Incisions in Gynecological Surgery

General Principles for Choosing an Incision

1. Simplicity of the incision
2. Need for exposure (type and extent of surgery)
3. Potential need for enlarging the incision intraoperatively
4. Strength of the healed wound
5. Cosmetics of the healed incision
6. Location of previous surgical scars

A. ABDOMINAL INCISIONS

1. Midline (Vertical) Incision

• Position: Runs from the umbilicus (or above) down to the pubic symphysis
• Layers divided: Skin, subcutaneous tissue, linea alba (avascular), peritoneum
• Advantages:
  • Rapid entry and exit
  • Easily extended upward (above umbilicus) for better exposure
  • Excellent access for radical procedures (radical hysterectomy, staging laparotomy for gynecologic malignancy)
  • Suitable when pathology is uncertain or upper abdominal exploration is needed
• Disadvantages:
  • Poor cosmesis
  • Higher risk of incisional hernia compared to transverse incisions
  • More postoperative pain
• Used in: Radical hysterectomy, staging procedures for ovarian/endometrial cancer, emergency surgeries

2. Pfannenstiel Incision

• Position: Transverse skin crease incision, placed just above the pubic symphysis (in the interspinous crease)
• Layers:
  • Skin + subcutaneous tissue are cut transversely
  • Anterior rectus sheath is cut transversely
  • Superior and inferior fascial leaflets are dissected off the underlying rectus muscles (superiorly to umbilicus, inferiorly to pubic symphysis)
  • Rectus muscles are retracted laterally
  • Peritoneum is opened vertically in the midline
  • Bladder is protected at the inferior aspect
• Advantages:
  • Cosmetically excellent - scar lies in skin crease at belt line
  • Strong wound closure, low hernia risk
  • Less postoperative pain
• Disadvantages:
  • Limited exposure - cannot be easily extended for upper abdominal access
  • Slower to open and close than midline
  • Lateral pelvic exposure is limited
• Used in: Simple hysterectomy, myomectomy, cesarean section, benign pelvic surgery

3. Maylard Incision

• Position: Transverse incision, similar level to Pfannenstiel
• Layers:
  • Skin and subcutaneous tissue divided transversely
  • Anterior rectus sheath opened transversely
  • Rectus abdominis muscles are transversely divided (key difference from Pfannenstiel)
  • Inferior epigastric vessels identified and ligated before muscle division
  • Peritoneum opened transversely
• Advantages:
  • Excellent lateral pelvic exposure - far superior to Pfannenstiel
  • Ideal for pelvic lymphadenectomy
  • Cosmetically acceptable (low transverse scar)
• Disadvantages:
  • More bleeding (muscle division)
  • Risk of injury to inferior epigastric vessels
  • Potential for nerve injury (iliohypogastric, ilioinguinal) leading to abdominal wall weakness
  • Technically more demanding
• Used in: Radical hysterectomy with pelvic lymphadenectomy, wide lateral pelvic dissection, cervical cancer surgery

4. Cherney Incision

• Position: Transverse, same level as Pfannenstiel/Maylard
• Layers:
  • Skin and anterior rectus fascia divided transversely
  • Rectus muscles are detached at their tendinous insertions on the pubic symphysis (not cut through the belly - key difference from Maylard)
  • Inferior epigastric vessels preserved
  • Provides access to retropubic/space of Retzius
• Advantages:
  • Excellent lateral and retropubic exposure
  • Better than Pfannenstiel for lymphadenectomy
  • Inferior epigastric vessels spared (less bleeding than Maylard)
• Disadvantages:
  • Risk of rectus muscle denervation
  • Technically demanding
• Used in: Radical hysterectomy, pelvic lymphadenectomy, procedures requiring retropubic access

As stated in Berek & Novak's Gynecology (p. 2243): "The abdomen is opened through a midline incision or a low transverse incision after the methods of Maylard or Cherney. The low transverse incision requires division of the rectus muscles and provides excellent exposure of the lateral pelvis. It allows adequate pelvic lymphadenectomy and wide resection of the primary tumor."

B. VAGINAL INCISIONS

5. Schuchardt Incision (Paravaginal Relaxing Incision)

• Technique (Berek & Novak's Gynecology, p. 1451-1452):
  • Area infiltrated with lidocaine + epinephrine to reduce blood loss
  • Incision follows a curved line from the 4-o'clock position at the hymenal margin to a point halfway between the anus and the ischial tuberosity
  • Can be extended into the vaginal vault superiorly as needed
  • Depth: reaches the medial portion of the pubococcygeus muscle (may be divided in extreme cases)
  • Must be closed in layers at the end of the procedure
• Indication: When vaginal exposure is difficult - radical vaginal (Schauta) hysterectomy, vaginal fistula repair

6. Colpotomy (Vaginal Incision)

• Anterior colpotomy: Incision through the anterior vaginal wall into the vesicovaginal space
• Posterior colpotomy (culdotomy): Incision through the posterior vaginal fornix into the pouch of Douglas (cul-de-sac of Douglas)
  • Used for: drainage of pelvic abscess, culdoscopy, retrieval of ectopic procedures
• Incision of posterior peritoneum: Standard step in vaginal and abdominal hysterectomy

C. LAPAROSCOPIC PORT INCISIONS

7. Trocar/Port Site Incisions

• Fascial incisions >10 mm in diameter significantly increase risk of dehiscence and hernia (Berek & Novak's Gynecology, p. 1336)
• Fascia must be closed with suture ligatures under laparoscopic vision or with 5/8 round needles
• Peritoneum should be closed to reduce risk of Richter hernia (loop of bowel caught at port site)

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