Thus, compared with vertical ones, Pfannenstiel incisions ofer superior cosmesis and lower incisional hernia rates. Use of the Pfannenstiel incision, however, is often discouraged for cases in which a large operating space is essential or in which access to the upper abdomen may be needed. With transverse incisions, because of the layers created during incision of the internal and external oblique aponeuroses, purulent fluid can collect between these. Therefore, some favor a midline vertical incision for cases with high infection risks. Emergent entry is typically faster with vertical incision during primary and repeat cesarean delivery (Wylie, 2010). Last, neurovascular structures, which include the ilioinguinal and iliohypogastric nerves and supericial and inferior epigastric vessels, are often encountered with transverse inCISIons. Logically, bleeding, wound hematoma, and neurological disruption may more frequently complicate these incisions compared with vertical ones. he best incision for the morbidly obese parturient is unclear (Smid, 2016). As discussed in Chapter 48 (p. 943), our preference with very obese women is a periumbilical midline vertical incision.
he Maylard incision difers mainly from the Pfannenstiel in that the bellies of the rectus abdominis muscle are transected horizontally to widen the operating space. It is technically more diicult due to its required muscle cutting and isolation and ligation of the inferior epigastric arteries, which lie laterally to these muscle bellies.
Once access is gained, metal handheld retractors provide exposure for hysterotomy. A few small randomized studies have evaluated postcesarean wound infection rates with a disposable plastic barrier retractor (Alexis-O). Results showing benefit are contradictory (Hinkson, 2016; Scolari Childress, 2016; heodoridis, 2011).
With the Pfannenstiel incision, the skin and subcutaneous tissue are incised using a low, transverse, slightly curvilinear incision. his is made at the level of the pubic hairline, which is typically 3 cm above the superior border of the symphysis pubis. The incision is extended laterally suiciently to accommodate delivery-12 to 15 cm is typical.
Sharp dissection is continued through the subcutaneous layer to the fascia. The supericial epigastric vessels can usually be identiied halway between the skin and fascia, several centimeters from the midline, and are coag ulated. If lacerated, these may be suture ligated with 3-0 plain gut suture or coag ulated with an electro surgical blade.
he fascia is then incised sharply at the midline. he anterior abdominal fascia is typically composed of two visible layers, the aponeurosis from the external oblique muscle and a fused layer containing aponeuroses of the internal oblique and transverse abdominis muscles. Ideally, the two layers are individually incised during lateral extension of the fascial incision. The inferior epigastric vessels usually lie outside the lateral border of the rectus abdominis muscle and beneath the fused aponeuroses of the internal oblique and transverse abdominis muscles. hus, although infrequently required, extension of the fascial incision further laterally may cut these vessels. With extension, these vessels are best identiied and coagulated or ligated to prevent bleeding and vessel retraction.