DOI: 10.1111/tog.

12063 2014;16:1318
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Abdominal incisions and sutures in obstetrics and

gynaecology
a,
Radhae Raghavan MRCOG, * Pallavi Arya,b Prathibha Arya FRCOG,
c
Susnata China MRCOG
d

a
Specialty Trainee, Worcestershire Royal Hospital, Charles Hastings Way, Worcester WR5 1DD, UK
b
Medical Student, University of Nottingham, University Park, Nottingham NG7 2RD, UK
c
Consultant in Obstetrics and Gynaecology, Alexandra Hospital, Woodrow Drive, Redditch B98 7UB, UK
d
Consultant Gynaecologist, Worcestershire Royal Hospital, Charles Hastings Way, Worcester WR5 1DD, UK
*Correspondence: Radhae Raghavan. Email: drradhae@gmail.com

Accepted on 23 April 2013

Key content  To outline the anatomical and technical aspects that influence the
 Selection of any incision must be highly individualised. choice of incisions and sutures.
 Numerous options of skin closure have become available and it is  To assess the safety aspects, risks and the appropriate use of various
paramount to choose the method tailored to each patient and closure techniques.
surgical procedure.
Ethical issues
 The ideal wound closure device should be easy to use, painless,
 Is it ethical to allow the selection of an incision dictated by
provide good cosmesis and be cost-effective.
 This article reviews the traditional closure materials as well as
patient choice to preserve cosmesis if it may compromise the
surgical approach?
some materials that have recently become available, such as staples  Is it ethical to subject high-risk women to laparotomy for
and glue.
 Use of electrosurgery on the skin.
diagnostic or therapeutic purposes when laparoscopic
management has demonstrated benefits?
Learning objectives
Keywords: closure / electrosurgery / incision / laparoscopy / suture
 To review the medical literature on this subject.

Please cite this paper as: Raghavan R, Arya P, Arya P, China S. Abdominal incisions and sutures in obstetrics and gynaecology. The Obstetrician & Gynaecologist
2014;16:1318.

Introduction to prevent interference with wound approximation in

certain incisions.1
One of the lasting marks of any abdominal surgery and
most noticeable to the patient is the scar at the site
of incision. In selecting an incision, the surgeon must take
Abdominal incisions
into account the underlying pathology prompting Incisions of the skin should not be made with a monopolar
the surgery, the possibility of adhesions or malignancy, electrosurgical device. The same scalpel can safely be used for
and comorbidities. In this review we aim to present superficial and deep incisions.4
the various abdominal incisions, sutures and closure Abdominal incisions used for most gynaecological
methods used in obstetrics, benign gynaecology and procedures can be divided into transverse or vertical
oncology practice. incisions. Most of the transverse incisions are identified by
the name of the surgeon who first described them, whereas
the vertical incisions have no such eponyms.
Skin preparation
The incidence of significant wound infections is 5% for all Transverse incisions (Box 1)
abdominal operations and is related to patient and surgical
factors.1 Preoperative showering with antiseptics reduces the Pfannenstiel incision
infection rate in clean wounds (1.3% versus 2.3%).2 Wound Introduced by Pfannenstiel in 1900, this curved incision
infection rates for depilatory preparations versus no hair is approximately 1015 cm long and 2 cm above the pubic
removal are equal (0.6%).3 The reason for hair removal is symphysis. The skin and rectus sheath are opened

2014 Royal College of Obstetricians and Gynaecologists 13

 Abdominal incisions and sutures

Box 1. Advantages and disadvantages of transverse incisions

Advantages:

 best cosmetic results

 less painful
 less interference with postoperative respirations
 greater strengtha

Disadvantages:

 more time-consuming
 more haemorrhagic
 compromised ability to explore upper abdominal cavity
 division of multiple layers of fascia and muscle and nerves, may
result in potential spaces with haematoma or seroma
a
Earlier studies reported that increased incidence of eviscerations with
vertical incisions might be associated with inappropriate closures.
Recent studies have shown no difference in fascial dehiscence between
transverse and vertical incisions.5
Figure 1. Joel-Cohen versus Pfannenstiel incisions.

transversely using sharp dissection. The rectus muscles are

The muscles are divided above the openings of the
not cut and the fascia is dissected along the rectus muscles.
inguinal canals.
K
ustner incision
Joel-Cohen incision
The K ustner incision, sometimes incorrectly referred to as
Professor Joel-Cohen introduced this incision for abdominal
modified Pfannenstiel incision, involves a slightly curved skin
hysterectomy in 1954 and obstetricians have since used
incision beginning below the level of the anterior superior
this widely to perform caesarean sections.6 This is a
iliac spine and extending just below the pubic hairline. The
straight transverse incision through the skin, 3 cm below
superficial branches of the inferior epigastric artery or vein
the level of the anterior superior iliac spines (higher than
may be encountered in the fat. This incision is more
the Pfannenstiel incision; Figure 1). The subcutaneous
time-consuming and extensibility is limited.
tissues and fascia are opened in the midline and extended
laterally with blunt finger dissection. Blunt dissection is
Cherney incision
used to separate the rectus muscles vertically and then open
The Cherney incision involves transection of the rectus
the peritoneum.
muscles at their insertion on the pubic symphysis and
retraction cephalad to improve exposure. This can be used Vertical incisions (Box 2)
for urinary incontinence procedures to access the space of
Retzius and to gain exposure to the pelvic side-wall for Midline (median) incision
hypogastric artery ligation. The midline incision is the most versatile incision as it can be
easily extended. The pyramidalis muscle can be a useful
Maylard incision landmark to identify the midline.
The Maylard incision is a muscle-cutting incision, in which
all layers of the lower abdominal wall are incised transversely Box 2. Advantages and disadvantages of vertical incisions
approximately 38 cm above the symphysis, depending on
Advantages:
the patient habitus and indication for surgery. The fascia is
not dissected free of the rectus muscles. The peritoneum is  excellent exposure
usually entered in a transverse fashion. In a patient with  easily extendable
 median incision is least haemorrhagic
clinical evidence of impaired circulation in the lower  minimum nerve damage
extremity, a midline incision should be preferred to the  rapid entry into abdomen and pelvis with median incision
Maylard incision, in view of the risk of lower extremity
Disadvantages:
ischaemia secondary to inferior epigastric artery ligation.
 wound dehiscence and hernia may be more frequent5
 poorer cosmetic results
Mouchel incision  higher infection rates, haemorrhage and operative time with
The Mouchel incision runs at the upper limit of the pubic paramedian incision7
hair and is thus lower than the Maylard incision.

14 2014 Royal College of Obstetricians and Gynaecologists

 Raghavan et al.

Paramedian incision A continuous suture leaves less foreign body mass in the
The paramedian incision offers the advantage of extensibility, wound. It derives its strength from tension distributed evenly
especially on the side of the pelvis where the incision has along the full length of suture strand. Interrupted sutures
been made. There is no difference in wound infection, may be used in the presence of infection: if one suture breaks,
dehiscence or respiratory problems with midline and the remaining sutures will hold the wound edges in
paramedian incisions.7 approximation. Evidence shows no difference in continuous
versus interrupted closure, with a similar incidence of wound
Oblique incisions breakdown and hernia formation.12
Oblique incisions can be used for a transperitoneal or Buried sutures are placed so that the knot protrudes to the
extraperitoneal approach to abdominal surgery, and include inside, under the layer to be closed. Subcuticular sutures are
the Gridiron (muscle-splitting) incision of McBurney and the continuous or interrupted sutures placed in the dermis,
RockeyDavis (or Elliot) incisions. beneath the epithelial layer.
The Gridiron incision is a downward and inward incision
from the McBurney point. The incision is carried through the Secondary suture line
skin and subcutaneous fat to the abdominal wall muscles, The secondary suture line, called retention sutures, is done to
which is split along the direction of the fibres. The reinforce the primary suture line, eliminate dead space and
peritoneum may then be reflected away from the prevent fluid accumulation in abdominal wound during
abdominal wall inferiorly. This allows extraperitoneal healing by first intention. Retention sutures are placed about
drainage of abscess, avoiding peritoneal contamination. The 2 inches from each edge of the wound. It is the authors
Gridiron incision can be performed on the left lower opinion that if secondary sutures are used in cases of
quadrant to drain abscess on the left side of the pelvis and non-healing, they should be placed in the opposite fashion
can be varied for appendicectomy in pregnant women. from the primary sutures (i.e. interrupted if the primary
RockeyDavis incision is a transverse incision made at the sutures were continuous, continuous if primary sutures
junction of the middle and lower thirds of the line joining the were interrupted).
anterior superior iliac spine to the umbilicus.
Fascial closure
If transverse incision is extended laterally beyond the edge of
Incisions for caesarean section the rectus muscles and into the substance of the external and
Caesarean section is the most frequent major operation internal oblique muscles, injury to the iliohypogastric and
performed on women worldwide. Operative techniques ilioinguinal nerves can occur, with resulting neuroma.
used for caesarean section vary and some of these Hence, with laterally extended transverse incisions, the
techniques have been evaluated through randomised trials. extensions should have sutures placed only in the external
Traditionally, vertical incisions were used for caesarean oblique fascia.
delivery.8 Many studies have compared the Joel-Cohen with
Pfannenstiel incision and found the former to be superior Layered versus mass closure
for reasons such as less postoperative febrile morbidity, less Evidence is in favour of mass closure technique using looped
analgesia requirements, shorter operating time, less delayedabsorbable suture, with a wound:suture length ratio
intraoperative blood loss and adhesion formation, of at least 1:4 (Figures 2 and 3).13 In general, subcutaneous
reduction in hospital stay and in wound infection.9 For sutures should be avoided because the subcutaneous tissue
very obese women, a transverse incision above the umbilicus does not provide support.
has been suggested, but not shown, to decrease morbidity.10

Closure techniques
A
In closure of abdominal incisions, it must be remembered D T
that tissues need approximation, not strangulation. B

Primary suture line

The primary suture is the line of sutures that holds the
wound edges in approximation during healing by first Figure 2. Jenkins diagram showing geometric use of an individual
intention. It can either be continuous or interrupted. Other stitch, ATB, in a continuous suture closure. AB is the stitch interval and
sutures include buried, purse string and subcuticular sutures. TD comprises the two tissue bites.

2014 Royal College of Obstetricians and Gynaecologists 15

 Abdominal incisions and sutures

Delayed primary closure and secondary closure

Delayed closure should be used for contaminated or dirty
wounds. Staples or monofilament delayed sutures or
non-absorbable sutures can be placed. If the abdomen is
opened for abscess drainage and delayed closure is not used,
copious saline irrigation of all layers should be done.

Incisions and closure for obese patients

Morbid obesity poses problems with incision placement and
closure. Morbid obesity carries a seven-fold increased risk of
wound infection.16 If any transverse incision is chosen for obese
patients, it should be far removed from the anaerobic moist
environment of the subpannicular fold. The midline vertical
incision is made by first retracting the panniculus inferiorly to
avoid the most anaerobic moist area. Closure is done by
Figure 3. Relationship between the rise in tension between sutures
and tissues caused by a 30% wound stretch and suture length SmeadJones or running mass closure. An intrafascial drain
(SL):wound length (WL) ratio. should be left in situ until drain is <50 ml/24 hours. The skin is
closed using staples in preference to subcuticular sutures.16

Laparoscopic incisions and closure

Principles of suturing skin incisions (Box 3) It has been suggested that primary incision for laparoscopy
should be vertical from the base, not below the umbilicus.17
SmeadJones Any non-midline port >7 mm and any midline port >10 mm
The SmeadJones closure is a mass closure technique of the requires formal deep sheath closure to avoid the occurrence of
anterior abdominal wall using a farfar, nearnear approach. port site hernia.17
The closure is done using a delayed absorbable suture, to A laparoscopic wound closure device named V-Loc consists
include all of the abdominal wall structures on the farfar of a barbed absorbable thread that is self-anchoring and
portion (at least 1.52 cm from the fascial edges) and only eliminates the need to tie a knot. This is feasible and appears
the anterior fascia on the nearnear portion. This allows to be a promising alternative to frequently used peritoneal
good healing without intervening fat or muscle. This closure closure techniques but is yet to be evaluated in clinical studies.18
technique can be performed in an interrupted fashion or as a
running suture.14 The fascial dehiscence rate with running
mass closure of the abdomen is 0.4%.3 Electrosurgery
Incisions of the skin must not be made with a monopolar
Gallup closure electrosurgical device as the desiccation effect may cause skin to
The Gallup closure technique is the closure of midline blister and heal poorly.19 High electrical current delivered with a
incisions using No. 2 polypropylene suture, placing bites fine electrode of a small surface area generates the most efficient
1.52 cm from the fascial edge and including all layers of the cutting effects and the least thermal damage. Therefore, to incise
anterior abdominal wall (peritoneum, fascial layers and the tissue, cut current should be used with a small or thin electrode
intervening muscle). One suture is started from each end and that is activated just before making contact with the target tissue.
tied in the middle with three square knots.15 Abdominal fat, which has high intrinsic impedance, can be
readily cut using a blade electrode with a coagulation waveform
Box 3. Principles of suturing skin incisions
because of the high current density at the edge of the electrode.
There are no data indicating that using electrosurgery in
 The primary function of suture is to maintain tissue approximation pregnancy causes untoward effect on the fetus.
during healing
 Debridement of skin edges should be done if necessary
 Avoidance of direct tissue trauma helps ensure best outcomes Wound closure materials
 Clean passage of the needle following the arc is imperative
 Skin sutures that blanch the underlying skin are too tight Sutures, staples and adhesive tapes are the traditional
 Skin edges must just touch each other methods of wound closure; tissue adhesives have entered
clinical practice more recently.

16 2014 Royal College of Obstetricians and Gynaecologists

 Raghavan et al.

Table 1. Characteristics of various sutures

Tissue Tensile Absorption

Suture types Filament type reaction strength (days) Handling

Absorbable
Catgut Twisted Moderate Poor 80
Polyglycolic acid (DexonTM; Covidien Inc., Manseld, MA, USA) Braided or Low Good 90120
monolament
Polyglactin (VicrylTM; Ethicon Inc., Menlo Park, CA, USA) Braided Low Good 6090
Polyglactic 910 (VicrylRapideTM; Ethicon Inc., Menlo Park, CA, USA) Monolament Low Good 714
Polydioxanone (PDSTM; Ethicon Inc., Menlo Park, CA, USA) Monolament Low Greatest 180210
Polyglecaprone (MonocrylTM; Ethicon Inc., Menlo Park, CA, USA) Monolament Low Good 90120
Polytrimethylene carbonate (MaxonTM; Ethicon Inc., Menlo Park, Monolament Low Good 180210
CA, USA)
Non-absorbable
Surgical silk Braided or twisted High Low Good
Nylon Monolament Low High Poor
Polypropylene (ProleneTM; Ethicon Inc., Menlo Park, CA, USA) Monolament Least Good Poor
Polyester (MersileneTM; Ethicon Inc., Menlo Park, CA, USA) Braided Low High Good
Polytetrauoroethylene Monolament Low High Excellent
(Gore-Tex; W.L Gore Associates, Inc., Newark, DE, USA)

Sutures U-shaped absorbable staples into the dermal layer of tissue.

In selecting the ideal suture, many factors must be considered These staples contain an absorbable copolymer of
including age of the patient, location of the wound, presence/ predominantly polylactide and a lesser component of
absence of infection, and surgeons experience in handling a polyglycolide.24 They maintain 40% of their strength at
suture material. 14 days and are completely absorbed over a period of months
Three main types of suture include the non-absorbable, slowly (tissue half-life of 10 weeks). The Insorb staples are
absorbable, and the rapidly absorbable. These can be further associated with a significantly lower infection rate.25
divided into monofilament or braided sutures. The incidence of
wound infection is low with monofilament sutures.20 Glue
Tissue adhesives are a valuable alternative for mechanical
Characteristics of various sutures (Table 1) tissue fixation by sutures or staples. Box 4 summarises the
The incidence of wound dehiscence and hernia is similar for classification of adhesives and glues.
non-absorbable and slowly absorbable sutures. The incidence
of prolonged wound pain and suture sinus is significantly
Box 4. Adhesives and glues
higher with a non-absorbable suture.21
Types:
Staples  biological: include brin-based glues, gelatin-based hydrogels, and
There are two types of staple: non-absorbable and absorbable. composite glues
The non-absorbable staple (Proximate; Ethicon Endo-  synthetic: cyanoacrylates and polymeric sealants
Surgery, Inc., Blue Ash, OH, USA) is made of stainless steel non-resorbable: limited to surface applications
resorbable (biodegradable): deployed for both surface
and has the highest tensile strength of any wound closure
applications and internal use
material. Staples have a low tissue reactivity.22 Prior to  genetically engineered protein glues
stapling, it is useful to grasp the wound edges with forceps to
Advantages:
evert the tissue so as to prevent inverted skin edges.
 faster, no need for suture removal
Additionally, contaminated wounds closed with staples  cyanoacrylates have been shown to have antimicrobial properties
have a lower incidence of infection compared with those (especially against Gram-positive organisms)
closed with sutures.23 Disadvantages of staples include the
potential for staple track formation, bacterial migration into
the wound bed, and discomfort during staple removal. Currently, 2-octylcyanoacrylate (Dermabond, Ethicon) is
The absorbable staple (Insorb; Incisive Surgical, Inc., the only US Food and Drug Administration-approved
Minneapolis, MN, USA) is a novel device which deploys surgical adhesive. The cyanoacrylates polymerise upon

2014 Royal College of Obstetricians and Gynaecologists 17

 Abdominal incisions and sutures

contact with blood, forming a solid film that bridges the 5 Hendrix SL. SchimpV, Martin J, Singh A, Kruger M, McNeeley SG. The
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18 2014 Royal College of Obstetricians and Gynaecologists