrated by Stark and colleagues52,53 into a minimalist cesarean technique called theMisgav Ladach method. Thus far, studies reporting the benefits of the Joel-Cohen incision include multiple aspects of the CD technique, not just the skin incision18; and are therefore not clinically helpful in determining the benefit of the individual CD steps.54Given this, there is no strong evidence to recommend the Joel-Cohen incision over the Pfannenstiel cesarean technique. For most repeat CDs, the prior skin incision is used and transverse skin incisions are preferable to vertical incisions (seeTable 19.1).

Abdominal sacrocolpopexy

Indication: Vaginal vault prolapse.

This procedure may be performed through a lower midline or Pfannenstiel incision after packing the vagina. The apex of the vagina and sacral promontory are identified and a retroperitoneal tunnel is created between the two just to the right of the midline and medial to the right ureter. A strip of Mersilene tape is then passed through the peritoneal tunnel and sutured to the vaginal vault and posterior vaginal wall using interrupted non-absorbable ethylene sutures (Figure 58.13). Once the other end of the tape has been secured to the periosteum overlying the sacral promontory the sutures are tied, allowing gentle elevation of the vaginal vault towards the sacrum but without tension. The peritoneum is then closed over the vaginal vault and sacral promontory. Complications include bleeding from the pre-sacral venous plexus and sacral artery and damage to the right ureter and sigmoid colon.

A 93% success rate has been reported (Addison et al, 1988) although associated cystocele or rectocele may still require a vaginal colporrhaphy. In addition, since the vaginal axis is changed there is also the risk of developing dyspareunia and stress incontinence following the procedure. Mesh erosion into the vagina, and rarely into the bladder or bowel, is a possible late complication.

Technique of Repeat Cesarean Section

The most common incisions used for repeat cesarean section are transverse incisions (Pfannenstiel, Maylard, or Cherney). Vertical incisions are usually used in emergency situations for rapid entry into the abdominal cavity. A Pfannenstiel incision was used in this patient based on the fact that this same incision was used on her previous cesarean section. Once the incision was made, the subcutaneous tissue was opened and bleeding was cauterized with suture ties or electrocautery. The fascial layer was then opened and extended with the scissors or knife. It is then reflected cephalad and posterior. The peritoneum is entered and the gravid uterus is visualized and inspected for any rotation or abnormal anatomy. The visceral peritoneum or bladder flap is taken off the lower uterine segment. The lower uterine segment is incised transversally and extended laterally either bluntly or sharply with scissors. The amniotic sac is ruptured and the fetus is delivered in the vertex presentation. Suctioning of the nasopharynx is performed followed by cord clamping and cutting. The placenta is delivered by gentle traction or manually. The uterus is exteriorized through the anterior abdominal wall, and the uterine cavity is explored for any placental remnants. The lower uterine segment is closed in two layers using absorbable suture. The uterus is repositioned back into the abdominal cavity and the gutters are cleaned and irrigated; and when the sponge and needle count is correct, the abdomen is closed. The fascia is closed with an absorbable suture. The subcutaneous tissue is reapproximated and the skin is closed. (See the DVD for video demonstration of a repeat cesarean section.

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Epidemiology

Overall incidence of ilioinguinal and/or iliohypogastric nerve injury after a Pfannenstiel incision has been estimated at 2% to 4%.99,100,102 The incidence of chronic groin pain after hernia repair attributable to injury of one of these three nerves is thought to be as high as 16%, with 6% to 8% of all patients after herniorrhaphy having moderate-to-severe disabling symptoms.31,133 Reported incidence of pudendal neuralgia in the general population has ranged from 1% to 4%.74 Allen et al.7 recruited a group of 75 women who agreed to PNTML testing and needle electromyography (EMG) of the external anal sphincter at 36 weeks’ gestation and again at 2 months’ postpartum. During pregnancy, pudendal neurophysiology testing was normal, but EMG evidence of pelvic floor reinnervation potentials were seen in 80% of the postpartum women.

Type of Incision

The abdominal incision depends on the surgeon’s preference and training; choices include a standard vertical incision, a Pfannenstiel incision, a Maylard incision, or a Cherney incision. The vertical incision is likely the fastest and the one to offer the greatest access to the upper abdomen. There is no evidence that a lower transverse incision limits exposure, but the choice of each of these is certainly a matter of the surgeon’s preference. The Maylard and Cherney incisions offer the advantage of great exposure to the lateral pelvic sidewall; however, the former may be associated with a greater degree of postoperative pain, because the rectus muscle must be transected. In addition, with the Maylard incision the inferior epigastric vessels may potentially be sacrificed. The Cherney incision offers the advantage that the rectus muscle and its vasculature remain intact, but, given the fact that the muscle must be severed from its aponeurosis to the pubic bone, this incision may be associated with osseous infectious complications.

Minimal Access Donor Nephrectomy

Live donor nephrectomy has traditionally been performed through an open incision, necessitating a prolonged period of recovery. This and the cosmetic implications of a large flank wound may discourage potential donors (Fig. 99.3). To reduce such disincentives, there has been a move toward minimally invasive donor nephrectomy, first performed as a transperitoneal laparoscopic procedure (laparoscopic donor nephrectomy [LapDN]).10 LapDN is associated with decreased severity and duration of postoperative pain, shorter inpatient stay, quicker return to work and normal activities, and improved cosmetic result compared with open donor nephrectomy (Fig. 99.4).11 Furthermore, the overall societal cost of LapDN is lower, and the recipient's quality of life scores are higher.12 The procedure is technically demanding, however, and there is potential for damage to the renal parenchyma, vessels, and ureter during dissection. It takes longer than open nephrectomy and exposes the allograft to a longer period of warm ischemia.11

Nevertheless, retrospective data suggest that minimal access donor nephrectomy not only offers postoperative advantages to the donor but also increases the number of transplants performed by reducing donor disincentives; estimates range from a 25% to a 100%13 increase in transplantation activity. The widespread introduction of LapDN at the beginning of this decade saw an initial dramatic increase in the number of live kidney donors. However, rates have been static in both the United States and the United Kingdom during the last 5 years, suggesting that we may have seen the maximum benefits of this effect. Three minimal access approaches have been described: transperitoneal, extraperitoneal, and hand-assisted live donor nephrectomy.