MAYLARD INCISION OF THE ABDOMINAL WALL

Cares need to be taken to avoid the inferior epigasteric vessels while using accessory trochars during laparascopy and to ensure that they are identified and closed appropriately when making a maylard incision of the abdominal wall.

Pfannenstiel incision

The Pfannenstiel incision results in good exposure to the central pelvis but limits exposure to the lateral pelvis and upper abdomen. These factors limit the usefulness of this incision for gynecologic cancer surgery. If the patient is thin and has a gynecoid or platypelloid pelvis, this incision can be used for a radical hysterectomy and pelvic lymph node dissection.

The incision is usually made 1-2 fingerbreadths above the pubic crest. Use of a marking pen is helpful to keep the incision symmetric. An incision length of 10-14 cm is sufficient. Increasing the length of the skin incision usually does not improve exposure due to the rectus muscles. The incision is made through the subcutaneous fat to the fascia. The superficial epigastric vessels are often near the lateral edges of the incision.

The anterior fascia is incised in the midline with a scalpel or electrocautery. Using curved scissors or electrocautery, the fascia is incised in a curvilinear fashion 1-2 cm lateral to the rectus muscle. The upper edge of the fascia is grasped with 2 Kocher clamps on either side of the midline. Using electrocautery, the rectus muscle is dissected free from the fascia. Electrocautery allows coagulation of multiple small vessels that perforate the rectus muscle to the fascia. The rectus muscles are mobilized off the fascia to the level of the umbilicus. Next, the lower fascial edge is grasped with Kocher clamps. Electrocautery is used again to dissect the rectus muscles and the pyramidalis muscle from the fascia. The rectus muscles are separated. The peritoneum is opened and incised vertically to complete a Pfannenstiel incision.

Closure of the Pfannenstiel incision is straightforward. The peritoneum does not need to be closed separately as re-epithelization occurs within 48 hours. Closure of the peritoneum does not add to the strength of the incision. Regardless of whether the peritoneum is closed, the rectus muscles should be thoroughly irrigated with water or saline, and any bleeding areas should be cauterized or ligated. Bleeding from small perforating vessels through the rectus muscle is the most common source of subfascial hematoma. The fascia is approximated with a delayed absorbable suture. Usually, a separate suture is started at each end of the fascial incision, and all layers of the anterior rectus sheath are incorporated. Unless a large area of dead space exists between the fascia and the skin, closure of the Scarpa fascia is not needed. Placement of a closed drainage system, like a Jackson-Pratt drain, may be needed if a large amount of fluid collection is anticipated.

Maylard incision

In an effort to improve surgical exposure to the lateral pelvic sidewall with a transverse incision, Maylard proposed a transverse muscle-splitting incision. This incision usually refers to a subumbilical transverse incision. For gynecologic surgery, the incision is made 3-8 cm superior to the pubis symphysis. The anterior rectus sheath is cut transversely. The inferior epigastric vessels are identified under the lateral edge of each rectus muscle and then are ligated. Patients with significant peripheral arterial disease may experience ischemia from ligation of the inferior epigastric vessels. These patients may have collateral flow from the epigastric vessels to the lower extremities. After ligation of the inferior epigastric vessels, electrocautery is used to transversely cut the rectus muscle. The peritoneum is opened and cut laterally.

To facilitate closure of a Maylard incision, flex the operating table. Close the peritoneum with an absorbable suture. Next, inspect the ties placed on each inferior epigastric vessel, and irrigate with water. Examine the cut edges of the rectus muscles for any bleeding areas. The fascia and underlying rectus muscle can be closed with a monofilament absorbable suture.