This is part of the Gynsurgery guidelines used in an educational setting for residents in Ob-Gyn.


  1. Midline
    1. Repeat midline if previous midline
    2. Pelvic mass at umbilicus or above
    3. Pelvic mass with 5% or greater chance of malignancy
    4. Emergent laparotomy due to severe hemorrhage
    5. Transverse incision would fall under a pannus
  2. Maylard
    1. For benign uterine masses with lateral extension (e.g. fibroids)
    2. For ovarian enlargement >8cm and likely (>95%) to be benign
    3. Repeat if previous Maylard incision and none of criteria for midline incision met
  3. Pfannenstiel
    1. Repeat if previous and none of criteria for midline or Maylard incision met
    2. Used for most reproductive excisional sugery when vaginal procedure is not indicated


  1. Wound dehiscence
    1. Place fascial sutures approximately 1.0 cm from edge of facscia and approximately 1.0 cm apart
    2. Avoid excessive tightness of fascial sutures
    3. On midline incisions close peritoneum with fascia through the rectus sheath using continuous monofilament delayed absorbable or permanent suture
    4. On Pfannenstiel or Maylard incisions, close or approximate abdominal peritoneum as a separate layer.
    5. Memorize the risk factors for wound dehiscence to identify high risk patients: diabetes, smoking, obesity, chronic lung disease., previous irradiation, poor nutritional status
    6. Postoperatively, avoid excessive Valsalva
  2. Wound seroma/hematoma
    1. If midline incision is extended above the umbilicus, extend around the left of the umbilicus to avoid the ligamentum terres
    2. Cauterize or ligate superficial epigastric vessels on transverse incision even if not bleeding at time of transection
    3. Cauterize or ligate rectus perforating vessels on Pfannenstiel incision even if not bleeding at time of transection
    4. Ligate inferior epigastic vessels on Maylard incision
    5. Observe subfascial space at the end of procedure for bleeding.
    6. Use compression dressing for 48 hours before removing
  3. Wound Infection
    1. Advise to discontinue smoking at least 30 days prior to procedure
    2. For hair removal if needed, use clipping just prior to surgery rather than shaving
    3. Avoid excessive use of cautery (do not cut incision with cautery)
    4. Close subcutaneous tissue with running continuous absorbable suture if 2.0 cm of subcutaneous fat or more
  4. Poor cosmetic result
    1. Symmetry
      1. Identify midline and anterior iliac spine and mark on skin the line of the incision if needed
    2. Approximation
      1. Incise along lines of Langer’s
      2. When removing old scar, excise subcutaneous tissue symmetrically
      3. On transverse incisions, reapproximate Scarpa’s fascia superiorly to Scarpa’s fascia inferiorly
    3. Keloid formation
      1. Avoid suture in dermis (it should be below dermis)
      2. Close skin with steristrips or bonding
    4. Peripheral scarring
      1. Avoid skin staples or if used, remove by 3rd day
    5. Nerve entrapment/persistent incisional pain
      1. Illiohypogastric and illioinguinal nerves (transverse incisions)
        1. Follow lines of Langer curving transverse incisions upward laterally so as not to transect nerves
        2. Start incision at least 3-5 cm above symphysis pubis in midline so as not to transect nerves
        3. Avoid extreme lateral extension of incision into internal oblique muscle
        4. When closing anterior rectus fascia avoid subcutaneous tissue to prevent nerve entrapment
      2. Genitofemoral nerves
        1. Avoid lateral retraction compressing psoas muscle (especially self-retaining Balfour, OConner-O’Sullivan)
    6. Postoperative hernia
      1. See wound dehiscence principles

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