Abdominal Incisions - Indications and Complications

Indications

 * 1) Midline
 * 2)   Repeat midline if previous midline
 * 3)   Pelvic mass at umbilicus or above
 * 4)   Pelvic mass with 5% or greater chance of malignancy
 * 5)   Emergent laparotomy due to severe hemorrhage
 * 6)   Transverse incision would fall under a pannus
 * 7) Maylard
 * 8)   For benign uterine masses with lateral extension (e.g. fibroids)
 * 9)   For ovarian enlargement >8cm  and likely (>95%) to be benign
 * 10)   Repeat if previous Maylard incision and none of criteria for midline incision met
 * 11) Pfannenstiel
 * 12)   Repeat if previous and none of criteria for midline or Maylard incision met
 * 13)   Used for most reproductive excisional sugery when vaginal procedure is not indicated

Complications

 * 1) Wound dehiscence
 * 2)   Place fascial sutures approximately 1.0 cm from edge of facscia and approximately 1.0 cm apart
 * 3)   Avoid excessive tightness of fascial sutures
 * 4)   On midline incisions close peritoneum with fascia through the rectus sheath using continuous monofilament delayed absorbable or permanent suture
 * 5)    On Pfannenstiel or Maylard incisions, close or approximate abdominal peritoneum as a separate layer.
 * 6)    Memorize the risk factors for wound dehiscence to identify high risk patients: diabetes, smoking, obesity, chronic lung disease., previous irradiation, poor nutritional status
 * 7)     Postoperatively, avoid excessive Valsalva
 * 8) Wound seroma/hematoma
 * 9)   If midline incision is extended above the umbilicus, extend around the left of the umbilicus to avoid the ligamentum terres
 * 10)   Cauterize or ligate superficial epigastric vessels on transverse incision even if not bleeding at time of transection
 * 11)   Cauterize or ligate rectus perforating vessels on Pfannenstiel incision even if not bleeding at time of  transection
 * 12)   Ligate inferior epigastic vessels on Maylard incision
 * 13)   Observe subfascial space at the end of procedure for bleeding.
 * 14)   Use compression dressing for 48 hours before removing
 * 15) Wound Infection
 * 16)   Advise to discontinue smoking at least 30 days prior to procedure
 * 17)   For hair removal if needed, use clipping just prior to surgery rather than shaving
 * 18)   Avoid excessive use of cautery (do not cut incision with cautery)
 * 19)   Close subcutaneous tissue with running continuous absorbable suture if 2.0 cm of subcutaneous fat or more
 * 20) Poor cosmetic result
 * 21)   Symmetry
 * 22)       Identify midline and anterior iliac spine and mark on skin the line of the incision if needed
 * 23)   Approximation
 * 24)       Incise along lines of Langer’s
 * 25)       When removing old scar, excise subcutaneous tissue symmetrically
 * 26)       On transverse incisions, reapproximate Scarpa’s fascia superiorly to Scarpa’s fascia inferiorly
 * 27)   Keloid formation
 * 28)       Avoid suture in dermis (it should be below dermis)
 * 29)       Close skin with steristrips or bonding
 * 30)   Peripheral scarring
 * 31) Avoid skin staples or if used, remove by 3rd day
 * 32) Nerve entrapment/persistent incisional pain
 * 33) Illiohypogastric and illioinguinal nerves (transverse incisions)
 * 34)       Follow lines of Langer curving transverse incisions upward laterally so as not to transect nerves
 * 35)       Start incision at least 3-5 cm above symphysis pubis in midline so as not to transect nerves
 * 36)      Avoid extreme lateral extension of incision into internal oblique muscle
 * 37)        When closing anterior rectus fascia avoid subcutaneous tissue to prevent nerve entrapment
 * 38)   Genitofemoral nerves
 * 39)       Avoid lateral retraction compressing psoas muscle (especially self-retaining Balfour, OConner-O’Sullivan)
 * 40) Postoperative hernia
 * 41)   See wound dehiscence principles