a. This incision allows for greater exposure than the Pfannenstiel as the rectus abdominis muscle is transected and retracted superiorly and inferiorly.
b. Through this incision, pelvic and paraaortic node dissections can be done, as well as the removal of large pelvic tumors.
c. When compared with the midline incision, the Maylard has less postoperative pain, stronger healing, and fewer adhesions, although accessibility to the upper abdomen through this incision is limited.
d. To perform the Maylard incision, the following is done:
(1) An incision is made 2 to 3 cm above the pubic symphysis and carried down to the rectus fascia, as is done in the Pfannenstiel incision.
(2) Once the rectus fascia has been identified, it is nicked using the scalpel and extended bilaterally using sharp dissection.
(3) At this point, the incision differs from the Pfannenstiel in that the rectus fascia is not dissected off the rectus abdominis muscles. Instead, the inferior epigastric arteries are isolated in the connective tissue lying at the lateral border of the rectus muscles.
Figure 1. The Maylard incision. A, A transverse skin incision is made 5 cm above the superior border of the pubis. B, The anterior rectus sheath is incised in the same line, exposing the bellies of the rectus abdominis muscles. The muscle is bluntly dissected from the underlying transversalis fascia and incised transversely on each side, along the path of the broken side, using the electrosurgical scalpel (C).
Figure 2, cont’d D, The transversalis fascia and peritoneum are opened, and the superior cut edge of the rectus abdominis is secured to the anterior sheath with mattress sutures. E, The peritoneal incision is extended laterally, and the inferior epigastric vessels must usually be ligated and cut.
(a) These can be identified by palpation and dissected out using blunt dissection with a clamp.
(b) Once identified, they should be ligated by passing a free 2-0 Vicryl tie around the vessel on a right-angle clamp.
(c) They should be doubly ligated and incised in between the ligatures.
(4) After the epigastrics are ligated, attention can be turned to the rectus abdominis muscles. These can be transected, about 3 to 5 cm above their origin on the pubic symphysis, using electrocautery, and proceeding across the muscle in a zigzagging motion to achieve adequate hemostasis.
(5) Often, a Penrose drain can be passed beneath each rectus muscle, allowing elevation of the muscle while the incision is made.
(6) This also serves to protect the underlying tissues from extending beyond the limits of the muscle with the electrocautery.
(7) Once the rectus muscle has been transected, it can be retracted superiorly and inferiorly and the transversalis fascia and peritoneum can be entered using the technique mentioned previously, with the only difference being that the peritoneum is opened in a transverse fashion parallel to the skin incision.
(8) When closing this incision, it is not necessary to reapproximate the rectus muscles because these will spontaneously heal provided their tendinous insertions to the anterior rectus sheath remain intact.