This is a transverse incision that is generally considered to have the best postoperative strength.
However, it offers probably the least exposure of any abdominal incision.
cont’d and then beneath the cranial portion of the anterior rectus sheath (D). The peritoneum is identified betwee the bellies of the rectus muscles,and the transversalis fascia and peritoneum are grasped with forceps and incised in the midline at the cranial margin of the exposure (E)
cont’d F, The surgeon’s fingertips are inserted caudally beneath the peritoneum, and the incision is extended downward between the surgeon’s fingers, with care being taken to recognize and avoid the cranial margin of the apex of the bladder at the inferior pole of the incision. At the completion of surgery, it is optional whether the parietal peritoneum and transversalis fascia are closed.
To perform this incision, the following is done:
(1) The skin is incised approximately 2 cm above the symphysis pubis in a transverse fashion.
(2) This incision is carried down through Camper’s and Scarpa’s fascia to the rectus fascia with either the scalpel or electrocautery.
(3) The rectus fascia is then nicked in the midline, again in a transverse fashion.
(4) This incision is then carried laterally through the rectus fascia with either Mayo scissors, scalpel, or cautery.
(5) Often, the fascia can be elevated with a Rochester clamp to allow incision without extension into the deeper tissues.
(6) Once the rectus fascia has been incised, Kocher clamps are used to grasp the superior leaf of the fascia.
(7) This is then dissected off the rectus abdominis and pyramidalis muscles using either blunt or sharp dissection.
(8) While dissecting the fascia off the muscle, it is important to be aware of perforating vessels that come through the rectus muscle, mainly lateral to the midline, to give a blood supply to the anterior rectus sheath. These can be controlled with either cautery or fine free ties.
(9) After dissection of the superior leaf of the fascia is complete, attention is given to the inferior leaf of the incised fascia.
(a) This too is grasped with two Kocher clamps and dissected off the pyramidalis muscle using either blunt or sharp dissection.
(b) The dissection should be carried down to the level of the pubic symphysis.
(10) Following this, the rectus muscles are separated in the midline and retracted laterally, exposing the transversalis fascia and peritoneum.
(11) This layer is then grasped with two clamps and elevated.
(a) It is important at this point to make sure that the peritoneum is grasped sufficiently cranially to ensure the bladder is not included in the clamp.
(b) The possibility of picking up adherent bowel or omentum in the clamp should also be considered, particularly in a patient with previous abdominal surgery, endometriosis, or intraabdominal infection.
(12) Once the presence of bowel or omentum in the clamp has been M ruled out by palpation, Metzenbaum scissors can be used to sharply enter the peritoneum.
d. This incision can be extended cranially using the Metzenbaum scissors.
e. When extending the incision caudally, the transversalis fascia can be dissected sharply off the peritoneum and incised.
(1) Care must be taken at this point not to enter the bladder.
(2) Transillumination should be used while extending the peritoneal incision to ensure this does not occur.
(3) It may also be necessary to split the pyramidalis muscle in the midline to provide adequate exposure.
f. This completes the steps necessary to enter the abdomen through a Pfannenstiel incision.
g. As mentioned previously, this incision is limited by the amount of exposure it provides. If a Pfannenstiel incision is done and exposure is suboptimal, it can be converted to a Cherney incision. It is important that this incision not be converted to a Maylard, because once the fascia has been dissected off the rectus muscles, as in the Pfannenstiel, transecting the rectus abdominis muscle corpus, as is done in the Maylard, may cause the rectus muscle to retract and, without its insertions to the anterior sheath, it may not heal well.