Midline Incision Group Research Articles

Laparoscopic or Robotically Assisted Colectomy with a Pfannenstiel Incision Reduces the Incisional Hernia Incidence.

The present study examined the incidence of incisional hernia by comparing patients from whom a specimen was extracted either through a Pfannenstiel incision (PI) with an intracorporeal anastomosis or via a midline incision (MI) with an extracorporeal anastomosis. The records of 370 consecutive patients who underwent a laparoscopic or robotically-assisted colectomy were retrospectively analyzed. Regardless of the clinical symptoms, incisional hernia was objectively diagnosed based on abdominal computed tomography findings. The surgical outcomes and incisional hernia incidence were retrospectively compared between the groups. Propensity score matching (PSM) was used to balance background differences between the groups. Eighty-seven and 283 patients were in the PI group and MI group, respectively. After PSM, 71 patients were selected from each group. The median observation time was 572 and 1110 days in the PI and MI group, respectively. The PI group had no incidence of incisional hernia whereas the MI group had a 14% incidence, demonstrating that the former had significantly fewer incisional hernias (p=0.0014). The median interval from surgery to incisional hernia development was 295 days. The PI with an intracorporeal anastomosis was not associated with an increased complication rate. The PI was preferable for intraoperative specimen extraction owing to the low, associated incidence of incisional hernia.

Intraoperative and Postoperative Outcomes of Pfannenstiel and Midline Skin Incisions in Placenta Accreta Spectrum Disorders: Single-Center Experience.

Background: We compared Pfannenstiel and midline skin incisions for cesarean hysterectomy in women with confirmed Placenta Accreta Spectrum Disorders. Aims: A retrospective cohort study was conducted to evaluate the outcomes of Pfannenstiel and midline skin incisions in women undergoing cesarean section hysterectomy for suspected placenta accreta at Akdeniz University Hospital between January 2010 and February 2022. Histopathological confirmation was obtained for all cases. Demographic, perioperative, and postoperative data, along with neonatal outcomes, were extracted from the hospital's electronic database. Possible complaints related to the incision site or other issues (e.g., vaginal dryness or sexual life) were identified through telephone interviews. Subjects were stratified into Pfannenstiel and midline incision cohorts, with subsequent data comparison. Results: Data from 67 women with a histopathologically confirmed PAS diagnosis were analyzed. Of these, 49 (73.1%) underwent Pfannenstiel incision, and 18 (26.9%) had a midline skin incision. Incisions were based on the surgeon's experience. Pfannenstiel incision was more common in antepartum hemorrhage, preoperative hemorrhage, and emergency surgery (p = 0.02, p = 0.014, p = 0.002, respectively). Hypogastric artery ligation occurred in 30 cases (61.2%) in the Pfannenstiel group but none in the midline group. Cosmetic dissatisfaction and sexual problems were more prevalent in the midline group (p < 0.05, all). Preoperative and postoperative blood parameters, transfused blood products, and neonatal outcomes were similar between the two groups. Conclusions: Relaparotomy, bladder injury, blood loss, and need for blood transfusion were more prevalent in the Pfannenstiel group, while greater dissatisfaction with the incision was observed in the midline incision group. Midline incision seems to be more favorable in patients with Placenta Accreta Spectrum (PAS). Patients may be informed regarding the worse cosmetic outcomes and possible sexual problems related to vaginal dryness when midline laparotomy is planned. But before opting for a Pfannenstiel incision, patients should receive comprehensive information regarding the potential risks of relaparotomy and bladder injury.

Which incision is better for Lewis to Brown Norway rat liver transplantation, transverse or midline?

Orthotopic rat liver transplantation (OLT) is a complex microsurgical procedure extensively applied to basic science, myriad complications can occur, but incision-related self-biting has not been reported after OLT. For the project of tolerance induction through stem cells, we performed OLT from Lewis to Brown Norway (BN) rats as an acute rejection model and divided the study into the transverse incision group (n = 15) and midline incision group (n = 22), while cyclosporine A was subcutaneously injected for 10-day immunosuppression use, lidocaine cream was used for pain-relieving. The recipient survival and wound status were the primary endpoint of this study. For the transverse incision group, 30-day survival rate was 40% (6/15), self-biting occurred in 13 cases in 7–39 days, the degree 1 of biting occurred in 1 cases, the degree 2 in 2 cases. The degree 3 in 10 cases, which caused death or euthanasia, the self-biting rate was 86.7% (13/15), For the midline incision group, 30-day survival rate was 100% (22/22), the degree 1 of self-biting occurred in 3 cases, no severe self-biting occurred. There were significant differences for survival (p = 0.0003) and for self-biting rate (p < 0.01) between two groups. In conclusion, incision-related self-biting behavior occurs due to incisional injury, the transverse incision is severely pain-causing; the midline one is effective to avert occurrences.

The Optimal Cesarean Skin Incision in Patients with Super Obesity.

This study aimed to evaluate if supraumbilical midline vertical incision performed in patients with a hanging pannus (umbilicus at the level of the pubic bone) is a reasonable alternative to the Pfannenstiel in patients with body mass index (BMI) ≥ 50 kg/m2 undergoing cesarean delivery. Retrospective cohort study in patients with BMI ≥ 50 kg/m2 undergoing cesarean delivery at a single center from 2016 to 2020. Study groups were Pfannenstiel's versus supraumbilical vertical skin incision. If patients had a hanging pannus (umbilicus at the level of the pubic bone), vertical incisions were performed. Otherwise, Pfannenstiel's incision was performed. Decision for the incision was made prospectively. Primary outcome was a composite of need for blood transfusion, presence of immediate surgical complications, and presence of delayed surgical complications. Secondary outcomes included the individual components of the primary outcome, the median surgical blood loss, total operative time, time from skin incision to delivery of neonate, hysterotomy type, and neonatal outcomes. MedCalc 19.5.1 was used for analysis. A total of 103 patients with BMI ≥50 kg/m2 were included. Of those, 68 (66%) had Pfannenstiel's and 35 (34%) had supraumbilical vertical incisions. There was no statistically significant difference in the incidence of the primary outcome (12 vs. 11%, p = 0.96). There was neither significant difference in immediate or delayed postoperative complications nor in neonatal outcomes. However, patients in the vertical midline incision group were more likely to have a classical hysterotomy (52%) compared with the Pfannenstiel group (6%; p < 0.05), increased overall median surgical blood loss (1,000 vs. 835 mL, p < 0.05), and increased total surgical time by a median of 30 minutes (p < 0.05). In patients with super obesity and hanging pannus, performing a supraumbilical vertical midline incision offers a reasonable alternative to Pfannenstiel's incision, but patients should be counseled about the increased risk for classical hysterotomy and implications in future pregnancies. · Patients with BMI >50 kg/m2 were allocated to different incision types based on subcutaneous fat distribution pattern. If umbilicus was at level of pubic bone, supraumbilical vertical skin incision was made. · There were no significant differences between Pfannenstiel's and supraumbilical vertical incisions in terms of the composite outcome and immediate or delayed postoperative complications and neonatal outcomes.. · In patients with a hanging pannus, performing a supraumbilical vertical midline incision offers a reasonable alternative to Pfannenstiel's incision, but patients should be counseled about the increased risk for classical hysterotomy and subsequent implications in future pregnancies..

TU2.4 Synthesis review with meta-analysis on risk of incisional hernia following transverse versus vertical midline incision for specimen extraction in patients undergoing laparoscopic colorectal resections

Abstract Objective The objective of this article is to explore the risk of incisional hernia (IH) occurrence at the site of specimen extraction following laparoscopic colorectal resection (LCR), highlighting the comparison between transverse incision versus midline vertical abdominal incision. Method Analysis was conducted according to PRISMA guidelines. Systematic search of medical databases like MEBASE, MEDLINE and pubmed was performed to find all types of comparative studies reporting the incidence of IH at the specimen extraction site of transverse or vertical midline incision following LCR. The analysis of the pooled data was done using the RevMan statistical software. Result Twenty-five comparative studies (including 2 RCTs) on 10362 patients fulfilled the inclusion criteria. There were 4944 patIents in the transverse incision group and 5418 patients in the vertical midline incision group. In the random effects model analysis, the use of transverse incision for specimen extraction following LCR reduced the risk of IH development [odds ratio 0.30, 95% CI (0.19–0.49), z= 4.88, p=0.00001]. However, there was significant heterogeneity (Tau2 = 0.97; Chi2= 109.98, df = 24(p=0.00004; I2 = 78%) among included studies. Conclusion Transverse incision used for specimen extraction following LCR seems to reduce the risk of postoperative IH incidence compared to vertical midline abdominal incisions.

Erratum: Comparison of Laparascopic and Open Adrenalectomy

Purpose: Laparoscopic adrenalectomy, which was performed successfully for the first time in 1992, has become the preferred method in adrenal surgery especially in adrenal diseases. In this study, our aim is to compare the demographic and operative data of laparoscopic and open adrenalectomies performed in the general surgery clinic of our hospital. Methods: The records of the patients who were operated in hospital due to a surrenal mass between August 2006 and December 2012 have been retrospectively assessed. Demographic characteristics of the patients, such as age, sex, the size and location of tumors were included. Surgical indications were classified in terms of their radiologic and biochemical investigations. Type of the surgery (lateral transperitoneal laparoscopic or open approach), the incision used in these surgeries (midline, subcoastal and paramedian), the length of operation, the length of hospital stay, postoperative complications and the final pathology results were all examined. Results: During the afformentioned period, adrenalectomy was performed in 106 patients. Eighty of these patients (%75,4) were operated by open and 26 of them (%24,6) by lateral transperitoneal laparoscopic surgery. Subcostal incision was used 61 of 80 patients (% 82,4), whereas 17 patients (% 22,9) were operated by midline incision and 2(% 2,7) were by paramedian incision. No mortality was encountered. Operation time was statistically significantly shorter in the open group (p<0,0166). Duration of hospital stay was statistically significantly longer in open group (p<0,0083). Hospital stay time was statistically significantly longer in midline incision group (p<0,0083). Except for the weight of masses, statistically significant difference was not found between two groups (laparascopic and open surgery) in demographic and operative features (age,gender,side,pathological diagnose,size of mass) releated to postoperative complications. Conclusion: In carefully selected group of patients laparoscopic adrenalectomy offered lesser postoperative hospital stay than the open adrenalectomy. The longer operative time can be decreased when more experience is gained in laparascopic adrenalectomy. Laparoscopic adrenalectomy should be preferred in adrenal disease as the gold standard in centers with completed learning curve. "The list of authors in our article, which was published in the 2021-July issue, was made inadvertently. Considering the contribution of the author in the previous poster paper of the article in 2014, the list of authors has been changed." The original article was published on 01 July 2021. http://journal.acibadem.edu.tr/en/pub/issue/62213/862954

Feasibility and efficacy of surgical staging for endometrial cancer by using Pfannenstiel incision

Objective: The purpose of this study was to evaluate short-term oncological and perioperative outcomes of using Pfannenstiel incision for the surgical staging of endometrial carcinoma. Methods: This was a retrospective cohort study. All patients with endometrial carcinoma referred to the Department of Surgical Oncology, South Egypt Cancer Institute, for surgical staging between January 1, 2014, and July 1, 2016, were enrolled. The patients were grouped according to the type of surgical incision either through Pfannenstiel incision or midline incision, and the groups were compared. Demographic, clinical, operative, and short-term oncological features were analyzed. Results: A total number of 117 patients were recruited, of which 45 patients had Pfannenstiel incision, and 72 patients had midline incision. The clinical and pathological features of patients in both groups were similar. The operative outcomes showed no significant difference between the groups (p &gt; 0.1). Postoperatively, the Pfannenstiel incision group had a statistically significant lower rate of complications compared to the midline incision group (15.5% vs. 38.9%, p = 0.02). The short-term oncological outcomes in the form of total procured lymph nodes or para-aortic lymph nodes were not statistically different (p &gt; 0.1). Conclusion: Pfannenstiel incision can be safely performed for the surgical staging of endometrial cancer with acceptable oncological outcomes compared to the midline incision.

Comparison of Laparascopic and Open Adrenalectomy

An Erratum to this article was published on 01 January 2022. http://journal.acibadem.edu.tr/en/pub/issue/65423/1049054 Purpose Laparoscopic adrenalectomy, which was performed successfully for the first time in 1992, has become the preferred method in adrenal surgery especially in benign adrenal diseases. In this study, our aim is to compare the postoperative results of laparoscopic and open adrenalectomies performed in the general surgery clinic of our hospital. Methods The records of the patients who were operated in hospital due to a surrenal mass between August, 2006 and December 2012 have been retrospectively assessed. Demographic characteristics of the patients, such as age, sex, the size and location of tumors were included. Surgical indications were classified in terms of their radiologic and biochemical investigations. Type of the surgery (lateral transperitoneal laparoscopic or open approach), the incision used in these surgeries (midline, subcoastal and paramedian), the length of operation, the length of hospital stay, postoperative complications and the final pathology results were all examined. Results During the afformentioned period, unilateral adrenalectomy was performed in 106 patients. Eighty of these patients (%75,4) were operated by open surgery and 26 of them (%24,6) were operated by lateral transperitoneal laparoscopic surgery. Subcostal incision was used 61 of 80 patients (% 82,4), whereas 17 patients (% 22,9) were operated by midline incision and 2(% 2,7 were by paramedian incision. No mortality was encountered. The length of operation was statistically significantly shorter in the open group (p<0,0166).The length of hospital stay was statistically significantly longer in open group (p<0,0083). The length of hospital stay was statistically significantly longer in midline incision group(p<0,0083). No statistically meaningful difference was found in terms of age, sex and patological diagnosis releated to postoperative complications. Conclusion In carefully selected group of patients laparoscopic adrenalectomy offered lesser postoperative hospital stay and lesser postoperative complications than the open adrenalectomy. The longer operative time can be decreased when more experience is gained in laparascopic adrenalectomy. Complication rates of laparoscopic adrenalectomies are lower than conventional adrenalectomy and should be preferred as the gold standard in centers with completed learning curve. An Erratum to this article was published on 01 January 2022. http://journal.acibadem.edu.tr/en/pub/issue/65423/1049054

Midline incision vs. transverse incision for specimen extraction is not a significant risk factor for developing incisional hernia after minimally invasive colorectal surgery: multivariable analysis of a large cohort from a single tertiary center in Korea.

Incisional hernia (IH) is a commonly encountered problem even in the era of minimally invasive surgery (MIS). Numerous studies on IH are available in English literature, but there are lack of data from the Eastern part of the world. This study aimed to evaluate the risk factors as well as incidence of IH by analyzing a large cohort collected from a single tertiary center in Korea. Among a total number of 4276 colorectal cancer patients who underwent a surgical resection from 2006 to 2019 in Korea University Anam Hospital, 2704 patients (2200 laparoscopic and 504 robotic) who met the inclusion criteria were analyzed. IH was confirmed by each patient's diagnosis code registered in the hospital databank based on physical examination and/or computed tomography findings. Clinical data including specimen extraction incision (transverse or vertical midline) were compared between IH group and no IH group. Risk factors of developing IH were assessed by utilizing univariable and multivariable analyses. During the median follow-up of 41months, 73 patients (2.7%) developed IH. Midline incision group (n = 1472) had a higher incidence of IH than that of transverse incision group (n = 1232) (3.5% vs. 1.7%, p = 0.003). The univariable analysis revealed that the risk factors of developing IH were old age, female gender, obesity, co-morbid cardiovascular disease, transverse incision for specimen extraction, and perioperative bleeding requiring transfusion. However, on multivariable analysis, specimen extraction site was not significant in developing IH and transfusion requirement was the strongest risk factor. IH development after MIS is uncommon in Korean patients. Multivariable analysis suggests that specimen extraction site can be flexibly chosen between midline and transverse incisions, with little concern about risk of developing IH. Careful efforts are required to minimize operative bleeding because blood transfusion is a strong risk factor for developing IH.

Incisional hernia after upper abdominal surgery: a randomised controlled trial of midline versus transverse incision

ObjectivesTo determine whether a transverse incision is an alternative to a midline incision in terms of incisional hernia incidence, surgical site infection, postoperative pain, hospital stay and cosmetics in cholecystectomy.Summary background dataIncisional hernias after midline incision are commonly underestimated but probably complicate between 2 and 20% of all abdominal wall closures. The midline incision is the preferred incision for surgery of the upper abdomen despite evidence that alternatives, such as the lateral paramedian and transverse incision, exist and might reduce the rate of incisional hernia. A RCT was preformed in the pre-laparoscopic cholecystectomy era the data of which were never published.MethodsOne hundred and fifty female patients were randomly allocated to cholecystectomy through midline or transverse incision. Early complications, the duration to discharge and the in-hospital use of analgesics was noted. Patients returned to the surgical outpatient clinic for evaluation of the cosmetic results of the scar and to evaluate possible complications such as fistula, wound dehiscence and incisional hernia after a minimum of 12 months follow-up.ResultsTwo percent (1/60) of patients that had undergone the procedure through a transverse incision presented with an incisional hernia as opposed to 14% (9/63) of patients from the midline incision group (P = 0.017). Transverse incisions were found to be significantly shorter than midline incisions and associated with more pleasing appearance. More patients having undergone a midline incision, reported pain on day one, two and three postoperatively than patients from the transverse group. The use of analgesics did not differ between the two groups.ConclusionsIn light of our results a transverse incision should, if possible, be considered as the preferred incision in acute and elective surgery of the upper abdomen when laparoscopic surgery is not an option.

Comparison of modified Cherney incision and vertical midline incision for management of early stage cervical cancer

The aim of this study was to compare operative feasibility and surgical outcome of the modified Cherney incision and vertical midline incision in patients undergoing radical hysterectomy and pelvic lymphadenectomy. Between March 2005 and December 2007, retrospective data of 78 patients (n=17; modified Cherney incision, n=61; vertical midline incision) with early stage cervical cancer who received radical hysterectomy and pelvic lymphadenectomy were reviewed. Baseline characteristics of patients who underwent modified Cherney incision and vertical midline incision were similar except for age (mean+/-SD: 32.3+/-3.4 yr vs. 52.5+/-8.4 yr, p<0.001). Patients who received modified Cherney incision had earlier initiation of soft diet (mean+/-SD: 46.5+/-19.5 hr vs. 56.4+/-25.4 hr, p<0.016) and shorter hospital stay compared to those who received vertical midline incision (mean+/-SD: 18.0+/-4.8 days vs. 21.7+/-3.7 days, p<0.042). There was no difference in the number of dissected pelvic lymph nodes, hemoglobin change, postoperative pain, postoperative ileus, Foley indwelling duration, and perioperative complications. Excluding the selection bias for age, there was no significant difference of the clinical outcome between the modified Cherney incision group and the vertical midline incision group. Modified Cherney incision can be cosmetically performed in young age women obtaining equal number of lymph nodes without increased operative morbidity compared to vertical midline incision.

Choice of incision and pain following gallbladder surgery

A prospective randomized trial compared pain in the first 24 h after gallbladder surgery via an upper midline or a transverse incision. Pain was measured by the patients' self-administered consumption of pethidine, degree of postoperative respiratory impairment and a visual analogue pain scale. The upper midline incision group self-administered significantly more pethidine than the transverse incision group (P less than 0.001), but there was no difference between the groups in respiratory function or visual analogue pain scale results 24 h after operation. Length of hospital stay was not different. An upper midline incision is more painful than a transverse incision in the first 24 h following gallbladder surgery.

Minilaparotomy left iliac fossa skin crease incision vs. midline incision for left-sided colorectal cancer.

Midline laparotomies offer excellent exposure but are associated with increased postoperative pain and longer recovery. A minilaparotomy resection of leftsided colorectal cancers was studied as an alternative approach. We performed a case-control retrospective review of 280 randomly selected patients (140 midline incisions; 140 left skin crease incisions) who underwent elective, curative resection of left-sided colorectal cancers. Patients in both groups were of comparable age and sex. The left skin crease incision was shorter (median length, 13.5 cm) than the midline incision (median length, 20.0 cm). Median operation time was less in the left skin crease group (75 min) than in the midline incision group (105 min). Similar types of operations were performed, including left hemicolectomies, sigmoid colectomies, anterior resections and ultra-low anterior resections. Adequacy of resection was confirmed by histological analysis, with no involvement of margins. The median numbers of lymph nodes removed were comparable: 10 for the skin crease incision group and 12 for the midline incision group. Postoperative parameters for the skin crease incision group showed that feeding, ambulation, narcotic use and hospital stay were significantly better than the parameters in the midline group. Complications of intestinal obstruction were also reduced in the skin crease incision group. The limited left skin crease incision provides adequate margins of clearance in colorectal cancers when compared to the midline incision, but has advantages of shorter operation time, earlier feeding and ambulation, and earlier discharge from hospital.

Panniculectomy and Supraumbilical Vertical Midline Incisions in Morbidly Obese Gynecologic Oncology Patients

Background: We reviewed the outcomes of panniculectomy and supraumbilical vertical midline incisions in morbidly obese women undergoing gynecologic operations. Study Design: Medical records were reviewed for 62 morbidly obese women with a large dependent pannus who underwent gynecologic operations on the Gynecologic Oncology Service at the State University of New York at Stony Brook between May 1990 and July 1997. Thirty-five patients underwent panniculectomy and 27 had a supraumbilical vertical midline incision, forming the study groups. The patient charts were abstracted for demographic, perioperative, and postoperative data. Results: For the entire study population, the average age was 56 years, the mean body mass was 128.6 kg, and the mean Quetelet Index was 48.3 kg/m 2. The mean operative time and estimated blood loss were similar for both groups. Eight percent of the patients had urologic injuries, evenly distributed between the groups. Postoperative infections, wound breakdowns, and hospital stay were greater for the panniculectomy group than for the supraumbilical vertical midline incision group (p < 0.05). Uniform use of subcutaneous closed-suction drains (since 1995) was associated with a significant reduction in the incidence of wound breakdowns and a shorter hospital stay in the panniculectomy group. Conclusions: Panniculectomy and supraumbilical vertical midline incision provide reasonable peritoneal access with acceptable rates of postoperative complications for morbidly obese women undergoing gynecologic operations.