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Midline Vertical Incision
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Abdominal entry is the first step for many gynecologic surgeries. Either vertical or transverse incisions may be used, and each offers particular advantages. Vertical incisions may be midline or paramedian, but of the two, the midline is chosen more often. This incision offers quick entry, minimal blood loss, superior access to the upper abdomen, generous operating room, and the flexibility for easy wound extension if greater space or access is needed. No important neurovascular structures traverse this incision. Thus, it may be favored for patients using anticoagulation agents. Despite advantages, midline incisions are more frequently associated with greater postoperative pain, poorer cosmetic results, and increased risks of wound dehiscence or incisional hernia compared with low transverse incisions. Last, for those with prior laparotomy, the incision type is typically repeated for subsequent surgeries.
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For abdominal entry, patients are informed of wound infection or dehiscence risks. Additionally, the chance of bowel or bladder injury is present with any abdominal entry, especially when extensive adhesions are encountered.
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Laparotomy per se does not require antibiotic prophylaxis or bowel preparation. These are dictated by the planned procedure. Prevention for venous thromboembolism is warranted, and options are described in Chapter 39.
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Anesthesia and Patient Positioning
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After administration of adequate regional or general anesthesia, the patient is positioned supine. If needed, hair in the path of the planned incision is clipped; a Foley catheter is placed; and abdominal preparation is completed.
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Skin and Subcutaneous Layer
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The skin is incised vertically in the midline beginning 2 to 3 cm above the symphysis pubis and extending cephalad to within 2 cm of the umbilicus. If less space is required, this incision may be shortened. For greater space or access, the incision may arch around the umbilicus and then continue cephalad in the upper abdominal midline. This extension passes to the left of the umbilicus to avert transection of the ligamentum teres. This remnant of the umbilical vein courses in the free border of the falciform ligament. The umbilicus itself contains attenuated fascia. Thus, the periumbilical incision should arch laterally enough to provide quality fascia on either side of the incision to allow an ultimately secure closure.
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The subcutaneous layers of Camper and Scarpa are then incised either sharply with long even strokes or with electrosurgical blade to reach the linea alba fascia. Ideally, the number of blade strokes is minimized to avoid hatch marking the tissue, which increases tissue damage and wound infection risks.
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Tendinous fibers from the anterior abdominal wall aponeuroses merge in the midline of the abdomen ...