The comparison of type of incision for transperitoneal abdominal aortic surgery based on postoperative respiratory complications and morbidity. Approach to the abdominal aorta: impairment of respiratory function after supraumbilical transverse and midline laparotomy. Midline or transverse laparotomy? A random controlled clinical trial. Part II: Influence on postoperative pulmonary complications. Incisional hernia after upper abdominal surgery: a randomised controlled trial of midline versus transverse incision. Mini-lap cholecystectomy--an attractive alternative to conventional cholecystectomy. Choice of incision and pain following gallbladder surgery. Midline or transverse laparotomy? A random controlled clinical trial. Part I: Influence on healing. Randomized clinical trial of vertical or transverse laparotomy for abdominal aortic aneurysm repair. Pfannenstiel versus vertical laparotomy in patients undergoing radical retropubic prostatectomy with spinal anesthesia: results of a prospective, randomized trial. Midline or transverse abdominal incision for right-sided colon cancer-a randomized trial. Abdominal incisions: transverse vs vertical placement and continuous vs interrupted closure. Transverse versus midline incision for upper abdominal surgery. Prospective randomized study of two laparotomy incisions for gastrectomy: midline incision versus transverse incision. Midline versus transverse incision in major abdominal surgery: a randomized, double-blind equivalence trial (POVATI: ISRCTN60734227).
Equal access to the abdominal aorta can be attained through midline and transverse abdominal incisions. The surgical literature suggests that transverse incisions cause less postoperative pain and morbidity. Fifty patients (10 females and 40 males, mean age 67 years) undergoing abdominal aortic surgery were randomised to a midline (n = 25) or transverse (n = 25) incision. All patients were evaluated preoperatively and postoperatively for seven days. Changes in pulmonary function (FVC and FEV1), time to open and close the incision, analgesia used (morphine mg/kg/h), clinical or X-ray evidence of chest infection, and the duration of ICU stay were recorded. In the transverse group there was a reduction in the incidence of chest complications (20% vs. 28%, p = ns) and these incisions took longer to open (13.9 +/- 4.6 vs. 9.9 +/- 5.1, p < 0.05), but overall there was no significant difference between any other parameter in the two groups. Our results show no statistically significant difference in morbidity or analgesia consumption following transverse or midline abdominal incisions and we conclude that the type of incision used can be left to the surgeon's preference. Midline and transverse incision are commonly used in upper abdominal surgery. A comparison of the two procedures with respect to the respiratory function, assessed by spirometry, blood gas analysis, inspiratory and expiratory pressures, and thoraco-abdominal respiratory synchronism, was made in two groups of patients after surgery on the abdominal aorta. 32 patients affected by abdominal aortic obstructive or aneurysmatic disease, candidates for aortoiliac revascularization, were randomized into two groups of 17 (group A) and 15 (group B) patients respectively. Group A underwent midline laparotomy and group B supraumbilical transverse laparotomy. Ventilatory function and blood gas analysis were determined on the day before operation and on the second and eight postoperative day. All patients showed a depressed ventilatory function postoperatively, but the impairment was significantly minor after transverse laparotomy. In a series of 579 patients undergoing major laparotomy, the direction of incision (midline or transverse/oblique muscle-cutting) was decided randomly. The severity of postoperative pulmonary complications was expressed by a scoring system which allowed categorization into mild (score 0-3), moderate (score 4-6) and serious (score 7 or more) complications. The important determinants of high scores were found to be male sex, preoperative pulmonary dysfunction, postoperative ventilatory depression, hypovolaemic and septic shock, inhalation of gastric contents and embolism. In no stratum did the direction of incision have any significant effect. To 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. Incisional 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.
                One 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.
                Two 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.
                In 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. A prospective study was conducted to determine the safety and efficacy of cholecystectomy through a 5 cm transverse abdominal incision. 181 consecutive patients who underwent elective cholecystectomy for symptomatic gall stone disease in a single surgical unit at the All India Institute of Medical Sciences, New Delhi between December 1990 to February 1992, were prospectively randomized into 5 cm transverse and midline incision groups. Operative time, blood loss, post-operative stay and complications were compared in the two groups. Ninety seven patients were included in the transverse incision group and 84 patients in the midline group. Cholecystectomy could be safely performed through a 5 cm transverse incision in 84 patients (86.8%) without increase in operative complications, morbidity or mortality. In another 84 patients cholecystectomy was performed through a midline incision. The average operating time and blood loss were comparable in both groups. The average post-operative stay in 5 cm transverse incision group was 2.6 days (range 1-4 days) and in the midline group was 4.0 days (range 3-5 days). There were 7 post-operative complications (all wound infections) in the 5 cm transverse group and 12 post-operative complications (10 wound infections and 2 pneumonitis) in the midline group. However, the difference in wound infection rate was not statistically significant (p > 0.1). In Conclusion, Cholecystectomy can be safely performed through a 5 cm transverse incision. 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. Five hundred and seventy-nine patients undergoing major laparotomy were randomly allocated to have midline or transverse incisions. Transverse incisions took longer to make and caused more bleeding but (in the absence of wound sepsis) no transverse wound burst and there were only 2 incisional hernias. In the midline group, without wound sepsis, there were 2 burst abdomens and 9 incisional hernias. When, however, those patients who suffered wound sepsis were also considered, there were no significant differences between the two groups. The objective of this randomized trial was to evaluate the incidence of incisional hernia after transverse or vertical incisions for open aortic aneurysm repair.
                The study group comprised 69 patients who underwent elective aneurysm repair between November 1998 and November 2000 (60 men, nine women; mean age 72.8 (range 56-95) years). Patients were randomized to a transverse (n = 32) or vertical (n = 37) incision for the procedure. Of the 42 patients who were still alive in February 2004, 37 (15 transverse, 22 vertical incisions) attended for review. Laparotomy scars were assessed both clinically and ultrasonographically by the same examiner, to look for incisional hernia.
                Mean follow-up was 4.4 years. A multivariable logistic regression analysis revealed that the type of incision was the only parameter that significantly influenced the rate of incisional hernia: six of 15 patients with a transverse laparotomy versus 20 of 22 with a vertical laparotomy (P = 0.010).
                The incidence of incisional hernia was high after aortic aneurysm repair, but was lower in patients who had a transverse incision. To evaluate the impact of a standard vertical laparotomy versus a Pfannenstiel transverse laparotomy on intra-, peri-operative, and 6-month follow-up outcome in patients undergoing radical retropubic prostatectomy with pelvic lymphadenectomy with spinal anesthesia.
                Between January 2003 and June 2003, 69 age-matched consecutive patients with clinically localized prostate cancer underwent radical retropubic prostatectomy with pelvic lymphadenectomy with spinal anesthesia and were randomized into Group 1 (vertical laparotomy: 35 patients) and Group 2 (Pfannenstiel laparotomy: 34 patients). An extensive analysis of the critical intra-, peri-operative, and 6-month follow-up clinical parameters was performed.
                Both the hemodynamics and the biochemical balance were not significantly different between the two groups. Overall blood loss (p = 0.78), autologous (p = 0.88) and homologous (p = 0.36) blood transfusions were similar regardless of the type of laparotomy. Surgical time was not significantly (p = 0.27) different between the two groups. Similarly, the two forms of laparotomy did not differ regarding the length of the surgical incision (p = 0.21), as measured at the end of the procedure. Post-operative oxygen saturation percentage by pulse oximetry, as well as post-op sedation score, were not significantly different (p = 0.06 and p = 0.97, respectively). Waiting time in the post-operative holding area (p = 0.15), and pain score in the post-operative holding area (p = 0.9) as well as on post-operative day 1 (p = 0.1) were not significantly different between the two groups. The rate of first flatus passage and of unassisted ambulation were similar regardless of the type of laparotomy during post-operative day day 1. The two types of incision made it possible to remove a similar (p = 0.34) number of pelvic lymph nodes and were associated to a similar rate of positive surgical margins among pT2 patients. At the 6-month follow-up the occurrence of a pelvic lymphocele and of deep venous thrombosis was similar in the two groups (p = 0.6 and p = 0.16, respectively). Complete urinary continence and spontaneous erectile function recovery was reported in a similar number of patients regardless of the type of surgical incision (p = 0.59 and p = 0.40, respectively).
                These results suggest that a Pfannenstiel transverse suprapubic laparotomy does not result in a significantly different outcome from a standard vertical laparotomy in patients undergoing a radical retropubic prostatectomy with pelvic lymphadenectomy with L2-L3 spinal anesthesia for clinically localized prostate cancer. The influence of the type of abdominal incision on post-operative pain and pulmonary function was investigated in patients operated upon for a right-sided cancer of the large bowel.
                Fifty-three patients scheduled for a right hemicolectomy due to a right-sided colon cancer were randomized to a median vertical (M) or a transverse incision (T). Forty patients, 23 with a M and 17 with a T incision, completed the study and could be evaluated. Pain at rest and after physical activity was assessed with a visual analogue scale, and was also measured as reflected in the need for analgesics. Respiratory function was assessed with pre- and post-operative spirometry.
                Pain after activity was significantly less in patients with a T incision. This group also needed less analgesia. Vital capacity (VC) and forced expiratory volume in 1 s (FEV 1.0) were profoundly reduced after surgery in both groups of patients, but improvement of respiratory function was faster in patients with a transverse incision. No problem with access to the operative field was noted.
                We conclude that a transverse incision is preferable to a midline incision and should be used in right hemicolectomy. This abdominal incision reduces effort-induced pain and interferes less with post-operative pulmonary function, and may reduce the risk of pulmonary complications. A previous retrospective review of 2,006 emergency laparotomies had suggested that anesthesia and operative times could be reduced by using a continuous stitch closure for all layers of the incision. A prospective, randomized study was then implemented through use of odd/even digits in the last and next-to-last digits in the hospital number. Of 551 patients subjected to laparotomy because of abdominal trauma, no intraperitoneal injury was found in 212. There was no statistically significant difference in time expended or complications (wound or other, including pulmonary) on contrasting transverse (101) with vertical (111) incisions, or on comparing continuous (104) and interrupted (108) closure, with the exception of an average 26 minutes in time saved by a continuous suture (P = .02). Analysis of these same factors in 339 patients with trauma found at laparotomy could document no statistically significant difference. Such data support the use of a running suture for closure of the abdominal wall as a practical method to save anesthesia and operating time without increased risk of developing a wound or other postoperative complication. Transverse and midline abdominal incisions are both commonly used for laparotomy to perform surgery on the pancreas and stomach, but comparative data are limited, especially from prospective randomized trials.
                During a predefined 2-year recruitment period, 94 patients undergoing an elective major laparotomy for disorders of the pancreas or stomach were enrolled in this study. The outcome measures were pulmonary function, incisional pain, and wound characteristics.
                The operation groups were equally divided according to the type of incision used. The patients who underwent transverse incision laparotomy had significantly better postoperative pulmonary function and significantly less postoperative incisional pain than those who underwent midline incision laparotomy (P < 0.05), but there were no differences in morbidity and the incidence of wound complications.
                Performing a transverse incision for surgery on the pancreas or stomach results in better postoperative pulmonary function and less incisional pain than a midline incision, without affecting postoperative morbidity. We performed a randomized study to evaluate the differences between upper midline incision and transverse incision for gastrectomy.
                Patients undergoing distal gastrectomy or total gastrectomy for gastric cancer were randomly allocated to have either an upper midline incision or a transverse incision. The times taken to open and close the abdominal cavity, the number of doses of postoperative analgesics, and the incidence of postoperative pneumonia, wound infection, and intestinal obstruction were compared between the patients having the two incisions.
                Times for both opening and closing the abdominal cavity were longer with a transverse incision, in both the distal gastrectomy group and total gastrectomy group. In the patients in whom continuous epidural analgesia was used postoperatively, the number of additional doses of analgesics was smaller in the transverse-incision group after distal gastrectomy. The incidence of postoperative pneumonia was lower in the transverse-incision group after distal gastrectomy. The number of patients with postoperative intestinal obstruction was smaller in the transverse-incision group than in the midline-incision group after distal gastrectomy. In contrast to distal gastrectomy, there was no significant difference in the number of doses of postoperative analgesics, incidence of postoperative pneumonia, or incidence of postoperative intestinal obstruction between the two study groups after total gastrectomy.
                A transverse incision for distal gastrectomy may be more beneficial than an upper midline incision in attenuating postoperative wound pain, decreasing the incidence of postoperative pneumonia, and preventing postoperative intestinal obstruction. There are 2 main types of access for patients requiring major open, elective abdominal surgery: the midline or the transverse approach. The aim of this study is to compare both approaches by focusing on postoperative pain, complications, and frequency of incisional hernias.
                A recent Cochrane review suggested that transverse incisions may be less painful but incisional hernia rates do not differ.
                Randomized, patient- and observer-blinded, monocentric, equivalence clinical trial. Patients were scheduled for elective primary abdominal incisions. Composite primary end point measured 48 hours after surgery was the total amount of analgesics (piritramide) required in the last 24 hours and pain (Visual Analogue Scale). Secondary end points were early-onset and late complications. This study is registered in the ISRCTN registry and has the ID number ISRCTN60734227.
                Two hundred patients (101 midline and 99 transverse) were randomized. Both incision types resulted in similar amounts of required analgesics (95% confidence interval [-0.38; -0.33] was included in the equivalence level). For the Visual Analogue Scale, both the 95% and 90% CI (0-10) were neither within the equivalence levels nor were their differences significant at the 5% level. No relevant differences between midline and transverse incisions were observed for 30-day mortality (2 vs. 2, P = 0.99), mortality after one year (15 vs. 23, P = 0.15), pulmonary complications (13 vs. 17, P = 0.43), median length of hospital stay (11 vs. 12 days, P = 0.08), median time to tolerance of solid food (12 vs. 14 days, P = 0.30), and incisional hernias after one year (13 vs. 8, P = 0.48). More wound infections occurred in the transverse group (15 vs. 5, P = 0.02).
                The decision about the incision should be driven by surgeon preference with respect to the patient's disease and anatomy.
The analgesia use and the pulmonary compromise may be reduced with a transverse/oblique incision but this does not seem to be significant clinically as pulmonary complication rates and recovery times were the same. The likelihood of wound dehiscence and rupture appears to be reduced with a transverse incision and a transverse incision may look better. The methodological and clinical diversity and the potential for bias also mean that the results in favour of a transverse/oblique incision (particularly with regard to analgesic use) should be treated with caution. The optimal incision for abdominal surgery still remains the preference of the surgeon.