Rationale. Many oncologists use this approach for pelvic lymphadenectomy and staging procedures because the exposure to the lateral pelvis is excellent. The reason: This transverse incision cuts through all layers of the abdominal wall at the level of the anterior iliac spine. It also may be appropriate when pelvic pathology extends to the sidewall, e.g., endometriosis.
It is advisable to place a drain prior to closing Maylard’s.
Physicians should consider using this approach more than they currently are, especially when Pfannenstiel’s incision cannot provide satisfactory exposure or a longitudinal incision is thought to be the only alternative. The decision to use Maylard’s incision should be planned during the preoperative assessment, as Pfannenstiel’s incision should not be modified to Maylard’s intraoperatively.
Disadvantages. Although Maylard’s incision improves access to the upper abdomen compared to other transverse incisions, exposure is still limited. In addition, trauma to the deep epigastric arteries may result in considerable hemorrhage. And since hematomas commonly infiltrate the retroperitoneal space, large quantities of blood already may be lost before the hemorrhage is clinically apparent. Finally, oozing from the cut edge of the muscles may result in significant fluid collection, increasing the risk of infection. Therefore, it is advisable to place a drain prior to closure.
Like other transverse incisions, the wound parallels the nerves, providing a measure of protection. However, the rectus incision approaches the anterior iliac spine, where both the ilioinguinal and iliohypogastric nerves lie. Both may be damaged during the incision and can become entrapped during closure. Additionally, the femoral nerve, the lateral femoral cutaneous nerve, and the genitofemoral nerve are easily compressed by the lateral blades of the retractors because of the extreme lateral positions of the incision’s poles. Injury to these nerves can result in paresthesia, pain, and paralysis of the leg muscles.
FIGURE 9 Maylard’s incision
After incising the aponeuroses of the abdominal muscles medial to the anterior iliac crest, dissect the rectus abdominus muscle transversely.
FIGURE 10 Maylard’s incision
Isolate, ligate, and divide the epigastric vessels. Then incise the transversalis fascia and peritoneum transversely to access the peritoneal cavity.
In summary
While the midline and Pfannenstiel’s incisions are an integral part of the gynecologic surgeon’s armamentarium, the paramedian and Maylard’s incisions should be added to the repertoire because these incisions can greatly enhance exposure. The paramedian shares the advantages of the midline incision but also allows better access to the ipsilateral pelvis. Furthermore, although Maylard’s incision takes longer to perform than other techniques, the excellent exposure—both laterally and superiorly—makes it worthwhile.
The authors report no financial relationship with any companies whose products are mentioned in this article.