As mentioned, the vertical incisions allow for unparalleled exposure to both the pelvis and upper abdomen and can be extended from xiphoid to pubis if need be. They are, however, not as strong as the transverse incisions and, because Langer’s lines are transected, heal with a larger, less cosmetically appealing scar.
1. Median incision
a. In this procedure, the following is done:
(1) An incision is made between the umbilicus and pubic symphysis.
(2) This is carried down through the superficial fascia to the level of the rectus fascia, using either the scalpel or cautery.
(3) The fascia is then nicked in a vertical direction and a Rochester clamp is placed beneath the fascia to elevate it and allow it to be incised without extension into the deeper tissues.
(4) A scalpel or cautery can then be used to incise the fascia, opening it to the limits of the skin incision.
(5) The rectus muscles are then split in the midline along the linea alba and retracted laterally.
(6) Using clamps, the deeper tissues are then bluntly dissected and the transversalis fascia and peritoneum are identified and elevated between two clamps. As described previously, the peritoneum is palpated to ensure no bowel or omentum is adherent to the posterior surface of the peritoneum.
(7) The peritoneum is then entered sharply using Metzenbaum scissors.
(8) This incision is then carried cranially using Mayo scissors and transecting the posterior rectus sheath, transversalis fascia, and peritoneum in the midline. While making this portion of the incision, the posterior surface of the peritoneum should be explored intermittently to ensure that no bowel or omentum is adherent to the posterior surface.
(9) Once the incision has been extended to the length of the skin incision, the peritoneum can be incised in a caudal direction.
(a) Again, the position of the bladder should be demonstrated by transillumination to avoid entering it with extension of the incision.
(b) Once complete, this incision will allow adequate exposure for pelvic surgery and exploration of the upper abdomen and paraaortic lymphatics.
(c) Should the need arise, the incision can be carried around the umbilicus and as far cranially as the xiphoid process, allowing exposure to the entire upper abdomen.
The technique of a midline incision in the lower abdomen. A, Site of the incision between the umbilicus and the pubis. B, The midline incision continues through the subcutaneous tissue to expose the linea alba of the anterior rectus sheath.
cont’d C, This sheath is incised, (continued)
cont’d D, The peritoneum and transversalis fascia are grasped between forceps and opened at the cranial end of the incision. Transillumination of this flap by looking through its peritoneal side discloses the outline of the apex of the bladder, marking the caudal limit of the pubic peritoneal dissection (E). When it is necessary to extend the midline incision cranially to obtain additional exposure, it should be performed around the left side of the umbilicus to avoid the ligamentus teres (F).
- Paramedian incision (Fig. 3-10)
a. This incision is made to one side of the midline, usually on the side of the expected pathology.
(1) Instead of entering the peritoneal cavity through the linea alba, the rectus muscle is split longitudinally and reflected laterally.
(2) Or the abdomen is entered lateral to the rectus muscle following ligature of the inferior epigastric artery.
b. This incision is reported to be stronger than the median incision, as the avascular linea alba is left intact.
c. Denervation of the rectus muscle can occur if the incision is extended too far along the lateral border of the muscle. This can result in muscle atrophy.