170

J Anat. Soc. India 50(2) 170-178 (2001)

Surgical Incisions—Their Anatomical Basis

Part IV-Abdomen
*Patnaik, V.V.G.; **Singla, Rajan K.; ***Bansal V.K..

Department of Anatomy, Government Medical College, *Patiala, **Amritsar, ***Department of Surgery, Govt. Medical College &

Hospital, Chandigarh, INDIA.

Abstract. The present paper is a continuation of the previous ones by Patnaik et al 2000 a, b & 2001. Here the anatomical basis of
the various incisions used in anterior abdominal wall their advantages & disadvantages are discussed. An attempt has been made to add
the latest modifications in a concised manner.

Key words : Surgical Incisions, Abdomen, Midline, Paramedian, McBurney, Gridison, Kocher.

Introduction : be extensible in a direction that will allow for any

It is probably no exaggeration to state that, in probable enlargement of the scope of the operation,
abdominal surgery, wisely chosen incisions and but it should interfere as little as possible with the
correct methods of making and closing such wounds functions of the abdominal wall. The surgical
are factors of great importance (Nygaard and incision and the resultant wound represent a major
Squatrito, 1996). Any mistake, such as a badly part of the morbidity of the abdominal surgery.
placed incision, inept methods of suturing, or ill-
Planning of an abdominal incision :
judged selection of suture material, may result in
serious complications such as haematoma In the planning of an abdominal incision,
formation, an ugly scar, an incisional hernia, or, Nyhus & Baker (1992) stressed that the following
worst of all, complete disruption of the wound factors must be taken into consideration (a) pre-
(Pollock, 1981; Carlson et al, 1995). operative diagnosis (b) the speed with which the
operation needs to be performed, as in trauma or
Before the advent of minimally invasive
techniques, optimal access could only be achieved major haemorrhage, (c) the habitus of the patient,
at the expense of large high morbidity incisions. (d) previous abdominal operation, (e) potential
Endoscopic and laparoscopic technology has, placements of stomas (Funt, 1981; Telfer et al,
however revolutionized these concepts facilitating 1993). Ideally, the incision should be made in the
patient friendly access to even the most remote of direction of the lines of cleavage in the skin so that
abdominal organs (Maclntyre, 1994). a hairline scar is produced.

It should be the aim of the surgeon to employ The incision must be tailored to the patients
the type of incision considered to be the most need but is strongly influenced by the surgeon’s
suitable for that particular operation to be preference. In general, re-entry into the abdominal
performed. In doing so, three essentials should be cavity is best done through the previous laparotomy
achieved (Zinner et al, 1997): incision. This minimizes further loss of tensile
strength of the abdominal wall by avoiding the
1. Accessibility
creation of additional fascial defects (Fry & Osler,
2. Extensibility 1991).
3. Security Care must be taken to avoid ‘tramline’ or
The incision must not only give ready and ‘acute angle’ incisions (Figure 1), which could lead
direct access to the anatomy to be investigated but to devascularisation of tissues. It is also helpful if
also provide sufficient room for the operation to be incisions are kept as far as possible from
performed (Velanovich, 1989). The incision should established or proposed stoma sites and these
J. Anat. Soc. India 50(2) 170-178 (2001)
Patnaik, V.V.G., et al 171

Classification of incisions :
The incisions used for exploring the abdominal
cavity can be classified as :
(A) Vertical incision : These may be
(i) Midline incision
(ii) Paramedian incisions
(a) (b)
(B) Transverse and oblique incisions :
Fig. 1. (a) Tramline Incision. (b) Acute angle incision. (i) Kocher's subcostal Incision
(a) Chevron (Roof top
stomas should be marked preoperatively with skin Modification)
marking pencils to avoid any mistakes (Burnand & (b) Mercedes Benz Modification
Young, 1992).
(ii) Transverse Muscle dividing incision
Cosmetic end results of any incision in the
(iii) Mc Burney’s Grid iron or muscle
body are most important from patients’ point of view.
spliting incision
Consideration should be given wherever possible, to
siting the incisions in natural skin creases or along (iv) Oblique Muscle cutting incision
Langer’s lines. Good cosmesis helps patient morale. (v) Pfannenstiel incision
Much of the decision about the direction of the (vi) Maylard Transverse Muscle cutting
incision depends on the shape of the abdominal Incision
wall. A short, stocky person sometimes has a longer
(C) Abdominothoracic incisions
incision and frequently better exposure, if the
A. Vertical incisions :
incision is transverse. A tall, thin, asthenic patient
has a short incision if it is made transversally, Vertical incisions include the midline incision,
whereas a vertical incision affords optimal exposure paramedian incision, and the Mayo-Robson
(Greenall et al, 1980). extension of the paramedian incision.
Certain operations are ideally done through a (i) Midline Incision (Figure 2) :
transverse or subcostal incision, for example Almost all operations in the abdomen and
cholecystectomy through a right Kocher’s incision, retroperitoneum can be performed through this
right hemicolectomy through an infraumbilical universally acceptable incision (Guillou et al, 1980).
transverse incision, and splenectomy through a left Advantages (a) It is almost bloodless, (b) no muscle
subcostal incision. Vagotomy and antrectomy can be fibres are divided, (c) no nerves are injured, (d) it
done through a bilateral subcostal incision with a affords goods access to the upper abdominal
longer right and shorter left extension if the patient viscera, (e) It is very quick to make as well as to
is stocky or obese (Grantcharov & Rosenberg, close; it is unsurpassed when speed is essential
2001). (Clarke, 1989) (f) a midline epigastric incision also
Certain incisions, popular in the past, have can be extended the full length of the abdomen
been abandoned, and appropriately so. One curving around the umbilical scar (Denehy et al,
example of this is the para-rectus incision made at (1998).
the lateral border of the rectus sheath. This incision In the upper abdomen, the incision is made in
was used until the mid 1940 primarily for the the midline extending from the area of xiphoid and
removal of the gall bladder, the spleen, and the left ending immediately above the umbilicus (Ellis,
colon. It denervates the rectus muscle and produces 1984). Skin, fat, linea alba and peritoneum are
an ideal environment for the development of divided in that order. Division of the peritoneum is
postoperative ventral hernia, and has absolutely best performed at the lower end of the incision, just
nothing to recommend it (Nyhus & Baker, 1992). above the umbilicus so that falciform ligament can
J. Anat. Soc. India 50(2) 170-178 (2001)
172 Surgical Incisions-Abdomen

advantages. The first is that it offsets the vertical

incision to the right or left, providing access to the
lateral structures such as the spleen or the kidney.
The second advantage is that closure is theoretically
more secure because the rectus muscle can act as
a buttress between the reapproximated posterior
and anterior fascial planes (Cox et al, 1986).

Fig. 2. Midline Incision

be seen and avoided. If necessary for exposure, the

ligament can be divided between clamps and
ligated. A few centimeters of upwards extension can Fig. 3. Paramedian Incisions
be gained by extending the incision to either side of
the xiphoid process, or actually excising the xiphoid The skin incision is placed 2 to 5 cm lateral to
(Didolkar & Vickers, 1995). The extraperitoneal fat is the midline over the medial aspect of the bulging
abundant and vascular in this area, and small transverse convexity of the rectus muscle. Extra
vessels here need to be coagulated with diathermy. access can be obtained by sloping the upper
The infraumbilical midline incision also divides extremity of the incision upwards to the xiphoid
the linea alba. Because the linea alba is (Didolkar et al, 1995).
anatomically narrow at the inferior portion of the Skin and subcutaneous fat are divided along
abdominal wall, the rectus sheath may be opened the length of the wound. The anterior rectus sheath
unintentionally, although this is of no consequence. is exposed and incised, and its medial edge is
In the lower abdomen, the peritoneum should be grasped and lifted up with haemostats. The medial
opened in the uppermost area to avoid possible portion of the rectus sheath then is dissected from
injury to the bladder. the rectus muscle, to which the anterior sheath
It is a good practice to place a bladder catheter adheres. Segmental blood vessels encountered
before any surgery on the lower abdomen and to during the dissection should be coagulated. Once
curve the properitoneal and peritoneal incisions the rectus muscle is free of the anterior sheath it
laterally when approaching the pubic symphysis to can be retracted laterally because the posterior
avoid entry into the bladder (Nyhus & Baker, 1992). sheath is not adherent to the rectus muscle. The
posterior sheath and the peritoneum which are
Special care is needed when operating on
adherent to each other, are excised vertically in the
patients with intestinal obstruction or when re-
same plane as the anterior fascial plane (Brennan et
exploring following previous abdominal surgery (Fry
al, 1987). The deep inferior epigastric vessels are
& Osler, 1991). In intestinal obstruction, distended
encountered below the umbilicus and require
bowel loops may be there immediately below the
ligation and division if they course medially along
incision and in re-exploration, the bowel may be
the line of the incision (Chuter et al, 1992).
adherent to the peritoneum. The way to avoid this is
to open the peritoneum in a virgin area at the upper A paramedian incision below the umbilicus is
or lower part of the incision (Levrant et al, 1994). made in a similar manner. The only difference is
that inferior epigastric vessels are exposed in the
(ii) Paramedian Incision (Figure 3)
posterior compartment of the rectus sheath and the
The paramedian incision has two theoretical transversalis fascia is found in the anterior fascial
J. Anat. Soc. India 50(2) 170-178 (2001)
Patnaik, V.V.G., et al 173

layer below the semicircular line of Douglas. subcostal incision, transverse muscle dividing,
some surgeons still prefer to split the rectus McBurney, Pfannenstiel, and Maylard incisions.
muscle rather than dissect it free (Guillou et al, (i) Kocher subcostal incision (Figure 5)
1980). In this rectus-splitting technique, the muscle Theodore Kocher originally described the
is split longitudinally near its medial border (medial subcostal incision; it affords excellent exposure to
1/3rd or preferably one-sixth), after which posterior the gall bladder and biliary tract and can be made
layer of the rectus sheath and peritoneum are on the left side to afford access to the spleen
opened in the same line. This incision can be made (Kocher, 1903). It is of particular value in obese and
and closed quickly and is particularly valuable in muscular patients and has considerable merit if
reopening the scar of a previous paramedian diagnosis is known and surgery planned in advance.
incision. In such circumstances, it is very difficult, or
indeed impossible to dissect the rectus muscle away
from the rectus sheath.

Disadvantages :
1. It tends to weaken and strip off the
muscles from its lateral vascular and
nerve supply resulting in atrophy of the
muscle medial to the incision.
2. The incision is laborius and difficult to Fig. 5. Kocher’s Incision
extend superiorly as is limited by costal
margin. The subcostal incision is started at the midline,
3. It doesn’t give good access to 2 to 5 cm below the xiphoid and extends
contralateral structures. downwards, outwards and parallel to and about 2.5
cm below the costal margin (Hardy 1993; Dorfman
The Mayo-Robson extension of the
et al, 1997). Extension across the midline and down
paramedian incision is accomplished by curving the
the other costal margin may be used to provide
skin incision towards the xiphoid process. Incision of
generous exposure of the upper abdominal viscera.
the fascial planes is continued in the same direction
The rectus sheath is incised in the same direction as
to obtain a larger fascial opening (Pollock, 1981).
the skin incision, and the rectus muscle is divided
(B) Transverse Incisions (Figure 4) with cautery; the internal oblique and transversus
Transverse incisions include the Kocher abdominis muscles are divided with cautery. Some
authors have described the retraction of rectus
muscle instead of dividing it (Brodie et al, 1976; Fink
& Budd, 1984).
Special attention is needed for control of the
branches of the superior epigastric vessels, which
lie posterior to and under the lateral portion of the
rectus muscle. The small eighth thoracic nerve will
almost invariably be divided; the large ninth nerve
must be seen and preserved to prevent weakening
of the abdominal musculature. The incision is
deepened to open the peritoneum (Dorfman et al,
1997).
Fig. 4. Transverse and transverse-oblique
In the recent years, many surgeons have
Incisions. A. Kocher incision. B. Transverse
Incision. C. Rockey-Davis incision. D. Maylard advocated the use of a small 5-10 cm incision in the
incision. E. Pfannenstiel incision subcostal area for cholecystectomy - mini-lap
J. Anat. Soc. India 50(2) 170-178 (2001)
174 Surgical Incisions-Abdomen

cholecystectomy (Seenu & Misra, 1994). This because the incision passes between adjacent
incision is similar to the Kocher’s incision except for nerves without injuring them. The rectus muscle has
the length of the incision. The major advantages of a segmental nerve supply, so there is no risk of a
this incision are lesser postoperative pain, early transverse incision depriving the distal part of the
recovery from the surgery and return to work and rectus muscle of its innervation. Healing of the scar,
good cosmetic results (Coelho et al, 1993). But in effect, simply results in the formation of a man
diadvantage is less exposure, which can be made additional fibrous intersection in the muscle
dangerous in cases of difficult anatomy or lot of (Pemberton and Manaz, 1971).
adhesions and chances of injury to bile ducts or
(ii) Transverse Muscle-dividing incision (Figure 6)
other structures (Kopelman et al, 1994; Gupta et al,
1994). The operative technique used to make such an
incision is similar to that for the Kocher incision. In
(a) Chevron (Roof Top) Modification :
newborns and infants, this incision is preferred,
The incision may be continued across the because more abdominal exposure is gained per
midline into a double Kocher incision or roof top length of the incision than with vertical exposure
approach (Chevron Incision) (Figure 6), which because the infant’s abdomen has a longer
provides excellent access to the upper abdomen transverse than vertical girth (Gauderer, 1981). This
particularly in those with a broad costal margin is also true of short, obese adults, in whom
(Chute et al, 1968; Brooks et al, 1999). This is transverse incision often affords a better exposure.
useful in carrying out total gastrectomy, operations
(iii) McBurney Grid iron or Muscle-split incision
for renovascular hypertension, total
(Figure 7)
oesophagectomy, liver transplantation, extensive
hepatic resections, and bilateral adrenalectomy etc The McBurney incision, first described in 1894
(Chino & Thomas, 1985; Pinson et al, 1995; by Charles McBurney is the incision of choice for
Miyazaki et al, 2001). most appendicectomies (McBurney, 1894). The
level and the length of the incision will vary
according to the thickness of the abdominal wall and
the suspected position of the appendix (Jelenko &
Davis 1973; Watts & Perrone, 1997). Good healing
and cosmetic appearance are virtually always
achieved with a negligible risk of wound disruption
or herniation.

Fig. 6. A.. A: Rooftop incision; B..: Mercedes Benz extension

(b) The Mercedes Benz Modification :(Fig. 6)

Variant of this incision consists of bilateral low
Kocher’s incision with an upper midline limb up to
and through the xiphisternum (Sato et al, 2000).
This gives excellent access to the upper abdominal
viscera and, in particular to all the diaphragmatic Fig. 7. Surface markings of the right iliac fossa
hiatuses (Yoshinaga, 1969; Motsay et al, 1973; appendicectomy incision. A. The Classic McBurney incision
Brooks et al, 1999). is obnliquely placed. B. Most surgeons today use a more
transverse skin-crease incision
The rectus muscle can be divided transversely.
Its anterior and posterior sheaths are closed without Classically, the McBurney incision is made at
any serious weakening of the abdominal muscle the junction of the middle third and outer thirds of a
J. Anat. Soc. India 50(2) 170-178 (2001)
Patnaik, V.V.G., et al 175

line running from the umbilicus to the anterior (iv) Oblique Muscle-cutting incision
superior iliac spine, the McBurney point (Watts, This incision bears the eponym of the
1991). However, if palpation reveals a mass, the
Rutherford-Morrison incision (Talwar et al, 1997).
incision can be placed directly over the mass.
This is extension of the McBurney incision by
McBurney originally placed the incision obliquely,
division of the oblique fossa and can be used for a
from above laterally to below medially. However, the
right or left sided colonic resection, caecostomy or
skin incision can be placed in a skin crease
sigmoid colostomy.
transversely [Rockey-Davis Incision (Fig 4c) or Lanz
Incision or Bikini Incision], which provides a better (v) Pfannenstiel incision (Figure 4)
cosmetic result (Delany & Carnevale, 1976; The Pfannenstiel incision is used frequently by
Pleterski & Temple, 1990). Otherwise, the two gynaecologists and urologists for access to the
incisions are similar. pelvis organs, bladder, prostate and for caesarean
If it is anticipated that it may be necessary to section (Ayers & Morley, 1987; Mendez et al, 1999;
extend the incision, then the incision should be Hendrix et al, 2000). The skin incision is usally 12
placed obliquely, which enables it to be extended cm long and is made in a skin fold approximately 5
laterally as a muscle splitting incision (Losanoff & cm above symphysis pubis. The incision is
Kjossev, 1999). deepened through fat and superficial fascia to
After the skin and subcutaneous tissue are expose both anterior rectus sheaths, which are
divided, the external oblique aponeurosis is divided divided along the entire length of the incision. The
in the direction of its fibres; exposing the underlying sheath is then separated widely, above and below
internal oblique muscle. A small incision is then from the underlying rectus muscle. It is necessary to
made in this muscle adjacent to the outer border of separate the aponeurosis in an upward direction,
the rectus sheath. The opening is enlarged to permit almost to the umbilicus and downwards to the pubis.
introduction of two index fingers between the muscle
The rectus muscles are then retracted laterally and
fibres so that internal oblique and transversus can
the peritoneum opened vertically in the midline, with
be retracted with a minimal amount of damage. The
care being taken not to injure the bladder at the
peritoneum is then grasped with a thumb forceps,
lower end.
elevated and opened.
The incision offers excellent cosmetic results
If further access is required, the wound can be
because the scar is almost always hidden by the
easily enlarged by dividing the anterior sheath of the
rectus muscle in line with the incision, after which patient’s pubic hair postoperatively (Griffiths, 1976).
rectus muscle is retracted medially (Jelenko & Because the exposure is limited this incision should
Davis, 1973; Moneer, 1998). Wide lateral extension be used only when surgery is planned on the pelvic
of the incision can be affected by combination of organs (Mendez et al, 1999).
division and splitting of the oblique muscles along (vi) Maylard Transverse Muscle Cutting Incision
the line of their fibres in the lateral direction (Weir (Figure 4)
extension) (Askew, 1975).
Many surgeons prefer this incision because it
This incision also may be used in the left lower gives excellent exposure of the pelvic organs
quadrant to deal with certain lesions of the sigmoid (Helmkamp & Kreb, 1990; Brand, 1991). The skin
colon, such as drainage of a diverticular abscess.
incision is placed above but parallel to the traditional
The ilioinguinal and iliohypogastric nerves placement of Pfannenstiel incision. The rectus
cross the incision for appendectomy and their fascia and muscle are then cut transversely, and the
accidental injury should be prevented which can incision is continued laterally as far as necessary,
predispose the patient to inguinal hernia formation in
dividing external and internal oblique muscles; the
the postoperative period (Mandelkow & Loeweneck,
transverses abdominis and transversalis fascia are
1988).
opened in the direction of their fibres.
J. Anat. Soc. India 50(2) 170-178 (2001)
176 Surgical Incisions-Abdomen

(C) Thoracoabdominal Incision (Figures 8 & 9)

The thoracoabdominal incision, either right or
left, converts the pleural and peritoneal cavities into
one common cavity and thereby gives excellent
exposure. Laparotomy incisions, whether upper
midline, upper paramedian or upper oblique can be
easily extended into either the right or left chest for
better exposure (Nyhus & Baker, 1992).
The right incision may be particularly useful in
elective and emergency hepatic resections (Kise et
al, 1997). The left incision may be used effectively
in resection of the lower end of the esophagus and
proximal portion of the stomach (Molina et al, 1982; Fig. 9. Surface markings of the thoracoabdominal incision
Ti, 2000).
When liver resection is anticipated, it is now The thoracic incision is carried down through
more common to give a sternum splitting incision the subcutaneous fat and the lattismus dorsi,
than to extending it into the right pleural space (Sato serratus anterior and external oblique muscles. The
et al, 2000). The reasons for this are that the intercostals muscles are divided with cautery and
sternum heals with considerably less pain than does pleural cavity is opened and lung allowed to
the costochondral junction; the exposure is as good, collapse. The incision is continued across the costal
and the intrapericardial vena cava can be controlled margin, and the cartilage is divided in a V shape
through this incision if there is untoward venous manner with a scalpel so that the two ends
bleeding (Miyazaki et al, 2001). interdigitate and can be closed more securely. A
chest retractor is inserted and opened to produce
wide spreading of the intercostal space. After
ligation of the phrenic vessels in the line of the
incision, the diaphragm is divided radially (Zinner et
al, 1997).

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