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Laparoscopically assisted ileocolectomy for Crohn’s disease through a Pfannenstiel incision
HOW I DO IT
Laparoscopically Assisted Ileocolectomy for Crohn’s Disease through a Pfannenstiel Incision Arin K. Greene, MD, Pierre Michetti, MD, Mark A. Peppercorn, MD, Richard A. Hodin, MD, Boston, Massachusetts
Recently, laparoscopically assisted bowel resections have been shown to be less morbid than the traditional laparotomy, especially for benign conditions such as Crohn’s disease. While reports describing laparoscopically assisted bowel resections use a small midline or right transverse incision, we describe a novel laparoscopically assisted approach employing a Pfannenstiel incision for Crohn’s patients. We attempted the Pfannenstiel incision since it is well known to be associated with less postoperative pain, decreased ileus and hospital stay, and low rates of wound infection and incisional hernia, compared with midline or right transverse incisions. Furthermore, we found that the Pfannenstiel incision offers additional advantages that may be uniquely suited for Crohn’s patients. First, the cosmetic position of the incision is particularly attractive to the young population affected by Crohn’s. Second, the Pfannenstiel incision preserves fresh tissue in the midline, right, and left lower quadrants in the event that reoperation or stoma placement are required in the future owing to recurrent disease. We describe our technique in 10 consecutive patients undergoing ileocolectomy for Crohn’s disease. Our patients experienced minimal morbidity and were pleased with the cosmetic results of their incisions. Am J Surg. 2000;180:238 –240. © 2000 by Excerpta Medica, Inc.
S
eventy percent of patients with Crohn’s disease will require an operation over the lifetime of their disease.1 Surgery is generally reserved for complications of the disease, including small bowel obstruction, fistula, abscess, massive bleeding, or failure of medical therapy. The most common abdominal surgery for Crohn’s disease is an ileocolectomy, usually performed through a midline incision. Over the last several years, laparoscopically assisted small bowel and colon resections have been shown to
From the Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Requests for reprints should be addressed to Richard A. Hodin, MD, Beth Israel Deaconess Medical Center, Department of Surgery, 330 Brookline Avenue, Boston, Massachusetts 02215. Manuscript submitted April 13, 2000, and accepted in revised form July 15, 2000.
238
© 2000 by Excerpta Medica, Inc. All rights reserved.
offer certain advantages over the traditional laparotomy. Advantages of laparoscopic bowel resections include decreased pain, shorter hospitalization, fewer adhesions, and earlier return of bowel function.2– 4 Laparoscopically assisted bowel resections generally employ a small midline or right-sided transverse incision. In this report, we describe a laparoscopically assisted technique employing a Pfannenstiel incision for Crohn’s patients. The Pfannenstiel incision has been most commonly used for gynecologic and pelvic procedures, and offers several advantages that may be unique to Crohn’s patients. First, because Crohn’s disease often affects young patients aged 15 to 30 years, cosmesis is a significant concern.1 In contrast to midline and lateral transverse incisions, the Pfannenstiel incision is virtually invisible since it is placed in a skin crease usually hidden by pubic hair.5 Second, since 30% of Crohn’s patients will need a reoperation within 5 years, a Pfannenstiel incision ensures fresh tissue in the midline in case of a major laparotomy and facilitates stoma placement since the left and right lower quadrants remain untouched.1 Third, unlike the right transverse or extended McBurny incisions, the Pfannenstiel incision does not involve the division of muscle. Consequently, patients have less postoperative discomfort.6 Finally, the Pfannenstiel incision is associated with an extremely low incidence of incisional hernias. While the incidence of incisional hernias with midline laparotomies is as high as 10%, the Pfannenstiel incision is associated with a 0.1% to 0.5% hernia rate.6
PATIENTS AND METHODS A consecutive series of 10 patients underwent laparoscopically assisted ileocolectomy between May 1998 and August 1999 for Crohn’s disease. All 10 patients had significant inflammation and 5 had large phlegmons in the right lower quadrant. In addition to the resection of the inflamed bowel, 3 of the patients had an additional ileosigmoid fistula repaired and 1 patient had two concurrent stricturoplasties. Patient ages ranged from 22 to 41 years with a mean of 34.0 and a standard deviation of 9.7 (⫾9.7). There were 7 males and 3 females. All patients presented for a semielective resection because of recurrent abdominal pain and obstruction that was unrelieved despite maximal medical therapy. Eight patients were taking prednisone (average dose 17.8 ⫾ 3.9 mg/day), 1 patient was taking azathioprine, and 1 patient was taking 6-mercaptopurine at the time of surgery. Eight patients had no previous history of abdominal surgery. One patient had a previous Pfannenstiel incision for bladder surgery as a child, and another 0002-9610/00/$–see front matter PII S0002-9610(00)00473-6
LAPAROSCOPIC ILEOCOLECTOMY THROUGH PFANNENSTIEL INCISION/GREENE ET AL
separated in the midline and the peritoneum is opened vertically. After entering the abdomen, the entire small bowel is run in order to identify any areas of more proximal Crohns disease. The ascending colon is then delivered through the Pfannenstiel incision and examined. Since the laparoscopic portion of the procedure allowed the mobilization of normal tissue, the dissection of the inflamed ileum and cecum may be performed by standard techniques through the Pfannenstiel incision. Depending upon the degree of inflammation, extensive dissection may be required to mobilize the inflamed region of intestine and to takedown and repair any fistula. The resection and anastomosis are performed using standard techniques. The peritoneum is closed with a 0 polyglactin suture. The rectus muscles are reapproximated in the midline using interrupted 2-0 polyglactin sutures. The transverse fascial incision is closed using a running 0 polyglactin suture. Finally, the skin is closed with 4-0 subcuticular polyglactin sutures.
RESULTS Figure 1. Illustration of the operative technique. An infraumbilical incision is made in order to place the camera into the abdomen. Alternatively, a vertical incision can be made just superior to the umbilicus. Trochars are placed at the lateral edge of each rectus muscle along the line of the planned Pfannenstiel incision. The Pfannenstiel incision is made, incorporating the two trochar sites, approximately 2 to 4 cm superior to the pubis.
patient underwent a previous laparoscopy for a right ovarian cyst. Patient follow-up was obtained by chart review and telephone interviews. All 10 of the patients were able to be contacted for follow-up.
OPERATIVE TECHNIQUE With the patient in the supine position a small infraumbilical incision is made and the open laparoscopy technique used to gain access to the peritoneal cavity. After a CO2 pneumoperitoneum is obtained, a 5-mm trochar is placed at the lateral margin of each rectus muscle, along the line of the planned Pfannenstiel incision (Figure 1). Laparoscopic exploration is performed, and the diseased bowel identified. The cecum and ascending colon are then grasped and retracted medially. The right colon is then fully mobilized by dividing the retroperitoneal attachments with electrocautery. The entire right colon and hepatic flexure are mobilized laparoscopically, in order to ensure that the distal resection margin can be easily exteriorized through the Pfannenstiel incision. The diseased bowel does not need to be extensively mobilized since this portion of the procedure can be accomplished through the Pfannenstiel incision in a standard open fashion. Once the bowel is well mobilized, the trochars are removed and a 10-cm Pfannenstiel incision is made at a point 2 to 4 cm superior to the pubis, incorporating the two trocar sites. The dissection is carried down to the fascia, which is opened transversely along the length of the incision. Subfascial flaps are then raised superiorly to the umbilicus and inferiorly to the pubis. After raising the subfascial flaps, the right and left rectus muscles are easily
Hospital stays in this cohort of 10 patients averaged 4.2 days ⫾ 1.8. Although 1 patient had a 9-day hospital stay for social reasons, all of the other patients were discharged home on either postoperative day 3 or 4. The average operative time, from the initial laparoscopy incision to closure, was 158.7 ⫾ 30.9 minutes. Morbidity was low in this group of patients. One patient developed a wound infection and an intra-abdominal abscess that required computed tomography-guided drainage. The abscess resolved without further need for surgery. A second patient was readmitted for a partial small bowel obstruction, which resolved with nonoperative management. A third patient underwent a reoperation more than 4 months after her discharge. It is unclear whether this patient suffered an early recurrence of her Crohn’s disease or if there was a nonhealing anastomotic problem. Patients required postoperative narcotics for an average of 8.3 ⫾ 6.1 days. The average time to return to normal activity/driving was 11.2 ⫾ 6.6 days. Patients were satisfied with their incisions. On a scale of 1 to 10 (1 is an invisible scar and 10 is a terrible cosmetic result), patients rated their scar cosmesis a 2.2 ⫾ 1.2.
COMMENTS The use of laparoscopic techniques for small bowel and colon resections has increased over the last few years. In general, the major contraindication to laparoscopic surgery is the presence of significant adhesions. An additional contraindication to laparoscopically assisted ileocolectomy through a Pfannenstiel incision for Crohn’s disease includes Crohn’s involvement of the ascending colon and hepatic flexure. Extensive Crohn’s disease of this region may prohibit the laparoscopic mobilization that is required to enable the resection and anastamosis to be safely accomplished through the Pfannenstiel incision. Although controversy exists over the efficacy of laparoscopic surgery for the resection of carcinoma, numerous studies have shown that laparoscopically assisted resection for benign disease, especially Crohn’s disease, is safe and effective.3,7 In fact, compared with the traditional open laparotomy, laparoscopically assisted resections for Crohn’s
THE AMERICAN JOURNAL OF SURGERY® VOLUME 180 SEPTEMBER 2000
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LAPAROSCOPIC ILEOCOLECTOMY THROUGH PFANNENSTIEL INCISION/GREENE ET AL
disease have been shown to result in a shorter period of postoperative ileus, decreased pain, reduced hospital stay, and fewer wound infections.2– 4,8 Previous descriptions of laparoscopic ileocolectomy include either a midline or right transverse incision in order to complete the anastomosis.7,9 In contrast, we have employed a Pfannenstiel incision that incorporates the two trochar sites into the line of the incision (Figure 1). Although the Pfannenstiel incision offers many advantages over the midline or transverse incisions, it is not frequently used in general surgery because it offers limited exposure to the abdomen. However, the ability to mobilize the small bowel and colon laparoscopically will now allow the use of the Pfannenstiel incision in many types of gastrointestinal surgery. In gyneocolgic patients, the Pfannenstiel incision has been shown to be superior to standard laparotomy in regard to postoperative ileus, hospital stay, wound infections, and overall recovery time.6,10,11 The Pfannenstiel incision also has a significantly lower incisional hernia rate than a midline incision (0.1% to 0.5% versus 10%).6 The reason for the low incidence of incisional hernias is probably threefold.6 First, the muscle defect is remote from the incised fascia and subcutaneous tissue. Second, since the linea alba, which has the poorest blood supply of the abdominal wall, is not incised the risk of ischemic fascial breakdown is avoided. Finally, since the skin incision is along Langer’s lines, the tension on the Pfannenstiel incision is 30 times less than the tension on a vertical incision. Although nerve entrapment (1.0% to 3.7%) can occur if the Pfannenstiel incision is extended laterally beyond the rectus sheath, we avoid potential nerve injury by ending our incision at the lateral edge of the rectus muscles.6 Not only does the Pfannenstiel incision appear to be superior to a midline or right transverse incision in terms of ileus, hospital stay, wound infection, recovery time, and hernia, it also offers advantages unique to the Crohn’s patient. First, because Crohn’s patients tend to be young and more concerned with their body image, the virtually invisible position of the Pfannenstiel incision in the bikini line is particularly desirable. Second, the Pfannenstiel incision preserves the right lower quadrant in the event that a stoma will be needed in the future. It should be noted that since 30% of these patients will require an additional operation in 5 years, and the requirement for a stoma is much greater than for other types of intestinal disease.
240
Based upon the known advantages of a Pfannenstiel incision, we have employed this incision in a consecutive series of patients with ileocecal Crohn’s disease. As would be expected based on the separate literatures regarding laparoscopy and the Pfannenstiel incision, our patients had short hospital stays with minimal postoperative disability and complications. In addition, the patients were extremely pleased with the cosmetic aspects of their incision. The potential disadvantage of the Pfannenstiel incision in terms of exposure was overcome with the use of laparoscopy, enabling mobilization of the right colon. We suggest that this laparoscopically assisted method is a particularly favorable operative technique in patients with Crohn’s disease. This approach is associated with decreased morbidity, superior cosmesis, and preservation of tissue for potential stoma creation.
REFERENCES 1. Schraut W, Medich DS. Surgery—Scientific Principles and Practice. 3rd ed. Philadelphia: Appleton and Lange; 1997:831– 843. 2. Bohm B, Milson JW, Fazio VW. Postoperative intestinal motility following conventional and laparoscopic intestinal surgery. Arch Surg. 1995;130:415– 419. 3. Chen HH, Wexner SD, Weiss EG, et al. Laparoscopic colectomy for benign colorectal disease is associated with a significant reduction in disability as compared with laparotomy. Surg Endosc. 1998;12:1397–1400. 4. Sardinha TC, Wexner SD. Laparoscopy for inflammatory bowel disease: pros and cons. World J Surg. 1998;22:370 –374. 5. Ellis H. Incisions, closures, and management of the wound. In: Maingot’s Abdominal Operations. 10th ed. Stamford: Appleton and Lange; 1997:395– 426. 6. Luijendijk RW, Jeekel J, Huikeshoven FJ. The low transverse Pfannenstiel incision and the prevalence of incisional hernia and nerve entrapment. Ann Surg. 1997;225:365–369. 7. Ludwig KA, Milsom JW, Church JM, Fazio VW. Preliminary experience with laparoscopic intestinal surgery for Crohn’s disease. Am J Surg. 1996;171:52–55. 8. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Postoperative complications of laparoscopic-assisted colectomy. Surg Endosc. 1997;11:119 –122. 9. Schlinkert RT. Laparoscopic-assisted right hemicolectomy. Dis Colon Rectum. 1991;34:1030 –1031. 10. Orr JW, Orr PJ, Holimon JL. Radical hysterectomy: does the type of incision matter? Am J Obstet Gynecol. 1995;173:399 – 405. 11. Redman JF, Barthold JS. Experience with ileal augmentation cystoplasty using a short pfannenstiel incision. J Urol. 1996;155: 1726 –1727.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 180 SEPTEMBER 2000
Laparoscopically Assisted Ileocolectomy for Crohn’s Disease through a Pfannenstiel Incision Arin K. Greene, MD, Pierre Michetti, MD, Mark A. Peppercorn, MD, Richard A. Hodin, MD, Boston, Massachusetts
Recently, laparoscopically assisted bowel resections have been shown to be less morbid than the traditional laparotomy, especially for benign conditions such as Crohn’s disease. While reports describing laparoscopically assisted bowel resections use a small midline or right transverse incision, we describe a novel laparoscopically assisted approach employing a Pfannenstiel incision for Crohn’s patients. We attempted the Pfannenstiel incision since it is well known to be associated with less postoperative pain, decreased ileus and hospital stay, and low rates of wound infection and incisional hernia, compared with midline or right transverse incisions. Furthermore, we found that the Pfannenstiel incision offers additional advantages that may be uniquely suited for Crohn’s patients. First, the cosmetic position of the incision is particularly attractive to the young population affected by Crohn’s. Second, the Pfannenstiel incision preserves fresh tissue in the midline, right, and left lower quadrants in the event that reoperation or stoma placement are required in the future owing to recurrent disease. We describe our technique in 10 consecutive patients undergoing ileocolectomy for Crohn’s disease. Our patients experienced minimal morbidity and were pleased with the cosmetic results of their incisions. Am J Surg. 2000;180:238 –240. © 2000 by Excerpta Medica, Inc.
S
eventy percent of patients with Crohn’s disease will require an operation over the lifetime of their disease.1 Surgery is generally reserved for complications of the disease, including small bowel obstruction, fistula, abscess, massive bleeding, or failure of medical therapy. The most common abdominal surgery for Crohn’s disease is an ileocolectomy, usually performed through a midline incision. Over the last several years, laparoscopically assisted small bowel and colon resections have been shown to
From the Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Requests for reprints should be addressed to Richard A. Hodin, MD, Beth Israel Deaconess Medical Center, Department of Surgery, 330 Brookline Avenue, Boston, Massachusetts 02215. Manuscript submitted April 13, 2000, and accepted in revised form July 15, 2000.
238
© 2000 by Excerpta Medica, Inc. All rights reserved.
offer certain advantages over the traditional laparotomy. Advantages of laparoscopic bowel resections include decreased pain, shorter hospitalization, fewer adhesions, and earlier return of bowel function.2– 4 Laparoscopically assisted bowel resections generally employ a small midline or right-sided transverse incision. In this report, we describe a laparoscopically assisted technique employing a Pfannenstiel incision for Crohn’s patients. The Pfannenstiel incision has been most commonly used for gynecologic and pelvic procedures, and offers several advantages that may be unique to Crohn’s patients. First, because Crohn’s disease often affects young patients aged 15 to 30 years, cosmesis is a significant concern.1 In contrast to midline and lateral transverse incisions, the Pfannenstiel incision is virtually invisible since it is placed in a skin crease usually hidden by pubic hair.5 Second, since 30% of Crohn’s patients will need a reoperation within 5 years, a Pfannenstiel incision ensures fresh tissue in the midline in case of a major laparotomy and facilitates stoma placement since the left and right lower quadrants remain untouched.1 Third, unlike the right transverse or extended McBurny incisions, the Pfannenstiel incision does not involve the division of muscle. Consequently, patients have less postoperative discomfort.6 Finally, the Pfannenstiel incision is associated with an extremely low incidence of incisional hernias. While the incidence of incisional hernias with midline laparotomies is as high as 10%, the Pfannenstiel incision is associated with a 0.1% to 0.5% hernia rate.6
PATIENTS AND METHODS A consecutive series of 10 patients underwent laparoscopically assisted ileocolectomy between May 1998 and August 1999 for Crohn’s disease. All 10 patients had significant inflammation and 5 had large phlegmons in the right lower quadrant. In addition to the resection of the inflamed bowel, 3 of the patients had an additional ileosigmoid fistula repaired and 1 patient had two concurrent stricturoplasties. Patient ages ranged from 22 to 41 years with a mean of 34.0 and a standard deviation of 9.7 (⫾9.7). There were 7 males and 3 females. All patients presented for a semielective resection because of recurrent abdominal pain and obstruction that was unrelieved despite maximal medical therapy. Eight patients were taking prednisone (average dose 17.8 ⫾ 3.9 mg/day), 1 patient was taking azathioprine, and 1 patient was taking 6-mercaptopurine at the time of surgery. Eight patients had no previous history of abdominal surgery. One patient had a previous Pfannenstiel incision for bladder surgery as a child, and another 0002-9610/00/$–see front matter PII S0002-9610(00)00473-6
LAPAROSCOPIC ILEOCOLECTOMY THROUGH PFANNENSTIEL INCISION/GREENE ET AL
separated in the midline and the peritoneum is opened vertically. After entering the abdomen, the entire small bowel is run in order to identify any areas of more proximal Crohns disease. The ascending colon is then delivered through the Pfannenstiel incision and examined. Since the laparoscopic portion of the procedure allowed the mobilization of normal tissue, the dissection of the inflamed ileum and cecum may be performed by standard techniques through the Pfannenstiel incision. Depending upon the degree of inflammation, extensive dissection may be required to mobilize the inflamed region of intestine and to takedown and repair any fistula. The resection and anastomosis are performed using standard techniques. The peritoneum is closed with a 0 polyglactin suture. The rectus muscles are reapproximated in the midline using interrupted 2-0 polyglactin sutures. The transverse fascial incision is closed using a running 0 polyglactin suture. Finally, the skin is closed with 4-0 subcuticular polyglactin sutures.
RESULTS Figure 1. Illustration of the operative technique. An infraumbilical incision is made in order to place the camera into the abdomen. Alternatively, a vertical incision can be made just superior to the umbilicus. Trochars are placed at the lateral edge of each rectus muscle along the line of the planned Pfannenstiel incision. The Pfannenstiel incision is made, incorporating the two trochar sites, approximately 2 to 4 cm superior to the pubis.
patient underwent a previous laparoscopy for a right ovarian cyst. Patient follow-up was obtained by chart review and telephone interviews. All 10 of the patients were able to be contacted for follow-up.
OPERATIVE TECHNIQUE With the patient in the supine position a small infraumbilical incision is made and the open laparoscopy technique used to gain access to the peritoneal cavity. After a CO2 pneumoperitoneum is obtained, a 5-mm trochar is placed at the lateral margin of each rectus muscle, along the line of the planned Pfannenstiel incision (Figure 1). Laparoscopic exploration is performed, and the diseased bowel identified. The cecum and ascending colon are then grasped and retracted medially. The right colon is then fully mobilized by dividing the retroperitoneal attachments with electrocautery. The entire right colon and hepatic flexure are mobilized laparoscopically, in order to ensure that the distal resection margin can be easily exteriorized through the Pfannenstiel incision. The diseased bowel does not need to be extensively mobilized since this portion of the procedure can be accomplished through the Pfannenstiel incision in a standard open fashion. Once the bowel is well mobilized, the trochars are removed and a 10-cm Pfannenstiel incision is made at a point 2 to 4 cm superior to the pubis, incorporating the two trocar sites. The dissection is carried down to the fascia, which is opened transversely along the length of the incision. Subfascial flaps are then raised superiorly to the umbilicus and inferiorly to the pubis. After raising the subfascial flaps, the right and left rectus muscles are easily
Hospital stays in this cohort of 10 patients averaged 4.2 days ⫾ 1.8. Although 1 patient had a 9-day hospital stay for social reasons, all of the other patients were discharged home on either postoperative day 3 or 4. The average operative time, from the initial laparoscopy incision to closure, was 158.7 ⫾ 30.9 minutes. Morbidity was low in this group of patients. One patient developed a wound infection and an intra-abdominal abscess that required computed tomography-guided drainage. The abscess resolved without further need for surgery. A second patient was readmitted for a partial small bowel obstruction, which resolved with nonoperative management. A third patient underwent a reoperation more than 4 months after her discharge. It is unclear whether this patient suffered an early recurrence of her Crohn’s disease or if there was a nonhealing anastomotic problem. Patients required postoperative narcotics for an average of 8.3 ⫾ 6.1 days. The average time to return to normal activity/driving was 11.2 ⫾ 6.6 days. Patients were satisfied with their incisions. On a scale of 1 to 10 (1 is an invisible scar and 10 is a terrible cosmetic result), patients rated their scar cosmesis a 2.2 ⫾ 1.2.
COMMENTS The use of laparoscopic techniques for small bowel and colon resections has increased over the last few years. In general, the major contraindication to laparoscopic surgery is the presence of significant adhesions. An additional contraindication to laparoscopically assisted ileocolectomy through a Pfannenstiel incision for Crohn’s disease includes Crohn’s involvement of the ascending colon and hepatic flexure. Extensive Crohn’s disease of this region may prohibit the laparoscopic mobilization that is required to enable the resection and anastamosis to be safely accomplished through the Pfannenstiel incision. Although controversy exists over the efficacy of laparoscopic surgery for the resection of carcinoma, numerous studies have shown that laparoscopically assisted resection for benign disease, especially Crohn’s disease, is safe and effective.3,7 In fact, compared with the traditional open laparotomy, laparoscopically assisted resections for Crohn’s
THE AMERICAN JOURNAL OF SURGERY® VOLUME 180 SEPTEMBER 2000
239
LAPAROSCOPIC ILEOCOLECTOMY THROUGH PFANNENSTIEL INCISION/GREENE ET AL
disease have been shown to result in a shorter period of postoperative ileus, decreased pain, reduced hospital stay, and fewer wound infections.2– 4,8 Previous descriptions of laparoscopic ileocolectomy include either a midline or right transverse incision in order to complete the anastomosis.7,9 In contrast, we have employed a Pfannenstiel incision that incorporates the two trochar sites into the line of the incision (Figure 1). Although the Pfannenstiel incision offers many advantages over the midline or transverse incisions, it is not frequently used in general surgery because it offers limited exposure to the abdomen. However, the ability to mobilize the small bowel and colon laparoscopically will now allow the use of the Pfannenstiel incision in many types of gastrointestinal surgery. In gyneocolgic patients, the Pfannenstiel incision has been shown to be superior to standard laparotomy in regard to postoperative ileus, hospital stay, wound infections, and overall recovery time.6,10,11 The Pfannenstiel incision also has a significantly lower incisional hernia rate than a midline incision (0.1% to 0.5% versus 10%).6 The reason for the low incidence of incisional hernias is probably threefold.6 First, the muscle defect is remote from the incised fascia and subcutaneous tissue. Second, since the linea alba, which has the poorest blood supply of the abdominal wall, is not incised the risk of ischemic fascial breakdown is avoided. Finally, since the skin incision is along Langer’s lines, the tension on the Pfannenstiel incision is 30 times less than the tension on a vertical incision. Although nerve entrapment (1.0% to 3.7%) can occur if the Pfannenstiel incision is extended laterally beyond the rectus sheath, we avoid potential nerve injury by ending our incision at the lateral edge of the rectus muscles.6 Not only does the Pfannenstiel incision appear to be superior to a midline or right transverse incision in terms of ileus, hospital stay, wound infection, recovery time, and hernia, it also offers advantages unique to the Crohn’s patient. First, because Crohn’s patients tend to be young and more concerned with their body image, the virtually invisible position of the Pfannenstiel incision in the bikini line is particularly desirable. Second, the Pfannenstiel incision preserves the right lower quadrant in the event that a stoma will be needed in the future. It should be noted that since 30% of these patients will require an additional operation in 5 years, and the requirement for a stoma is much greater than for other types of intestinal disease.
240
Based upon the known advantages of a Pfannenstiel incision, we have employed this incision in a consecutive series of patients with ileocecal Crohn’s disease. As would be expected based on the separate literatures regarding laparoscopy and the Pfannenstiel incision, our patients had short hospital stays with minimal postoperative disability and complications. In addition, the patients were extremely pleased with the cosmetic aspects of their incision. The potential disadvantage of the Pfannenstiel incision in terms of exposure was overcome with the use of laparoscopy, enabling mobilization of the right colon. We suggest that this laparoscopically assisted method is a particularly favorable operative technique in patients with Crohn’s disease. This approach is associated with decreased morbidity, superior cosmesis, and preservation of tissue for potential stoma creation.
REFERENCES 1. Schraut W, Medich DS. Surgery—Scientific Principles and Practice. 3rd ed. Philadelphia: Appleton and Lange; 1997:831– 843. 2. Bohm B, Milson JW, Fazio VW. Postoperative intestinal motility following conventional and laparoscopic intestinal surgery. Arch Surg. 1995;130:415– 419. 3. Chen HH, Wexner SD, Weiss EG, et al. Laparoscopic colectomy for benign colorectal disease is associated with a significant reduction in disability as compared with laparotomy. Surg Endosc. 1998;12:1397–1400. 4. Sardinha TC, Wexner SD. Laparoscopy for inflammatory bowel disease: pros and cons. World J Surg. 1998;22:370 –374. 5. Ellis H. Incisions, closures, and management of the wound. In: Maingot’s Abdominal Operations. 10th ed. Stamford: Appleton and Lange; 1997:395– 426. 6. Luijendijk RW, Jeekel J, Huikeshoven FJ. The low transverse Pfannenstiel incision and the prevalence of incisional hernia and nerve entrapment. Ann Surg. 1997;225:365–369. 7. Ludwig KA, Milsom JW, Church JM, Fazio VW. Preliminary experience with laparoscopic intestinal surgery for Crohn’s disease. Am J Surg. 1996;171:52–55. 8. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Postoperative complications of laparoscopic-assisted colectomy. Surg Endosc. 1997;11:119 –122. 9. Schlinkert RT. Laparoscopic-assisted right hemicolectomy. Dis Colon Rectum. 1991;34:1030 –1031. 10. Orr JW, Orr PJ, Holimon JL. Radical hysterectomy: does the type of incision matter? Am J Obstet Gynecol. 1995;173:399 – 405. 11. Redman JF, Barthold JS. Experience with ileal augmentation cystoplasty using a short pfannenstiel incision. J Urol. 1996;155: 1726 –1727.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 180 SEPTEMBER 2000