Transverse verses midline incisions for abdominal surgery

Transverse abdominal access appears to affect pulmonary function less than midline access and may be less prone to rupture. There is a suggestion that a transverse incision is also less painful but this result is less clear. Other recovery and complication rates are similar although the transverse incision may look better.

The choice of abdominal surgical incision is determined largely by access. However, a transverse incision may be superior to a midline incision in terms of recovery and complications. All randomised controlled trials comparing these incisions were identified. Outcomes included analgesic use, pulmonary function, complication rates and hospital stay. Marked variability in methodology made comparison difficult and potential biases in all of the studies suggests results should be treated with caution. Nevertheless a trend was seen toward less analgesic requirement, less effect on pulmonary function and lower wound dehiscence and incisional hernia rates with a transverse incision. However, the lower pain and reduced effect on pulmonary function were not translated into other clinical advantages as recovery times and other complication rates (except cosmetic appearance) were similar.

Authors' conclusions: 

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.

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Background: 

The choice of surgical incision in the abdomen is determined by access. It has been suggested that other parameters such as recovery and complication rate may be influenced by utilising a transverse or oblique rather than a midline incision. However, there is little consensus in the literature as to whether a particular incision confers any advantage.

Objectives: 

To determine whether a midline incision or a transverse incision (including oblique incision) confers any recovery advantage to the patient.

Search strategy: 

Search terms include randomised trials containing combinations of the following: 'abdominal', 'incisions', 'horizontal', 'transverse', 'vertical', 'midline', 'laparotomy'

Selection criteria: 

All prospective randomised trials comparing midline with transverse incisions for abdominal surgery were included. Caesarian sections were excluded.

Data collection and analysis: 

Two reviewers assessed the methodological quality of potentially eligible trials and independently extracted data from the included trial. A wide range of outcome measures were considered.

Main results: 

Due to the differences in the method of assessment, the variability of data and the heterogeneity of the participant groups it was difficult to pool some of the outcome data. Despite these limitations and potentially significant biases related to methodological quality there was evidence to suggest that a transverse or oblique incision has less impact on pulmonary function particularly in the early post-operative period and is less prone to rupture (wound dehiscence/incisional hernia). The data on pain is less clear and should be interpreted with caution but some data suggests a transverse incision is less painful. There was no difference seen in other early or late post-operative complications and recovery times were similar although the transverse incision may be cosmetically more acceptable.

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