MIDLINE VERTICAL INCISION
Abdominal entry is the first step for many gynecologic surgeries. Incisions are vertical or transverse, and each offers particular advantages. Vertical incisions may be midline or paramedian, but of the two, the midline is predominantly chosen. 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, it may be favored for patients using anticoagulation agents. Despite advantages, midline incisions are more frequently associated with greater postoperative pain, poorer cosmetic results, and higher risk of wound dehiscence or incisional hernia compared with low transverse incisions (Bewö, 2019; Grantcharov, 2001). For those with prior laparotomy, the incision type is typically repeated for subsequent surgeries.
Specific to abdominal entry, the risks of wound infection and later dehiscence are discussed. In addition, the bowel or bladder may be injured during any abdominal entry, especially when extensive adhesions are encountered.
When weighing intraoperative contamination and infection risk, laparotomy itself is considered a clean procedure. Despite this, based on some evidence, antibiotic prophylaxis listed in Table 39-8 (p. 832) may be considered solely for the indication of laparotomy (American College of Obstetricians and Gynecologists, 2018b; Morrill, 2013). Bowel preparation is infrequently needed and is dictated by the planned procedure. Prevention for venous thromboembolism (VTE) is warranted and described in Chapter 39 (p. 834).
ANESTHESIA AND PATIENT POSITIONING
After administration of adequate regional or general anesthesia, the patient is supine or in low lithotomy position. If needed, hair in the path of the planned incision is clipped; a Foley catheter is placed; and abdominal preparation is completed.
SKIN AND SUBCUTANEOUS LAYER
The skin is incised vertically in the midline beginning 2 to 3 cm above the symphysis pubis and extending cephalad to within 2 cm of the umbilicus. If less space is required, this incision may be shortened. For greater space or access, the incision may arch around the umbilicus and then continue cephalad in the upper abdominal midline. This extension passes to the left of the umbilicus to avert transection of the ligamentum teres. This remnant of the umbilical vein courses in the free border of the falciform ligament. The umbilicus itself contains attenuated fascia. Thus, the periumbilical incision arches sufficiently lateral to provide quality fascia on either side of the incision for a secure final closure.
The more superficial fatty layer of the subcutaneous tissue (formerly Camper fascia) and then the deeper membranous layer of the subcutaneous tissue (formerly Scarpa fascia) are incised ...