Three Options for Abdominal Entry
- Pfannensteil or suprapubic transverse incision (the most commonly performed),
- The lower abdominal or subumbilical midline incision (performed when maximal exposure is required)
- Supraumbilical transverse incision (an option in the morbidly obese patient).
It is best to decide on your abdominal approach before the patient is prepped and draped. Observe the abdomen when the patient is supine. Take note of the fat distribution (pear or apple?) and observe where the umbilicus is located vis a vis the symphysis pubis. In a very obese patient, the pannus may extend well caudad to the pubis. Therefore, an incision made below the umbilicus may miss the peritoneal cavity entirely. Generally, we choose between three skin incisions (Pfannenstiel, Midline and supraumbilical). Each has its advantages and drawbacks.
Abdominal Incision: Horizontal Suprapubic
- Pfannenstiel (transverse suprapubic)
- 2cm above the pubic bone
- Better healing
- Stronger, less dehiscence
- Most commonly performed, familiar
- Potential for more blood loss with division of lateral blood vessels
The most commonly performed is the Pfannenstiel or horizontal suprapubic incision. This is a transverse incision made parallel to and approximately 2 fingerwidths cephalad to the pubic bone. It has the advantage of better healing with less tendency to wound dehiscence and hernia formation than vertical incisions. It may be associated with greater blood loss than the midline incision and cannot be easily extended if abdominal access proves to be inadequate.
Abdominal Incision: Vertical Midline
- Vertical Incision
- Lower abdominal midline
- Generally faster
- Better exposure
- Easy to extend if needed
- Less blood loss
- Poorer healing
The lower abdominal midline incision is less popular but should be employed if optimal exposure is desired. It is generally thought to be faster and easier to perform in the case of an emergency cesarean section. It can be easily extended to afford exposure of the entire peritoneal cavity. It will generally produce less blood loss than the Pfannenstiel because no large perforating vessels need be divided. The midline is relatively avascular. The disadvantages of the midline begin as the surgery ends with longer time for wound closure, higher rates of wound breakdown and hernia formation.
Abdominal Incision: Transverse Supraumbilical
- Transverse supraumbilical
- Avoids pannus in morbidly obese patient
- Thinner tissues, quick entry
- Uncommonly performed
- Better healing and exposure than midline incision in obese patient
The Transverse supraumbilical incision is reserved for the morbidly obese patient whose umbilicus has migrated south and the abdomen cannot be safely entered by means of a sub-umbilical incision. The abdominal wall is relatively thin in this area, allowing for easier entry and safer closure.
Joel-Cohen Incision
- Variation of the classic Pfannensteil incision
- Skin and midline subcutaneous tissue are incised with a scalpel
- Fat is swept laterally with fingers
- Fascia is incised in the midline then the incision is stretched horizontally
- Two bellies of the rectus muscle are separated bluntly
- Peritoneum is entered bluntly and stretch horizontally
The Joel Cohen technique involves blunt stretching of the tissue. It is associated with less blood loss and quicker abdominal entry than the conventional Pfannensteil incision. As a result, it has become very popular. It is particularly useful in nulliparous patients who have minimal scar tissue.