The low transverse muscle-cutting incision in gynecological surgery

THE

LOW

TRANSVERSE MUSCLE-CUTTING GYNECOLOGICAL SURGERY*

GERALD (From

the

Lkpurtvwnt

S. WILLIAJIS,

of Obstrtvics flrr Lhi~ersity

MT).,“”

INCISION

II~~I~~II,I,E,

IN

KY.

rind GynrcoTo~~y o,f tire Lotlisoille of Louisvillr School of Xedicinel

Gcnrral

Tfospifal

md

SATISFACTORY abdominal incision should (I) provide adequate esposure, (2) respect anatomical structures sufficiently to ljroduce the least possible damage to the abdominal wall, (;i) bc simple and allow for estension, and (4) be cosmet,ically acceptable to the patient. The transverse abdominal incision has been used over 100 years, lnxt its advantages have not hecn sufficiently rccogniacd for its universal adoption as the incision of choice, It, is my purpose to point 0ut the several basic advantages of this approach to pelvic lesions, ant1 to rrcommend its more widespread use in gynecological snrgcry.

A

History The great French obstetrician Eaudelocyue’ in 1823 was t.he first to describe a transverse incision of any type. 1 Te advocated it in the lower aldomen for use in cesarean section. Yfannenstiel,2 however, in 1900 was the first to popularize its use in pelvic surgery. Plis incision has met favor with many gynecologists but some claim that it does not provide sufficient esp0sure. Tn 1907 Maylard” advocated t,he transverse incision for all abdominal surgery and stated that, transverse incisions “a ffortl more room for t,he treatment of pelvic diseases.” His incision differs from the Pfannenstiel incision in that all the layers of the alxlominal wall, from the skin to the peritoneum, are divided in the transverse plane. In 1941 . C’herney* described A modification of the Maylard incision. The main difference is that the rectus muscles are no1 divided transversely, but, are cut at their insertion into the pubis anti arc resutured to this area on closure. JVe hare employed, and advocwt e, the original Maylard incision, i.e., transverse incision of all layers, including the rectus muscles. Anatomy and Physiology Any cliscussion of abdominal incisions must he lmetl upon a nurnher of l’or this reason certain practical armtomical and physiological considcrat.ions. points in the anatomy a~1 physiology of the :~ldomir~wl wall will 1~ x*eviewecl and discussed. lrkin.--lianger’s lines of skin cleavage (WISS the anterior ahtlominal wall in a generally t,ransverse direction. It is well recognized that skin incisions 1953.

*Presented *:kPrescnt

at a meeting aMress

:

of the Louisville

701 N. Peninsula

Obstetrical Drive, 398

Daytona

am1 C,ynecological Heath,

Fla

Society,

May

2.5,

\ nlume

\i,mher

hi

?

LOW

TRANSVERSE

MUSCLE-CUTTING

IN?ISIOX

399

lnatle parallel to these lines of cleavage result in much finer ant1 firmer scars than do those which are mntle perpendicular to them. J/~t.sc~lc cl~tl _l~~ne MNW.S.--T~~ muscles of the anterior abdominal wall may be divided into the flat group and the anterior group. The fibers of the anterior muscles run vcrtic*ally while those of the flat muscles run in all essentially transverse direction. The flat muscles are from without inward: the external oblique, the internal oblique, ant1 the transversus abdominis. The aponeurotic fibers of these muscles separate at the edge of the rectus muscle to enclose that st,ructure ant1 nkeet in the midline with those of the opposite side to form a firm, fil)rous band, the linea alba. This division of the aponeuroses does not take l)lace helow a point situated about midway between the umbilicus and the symphysis pubs. Here the fibers pass in front of the respective rect.i and insert into the lima alha. The lower margin of the divided sheath is represented posteriorly hy a well-defined lunated edge, known as the linea semicircularis. LSelow this line the rectus muscle is separated from peritoneum by the transversalis fascia and preperitoneal connecti~-e tissue. The rectus sheath is con~n~only thought of hy snrgcom as a separate entity in the abdominal wall, the sole purpose of which is to enclose the rectus muscles. In reality it is -Formctl 1)~ the aponeurotic fibers of the three flat muscles. These aponeurotic fihrrs are best thought of as the “little tendons”” of the flat mnscles which insert into the linea alba and take their ijoint of action in that structure. Thus the fibers of the rectus sheat,hs run transversely and a vertical incision through the sheath, or through the linea alha, must cut across the multiple tendons of the flat muscles. The anterior gronl) of al~dominal muscles includes the recti and the pyramidalis. The pyramidalis nluscles are frequently absent and play little part in abdominal incisions or in their closure. The rectus muscles do not extend uninterruptedly from origin to insertion, hut are divided into segments by four transverse lmncls of fil~roas tissue known as “ tendinous inscriptions. ” These fibwus bands are firmly attached to the anterior rectus sheath ant1 are arranged as follows: one ab the level of the cnsiform cartilage, the second between that point and the umbilicus, the third at the umbilicus, and the fourth between the umbilicus and the symphysis pubis. Because of these firm tendinous attachments of t,he rectus muscles to the anterior, rectus sheath there can he only minimal retraction of the muscle fibers when they are rut t~ransversely. When the rcctus muscles are diridetl transversely, they heal hy the formation of a fascial support similar to an aclditional tendinous inscription without functional impairment,.” Function of the abdominal musculature Iteed not be discussed in tletail hit certain pertinent points deserve mention. (‘ontrary to popular belief, the rectus muscle, which rims longitudinally in the abclomen, does not play the chief role in the production of increased intra-abdominal pressure. The flat muscles practically encircle the abdomen and by their contraction draw the lineu alha posteriorly, decrease the circumference of the aljdomen, and Strong contraction of t,he flat muscles is compress the ahtlominal cont,ents.

400

1PILLIAMS

necessary during normal expiration, and during the acts of coughing, vomiting, and defecation these muscles must cont,ract vigorously ill or(lcr II) raisci the iiltra-ahd(Jmind pI%SUrc. ‘l’ht, muscle l)ull (luring respiration with t !I(! patient under light general anrsthcsia. has IXV~II (VIlculat~il I,I SIo:tn; 21sbeirtg between SOand 50 pounds. With these facts in mind we may readily see that any vertical incision will hare at least 30 pounds of energy applied uninterruptetlly toward wound disruption. W’ith a transverse incision the opposite situation exists, that is to say, the muscle pull aids in closing the incision. Any surgeon who has closed vertica.1 incisions with the patient straining under light anesthesia must remember the estreme difficulty with which the peritoneum and lKOStf?ritJI’ rectus sheath is closed. &‘requentIy this closure is so difficult that the peritoneum is shredded. This tlifficulty in closure is not enc~omltcrcd with transverse incisions. Nerue Sup&.-The anterior abdominal wall receives its nerve supply from the lower six intercostals together wit,h the iliohypogastric and ilioinguinal nerves. These nerves course in a more or less transverse dir&ion. While running forward between the internal oblique and transversus muscles, there is a rich anastomosis between them. Once the nerves have rcuched the lateral border of the rectus muscles, however, little if any allastomosis occurs. For this reason any incision which passes vertically through the rectus muscle or through its lateral border must denervate that port,ion of the muscle medial to the incision. On the other hand, transverse incisions through the rectus muscle result in the least possible damage to its nerve Furthermore, transverse incisions enCounter the ncrvcs laterally supply. where they are mobile and can be retxactecl. Blood S,upp7y.-The main blood supply is derivecl from the superior and inferior epigastric arteries, These vessels lit Posterior to the rectus muscle and there is a rich anastomosis between t.hem. They also freely anastomose laterally with the intercostal, lumbar, and deep circumflex iliac arteries. The inferior epigastric artery provides the largest single blood supply and frequently must be ligated in transverse incisions in the lower ahclomen. The anastomotic blood supply is so rich, however, t,hat there is no danger in t,his procedure. There is very little anastomosis across the midline and the linca alba is provided with the poorest blood supply of any area in the abdominal wall. Lymphatic Drainage.--Lymphatic drainage of the lower abdomen is from the umbilicus downward toward the inguina1 and pubic segions. The linea alba is almost destitute of lymphatics. In any transrerse incision, the lymphatic~ vessels must be severed, but the ready absorption of exudates by means 01 abundant lymphatics promotes wound healing. Technique As stated previously, we advocate the original Maylard type of incision. The technique used will be briefly described. The skin is incised in a

curvilinear fashion heginning nhout two fingerbreadths Lelow and medial t,0 the anterior superior iliac sl)inc, caressing the midline just al~orc the pubic hairline, and terminating l)clow the iliac sI)ine 0I’ the opposite side. When ever possil)lo, the wriuklth lines in the skin shoultl 1~: followed. The incision is developed through the suhcutnneous tissue and anterior rectus sheaths. At either end of the incision thth superficial epigastric vein is usually encountered, divided, and ligated. The rectus muscles are transected over a finger inserted heneath them. The inferior epignstric vessels are usually fount1 beneat,h the lateral third of the muscle and are transected and ligated. The peritoneal cavity is entered at either side of the midline. The index finger is inserted into the peritoneal cavity, the height of the bladder is ascertained, and the peritoscum is incised transversely about one fingerbreadth above the line of its reflexion from the ahdominnl wall onto the Madder. In the midline, the urachus is divided, and the rare inst,ances of its patency should be kept in inind. When additional exposure is needed the incision may he extended 1)~ incdising the ol)liquc ntuscles either to the right, or left, or both, as is necessary. Cllosurc of thr incision is facilitated if the patient is flexed slightly, although this is usually not necessary. The peritoneum and t,ransversalis fascia arc closed as a single layer using chromic catgut suture material. A continuous mattress type stitch is used to evert the cut edges carefully so that smoc&h serosa meets snlooth serosa and exact approsimwt~ion is obtained. This is essential if postoperative adhesions to the abdominal wall are to be i~voided. Furthermore, inexact peritoneal closure may lay the groundwork for subsequent entrance of a weflge of omentum or bowel which may proceed to separate the layers of the abdominal wall ant1 result in herniation or disruption of the wouncl. Suturing of t,hc r&us muscle itself is not only difficult and unaatisfactory. lmt entirely unnecessary. When the anterior rectus sheath is approsimatrd t,he eclges of the muscle will be in close proximity. The aponeurotic layers of the abdominal wall represent the only portion of the closure in which real st,rength is obtained at the suture line. The anterior rectus sheath am1 thrb muscle and nponeurotic layers lateral to the sheat,h are closed separately with interrupted silk sutures. Interrupted sutures are us4 hecausc they ilnpnrt the greatest strength. Nona.hsorbal)le suture material is the most clel~cndal~le to allow sufficient time for firm wountl healing to take place. Scarpa’s fascia being a definite fascial layer presents the only layer in the ahdominnl subcutaneous tissues which can readily he sutured. This is closet1 with interrupted sutures of fine silk or chromic catgut. These sutures are used only to obliterate dead space for they acid nothing to the strength of t,he wound. Skin closure is accomplished with interrupted sutures of fine silk. Sta.p sutures am1 incisional drains are not used under any condition.

WILLIAMS

402

Material The operative records of all pelvic laparotomies performed on the Gymcological Service at the Louisville General Hospital in 1951 and 1952 were reviewed. The type of incision used is listecl in Table I. During this two-year period there were 388 pelvic lapar(Jtornies done, and in 96 of the CRSCS, or 23 per cent, a Maylard type of incision was used.

:=a--

~ -_____

m-p_

‘I’Y I’!3

Vertical Maylard Pfannenstiel Cherne? Total--~ ____

;:. ~-

--___

~~--

-. ~__ - ~~.~~--.---

1951

183 “7 -1 ..~_~~~~ 3~~._~.~ “14 -.~~~~-~~.~.__

195%

TOTAL

101 69 4 0

284

174

3X8

The increasing popularity of this type of incision can II. In 1951 the Maylard incision was used in only 12.6 laparotomies performed. In 1952, 40 per cent of pelvic done through this incision, and during the first three months in 50 per cent of cases.

!Jti

,5 3 ~~~-.

.-~~~~

be noted in Table per cent of pelvic laparotomies were of 1953 it was usecl

The hospital charts of the 96 patients upon whom pelvic laparotomy was performed through a Maylard incision were reviewed and the following dat.a tabulated (Table III) : Eighty-six patients were Negroes while 10 patients The mortality rate was 1.04 per were white. The average age was 36 years. The cent, one patient having died during the postoperative hospital stay. cause of death was adenocarcinoma of the fundus with generalized metastases. Stay sutures were not used in a single case. Subcutaneous drains were used in 2 instances. TABI,E

No.

of patients (Maylard) Negro patients White patients Average age Mortality Stay sutures Incisional drains

III.

GENERAL INFORMATIOK --.. .__-

..-

.~

96 sti 10 36

years

1 0 2

The type of operation performed upon these patients is listed in Table IV. The procedure most frequently performed was a total hysterectomy. The allpendix was removed in 79, or slightly more than 82 per cent, of these cases. The results indicate that the appendix can be safely removed in the average pelvic operation. Accidental injury to the ileum required resection in I instance and enterorrhaphy in another. As noted in Table V, there was a complete absence of postoperative pulThe incidence of intestinal clismonary and peripheral venous complications. tention due to adynamic ileus was very low. There were 2 cases of entero-

LOW

TRANSVERSE

MUSCLE-CUTTING

INCISION

403

cutaneous fistula. One of these was the result of accidental perforation of The the ileum in a patient with peritoneal, intestinal, and pelvic tuberculosis. other followed removal of a laparotomy pad which had been left in the peritoneal cavity at a previous operation. These 2 patients developed peritonitis and wound infection but these compIications cannot be attributed to the type of incision used. An additional patient developed a wound hematoma. Four patients had postoperative urinary retention and this was the most common complication. All 4 responded readily to bladder catheterization. There was not a single case of wound disruption or evisceration requiring secondary closure. Adequate follow-up in the way of return clinic visits was obtained The period of follow-up ranged from 4 months to 24 months on all patients. and only 1 case of incisional hernia was discovered. This occurred in the patient who developed a wound infection as the result of a hematoma. TABLE On

IV.

OPERATTONS

PERFORMED

Uterus.Hysterectomy Myomectomy Suspension Fundectomy Trachelectomy

Partial

or complete

adnexeetomy

XisceELaneous Procedwes.Appendectomy Presacral neurectomy Partial pelvic lymphadenectomy Resection of ileum Enterorrhaphy Pa,qi,nal

Above

Procedures

Done

at One

or More

of the

Operations.-

Dilatation and curettage Repair of cystocele Repair of rectocele 1Jrethral diverticulectomv TABLE

V.

POSTOPERATIVE

COMPLICATIONS -NO.

PERCENTAGE

‘Pulmowzru.Atelectasis Pneumonia Embolism Thrombophlebitis ItrtestinaZ.Obstruction Distention Fistula Peritonitis IJrinary retention Wound infection Wound disruption Evisceration Hernia

0 3

? -0 4 3

3.1 3.08 2.08 4.1 3.1

0 0

i

1.04

For comparative purposes, the lower abdominal incisional hernia repairs done during this two-year period were reviewed (Table VI). There was a total of 11 incisional hernias in the lower abdomen repaired ‘and 8, or 73 per

Less ZncisiomZ R&,--Even a limited experience with transverse laparotomy will convince the surgeon, who has not previously used this method of approach, that patients have much less pain during the postoperative period. The transverse wound is less painful because nerve injury is avoided and the Vertical incisions injure the intercostal nerves ill)OlleUrOSeS are not transected. and these sectioned nerves NW hyperirritable during the early postoperative course. LOZPW JIor$idit~ rracl ;lIo&Zity.-With an almost complete absence of evisceration, herniation, thrombophlebitis, and pulmonary complications, the mortality and morbidity are necessarily lower. In vertical incisions the postoperative hyprrirritnbility of the nerve’s causes the patient subconsciously to splint the abdominal wall in a.n effort to minimize pain. This splinting of the abdomen reduces the excursions of the diaphragm and a decrease in vital capacity resulfs.ll This decreased ventilation favors the development of anosia and atelectasis as well as pneumonia. Also when a vertical incision has been used the ineisional pain and splinting which result interfere with coughing, and the elimination of secretions from the t,racheol)ronchial tree is reduced. The accumulation of these secretions favors the development of atelectasis and pneumonia. Eecause of the minimal amount of pain associated with transverse incisions, early ambulation is more easiIy accomplished and this reduces both pulmonary and venous stasis. The combination of relatively painless motion, respiration, and coughing explains the low incidence of pulmonary and peripheral venous complications. In regard to wound infection, we believe that the transverse incision handles contamination or frank infection better than the vertical incision. Not only does the increased blood supply t,o the area enable the tissues to combat infection more efficiently, but pus, when it OCCUI’S. tan readily be drained from the lateral dependent angles of the wound. Vith t,he pat,ient lying in bed the rerticnl incision is in a plane of the nbdomcn which is level throughout its length, and no matter how widely the mound is opened, pus will necessarily collect in the middle of the incision. Thus, dependent drainage is readily established in the transverse wound but is almost impossil)le to accomplish in the vertical wound. Delayed complications of laparotomy, such as abdominal adhesions, freyuently constitute a more serious p~ol&m than the original operation. Sprengell’ not,ed when doing autopsies that it was rare to find adhesions to a transverse incision, whereas it was relatively common in T-ertical incisions. Other writerC I4 have also pointed out, that, adhesions are less frequent in This may l)e esplniued by inexact peritoneal closure transverse incisions. clue to the presence of lateral tension as well as the greater damage to the The value of fewer prritaneal adhesions is nerve supply of the peritoneum.‘i better a.ppreciated when it is realized that adhesions are the most, comnlon cause of acute intestinal oltstruetion and that this car&s a mortality rate of iIl?OUt 36 per CCllt.'" Rcftcr C’O,WP~~C Re.sltTfs.-An outstantling feature of the transverse illcision is the hairline scar which results. This is an indication of more com-

plete healing as well as evidence of a gootl cosmetic result. With the recent popularity of fashions exposing the midrAY, the cosmetic end result of al)dominal incisions is becoming of more importance. Disaclvnntages.-The one disadvantage to this incision is that it takes more time to enter the peritoneal cavity. For this reason it is not reccmmended for emergency hpurotonty, such as ruptnretl ectopic pregnancy 01 other instances of intraperitoneal hemorrhage. Summary 1. A review of 96 cases of low transverse abdominal incisions of the Maylard type performed on the Gynecological &rvice at the Louisville General Hospital is presented. 2. This incision is basetl upon sound anatomical and physiological principles and offers the following clinical advantages : (1) better exposure, (2) easier closure, (3) a stronger wound, (4) less incisional pain, (5) lower morbidity and mortality, and (6) better cosmetic results. the transverse incision is the most 3. Except for emergency laparotomy, logical approach to pelvic pathology and should be used more frequently by t.he gynecological surgeon.

References 1. Baudelocque, C. A.: Nouveau pro&de pour pratiquer 1 ‘operation Cesarienne, Thesis, Paris,, No. 132, 1823. 2. Pfannenstiel, J.: Ramml. klin. Vortr., Leipzig, No. 268 (Gynak. NO. 97): 1735, 1900. 3. Maylard, A. E.: Brit. M. J. 2: 595, 1907. 4. Cherney, L. R.: Surg., Gynec. & Obst,. 72: 92, 1941. 5. Mosehcowitz, A. V.: Ann. Surg. 64: 265, 1916. 6. Rosenblabt, Surg., Gynec. t Obst. 80: 641, 1945. M. H., and Colver, Il.: 7. Sloan, 0, A.: Surg., Gynec. & Obst. 45: 678, 1927. 8. Joergenson, E. J., and Smith, E. T.: Am. J. Rurg. 79: 252, 1950. 9. Caller, F. A., and Rees, Y. L.: Areh. Surg. 47: 136, 1943. 10. Singleton, il. O., and Blocker, T. G.: J. A. M. A. 112: 122, 1939. Beecher, H. K.: .J. Clin. Investigation 12: 639, 1933. :;: Sprengel, 0.: Arch. f. klin. Chir. 92: 536, 1910. 13. MeArthur, L. L.: Surg., Gynec. & Obst. 20: X3, 1915. 14. Moore, TV. J.: Bnn. Surg. 75: 70, 1932. 15. Quain, E. P.: Arch. Surg. 1: 585, 1920. 16. Boyce, F. F., and McFetridge, B. M.: South. Surgeon 6: 109, 1937.