Abdominal Incisions in Gynaecological Surgery
On this page
Direct answer
The main abdominal incisions in gynaecological surgery are the transverse Pfannenstiel, its lower Maylard and Cherney variants, and the vertical infraumbilical midline. The Pfannenstiel suits elective pelvic surgery because it is cosmetic and less painful, while the midline gives the fastest wide access for large masses and emergencies. The choice depends on the indication, the expected size of the organ and the need for upper abdominal exposure.
What you must remember
- Pfannenstiel: a transverse incision a few centimetres above the pubic symphysis, with the rectus muscles separated in the midline rather than cut, making it the cosmetic favourite.
- Maylard: a transverse suprapubic incision in which the rectus abdominis muscles are divided across, giving wider pelvic access but requiring the inferior epigastric vessels to be secured first.
- Cherney: a lower transverse incision in which the rectus and pyramidalis tendons are cut close to the symphysis, giving good retropubic exposure for procedures such as paravaginal repair.
- Midline: a vertical infraumbilical incision through skin, subcutaneous tissue and the linea alba, opened quickest and used for large masses, malignancy and emergencies, with a higher incisional hernia risk in many series.
- Pfannenstiel layers: skin, subcutaneous fat, the anterior rectus sheath cut transversely, the rectus muscles separated in the midline, then the posterior layers and peritoneum opened vertically.
- Complications: wound infection, haematoma, seroma, wound dehiscence and incisional hernia, plus injury to the ilioinguinal or iliohypogastric nerves causing numbness or chronic groin pain.
- Bleeding source: the inferior epigastric vessels lie lateral to the midline and bleed when the rectus muscle is cut, so they must be controlled.
Opening the Pfannenstiel incision, layer by layer
A woman booked for a hysterectomy or an adnexal procedure of moderate size is a typical Pfannenstiel case. The layers are opened in a fixed order, and each one is closed in the reverse order.
- Skin: Make a transverse incision a few centimetres above the pubic symphysis, following the skin crease where possible for a better cosmetic result.
- Subcutaneous tissue: Divide the fat down to the anterior rectus sheath, controlling superficial bleeding as the dissection proceeds.
- Anterior rectus sheath: Incise the sheath transversely and free it from the rectus muscles above and below, so that the muscles can be separated.
- Rectus muscles: Separate the two muscles along the linea alba rather than cutting them, and retract them laterally to expose the lower abdomen.
- Posterior layers: Open the transversalis fascia and the peritoneum vertically, taking care of the bladder, which may lie in the lower field.
- Closure: Close the peritoneum, muscles and anterior sheath in layers, because a well-closed sheath limits later incisional hernia.
Where the exam tries to catch you
Vignettes often pair the incision with the wrong indication, or test the layers that are actually cut.
- Trap: Choosing a Pfannenstiel for a very large mass or an emergency laparotomy. Correct: Its limited field makes a vertical midline incision the better choice when rapid and wide access is needed.
- Trap: Assuming a Maylard is just a Pfannenstiel with a different skin cut. Correct: Maylard divides the rectus muscles, so the inferior epigastric vessels must be secured first and postoperative pain is usually greater.
- Trap: Ignoring the nerves when closing a transverse incision. Correct: The ilioinguinal and iliohypogastric nerves can be trapped in the closure, causing numbness or chronic groin pain.
Frequently asked questions
Which abdominal incision is commonly used for elective gynaecological surgery?
The Pfannenstiel incision is widely used for elective gynaecological surgery. It is transverse, cosmetically favoured and associated with less postoperative pain than a vertical incision, although it gives a smaller field of view.
Why is a midline incision used for large pelvic masses?
A vertical midline incision gives the fastest access and the widest field for large pelvic masses, suspected malignancy and emergencies. It is quick to open and close and allows upper abdominal exploration, although it carries a higher incisional hernia risk in many series.
Which layers are cut in a Pfannenstiel incision?
A Pfannenstiel incision divides the skin, subcutaneous fat and the anterior rectus sheath, which is cut transversely. The rectus muscles are separated in the midline rather than cut, and the transversalis fascia and peritoneum are then opened vertically.
What is the main difference between Maylard and Cherney incisions?
A Maylard incision divides the rectus abdominis muscles transversely, giving wider pelvic exposure. A Cherney incision instead cuts the rectus and pyramidalis tendons close to the symphysis, which gives good retropubic access suited to paravaginal repair.
What complications follow abdominal gynaecological incisions?
Wound infection, haematoma, seroma, wound dehiscence and incisional hernia are the commonest complications of abdominal gynaecological incisions. Injury to the ilioinguinal or iliohypogastric nerves can cause numbness or chronic groin pain after a transverse incision.