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Abdominal entry is the first step for many gynecologic surgeries. Either vertical or transverse incisions may be used to gain access, and each offers particular advantages. Vertical incisions may be midline or paramedian, but of the two, the midline is chosen more often. This incision offers quick entry, minimal blood loss, superior access to the upper abdomen, generous operating room, and the flexibility for easy wound extension if greater space or access is needed. No important neurovascular structures traverse this incision. Thus, this incision may be favored in the patient who is using anticoagulation agents.

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Preoperative

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Consent

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Despite these advantages, midline incisions are more frequently associated with greater postoperative pain, poorer cosmetic results, and increased risk of incisional hernia compared with low transverse incisions. Risk of bowel injury is present with any abdominal entry, especially when extensive adhesions are present. Wound infection and venous thromboembolism may complicate abdominal surgery and are discussed in Chapter 39.

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Intraoperative

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Surgical Steps

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1 Anesthesia and Patient Positioning
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After administration of adequate regional or general anesthesia, the patient is positioned supine. If needed, hair in the path of the planned incision is clipped; a Foley catheter is placed; and abdominal preparation is completed.

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2 Skin and Subcutaneous Layer
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A midline vertical incision is made sharply beginning 2 to 3 cm above the symphysis pubis and is extended cephalad to within 2 cm of the umbilicus. In cases that require larger operating space or extensive access to the upper abdomen, the incision may arch around to the left of the umbilicus and continue cephalad as needed. The subcutaneous layers of Camper and Scarpa are incised to reach the fascia.

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3 Fascia
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Tendinous fibers from the anterior abdominal wall aponeuroses merge in the midline of the abdomen to form the linea alba. This fascia layer is sharply entered near the midpoint of the incision to avoid potential injury to the bladder. This incision is extended cephalad and caudally to mirror the length of the skin incision. During this extension of the fascial incision, the linea alba may be elevated with finger tips or the ends of a Pean clamp to minimize injury to tissues below (Fig. 41-1.1).

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4 Peritoneum
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The peritoneum is identified between the bellies of the rectus abdominis muscle, grasped with two fine forceps or hemostats, and sharply cut. Similarly, this incision is extended cephalad and caudally (Fig. 41-1.2). Fingers are placed underneath and elevate the peritoneum to prevent bowel injury. As the incision is extended caudally, the bladder dome can be identified by the increasing vascularity and thickness of ...

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