Pfannenstiel’sTechnique. Incise the skin and subcutaneous tissues 2 to 5 cm above the pubic symphysis.10 Then dissect the rectus sheath transversely, separating it sharply from the rectus muscle at the linea alba and retracting it superiorly toward the umbilicus and inferiorly toward the pubic symphysis (Figure 5). Divide the rectus abdominis muscle along the midline raphe and retract it laterally, exposing the transversalis fascia and the posterior rectus sheath. Incise these layers and the peritoneum vertically to expose the peritoneal cavity (Figure 6).
To minimize retraction of the rectus abdominus muscle during Maylard’s, do not separate it from the anterior rectus sheath.
Rationale. Since exposure is limited and the incision can be only minimally extended, this incision is appropriate for procedures that are limited to the pelvis, e.g., abdominal hysterectomy, cesarean delivery, retropubic urethropexy, and paravaginal defect repairs. (Extension of the incision can be achieved by modifying it to Cherney’s incision.)
Disadvantages. The fact that the incision severs multiple tissue planes is an advantage as well as a disadvantage. Postoperative dehiscence and incisional hernias are rare because the closed wound has a high tensile strength. However, the incidence of inguinal hernias may increase when the incision is placed close to the external inguinal ring,11 and very low incisions may increase the risk of femoral nerve injury.12 The ilioinguinal and iliohypogastric nerves may be damaged, especially if the rectus incision is extended far laterally. Most commonly, they are trapped in the suture during closure, producing postoperative pain. Incising multiple layers also slows entry and increases the risk of seromas, hematomas, and wound infections.
This approach is contraindicated when time is of the essence, e.g., hemorrhage, or in the face of an abdominal infection, e.g., sepsis.
FIGURE 5 Pfannenstiel’s incision
After incising the skin and subcutaneous tissues, dissect the rectus sheath transversely, separating it sharply from the rectus muscle.
FIGURE 6 Pfannenstiel’s incision
Divide and retract the rectus abdominus muscle and then incise the tranversalis fascia and posterior rectus sheath vertically.
Cherney’sTechnique. Dissect the skin and subcutaneous tissue 2 to 3 cm above the pubic symphysis, which is lower than most Pfannenstiel’s incisions. Then incise the anterior rectus sheath transversely and dissect it from the rectus abdominis muscle superiorly and inferiorly. Using blunt dissection, separate the rectus and pyramidalis muscles from the underlying bladder and adventitial tissue. Then incise transversely the tendons of the rectus and pyramidalis muscles 0.5 cm above the pubic symphysis (Figure 7). (This segment of tendon facilitates the reattachment of the muscles at closure.) Retract the muscles and tendons cephalad to expose the retropubic space. Incise the peritoneum transversely to expose the peritoneal cavity (Figure 8).
Rationale. Cherney’s incision provides excellent access to the retropubic space of Retzius, making it a good choice for retropubic urethropexy and paravaginal repair. Exposure is the main advantage to Cherney’s incision. The reason: It is a modification of Pfannenstiel’s incision and, as such, provides excellent lateral exposure because it is placed much lower on the abdominal wall.
Disadvantages. The benefits and risks of this incision are similar to those of Pfannenstiel’s incision since the same tissue planes are opened. However, it is more time consuming due to the dissection required to separate the muscles and tendons from the underlying tissues.
In addition, the deep inferior epigastric arteries could be injured as a result of the lateral dissection. Lastly, reattachment of the tendons is tedious.
FIGURE 7 Cherney’s incision
Incise transversely the tendons of the rectus and pyramidalis muscles 0.5 cm above the pubic symphysis.
FIGURE 8 Cherney’s incision
Retract the muscles and tendons cephalad and incise the peritoneum transversely to expose the peritoneal cavity.
Maylard’sTechnique. After transecting the skin and subcutaneous layers in a plane at the level of the anterior superior iliac spine, incise the rectus sheath transversely and extend the incision through the aponeuroses of the abdominal muscles to about 2 to 3 cm medial to the anterior iliac crest. Then dissect the rectus abdominis muscle transversely with a scalpel, electrocautery, or surgical stapler (Figure 9). To minimize retraction of this muscle, do not separate it from the anterior rectus sheath. (Alternatively, many surgeons recommend that the cut edge of the muscle be secured to the anterior sheath with mattress sutures to prevent retraction and reduce blood loss.)
Prior to transecting the peritoneum, isolate, ligate, and divide the deep inferior epigastric vessels. (Patients with significant aortoiliac atherosclerosis or aortic coarctation develop considerable collateral circulation through the epigastric vessels for perfusion of the lower extremities. Ligating these vessels may cause claudication and even lifethreatening ischemia. Therefore, assess iliac flow before ligating and transecting the arteries.) Then transect the transversalis fascia and peritoneum transversely, allowing access to the peritoneal cavity (Figure 10).