Vertical compared with transverse incisions in abdominal surgery

Objective: To reach an evidence-based consensus on the relative merits of v ertical and transverse laparotomy incisions. Design: Review of all published randomised controlled trials that compared the postoperative complications after the two main types of abdominal incis ions, vertical and transverse. Setting: Teaching hospital, Denmark. Subjects: Patients undergoing open abdominal operations. Interventions: For some of the variables (burst abdomen and incisional hern ia) it was considered adequate to include retrospective studies. Studies we re identified through Medline, Cochrane library, Embase, and a manual searc h of relevant journals. The references cited in these studies were reviewed to find out whether any other trials fitted the selection criteria. Main outcome measures: Early complications including postoperative pain, pu lmonary complications, burst abdomen, wound infection, and hospital stay, a nd late complications (incisional hernia). Results: Eleven randomised controlled trials and seven retrospective studie s were identified. The transverse incision offers as good an access to most intra-abdominal structures as a vertical incision. The transverse incision results in significantly less postoperative pain and fewer pulmonary compl ications. Vertical laparotomy, however, is associated with shorter operatin g time and better possibilities for extension of the incision. The pooled o dds ratio for burst abdomen in the vertical incision group was 2.86 (95% co nfidence interval 1.72 to 4.73, p = 0.0001), and regarding late incisional hernia the pooled odds ratio was 1.68 (95% confidence interval 1.10 to 2.57 , p = 0.02). Conclusions: Transverse incisions in abdominal surgery are based on better anatomical and physiological principles. They should be recommended, as the early postoperative period is associated with fewer complications (pain, b urst abdomen, and pulmonary morbidity) and there is lower incidence of late incisional hernia after transverse compared with vertical laparotomy. A mi dline incision is still the incision of choice in conditions that require r apid intra-abdominal entry (such as trauma) or where the preoperative diagn osis is uncertain, as it is quicker and can easily be extended.