Midline Abdominal Incision 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
 www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
The midline abdominal incision is by far the 
most commonly used incision in abdominal surgery. 
It allows rapid access to all the abdominal cavity. It 
is extensible if access is limited or if unexpected 
findings prompt a change in strategy. It does not 
require a muscle to be split and therefore it can be 
closed rapidly, in one layer.  
 
An understanding of the midline incision and 
all of its variations is part of the foundation of 
abdominal surgery. The incision and closure proceed 
in the following general steps:  
● Skin incision and division of the subcutaneous fat 
● Division of the linea alba 
● Dissection of the preperitoneal space  
● Division of the peritoneum 
● Intra-abdominal intervention 
● Closure, beginning separately at each end of the 
incision and meeting in the middle 
● Skin closure 
 
Steps: 
1. The surgeon generally stands opposite the side of 
expected pathology. For pelvic surgery, the 
surgeon stands on the side that will allow the 
dominant hand to have direct access to the pelvis.  
2. The area of planned incision is marked, if 
desired. If there is any possibility of an ostomy, 
curve the incision to the opposite side of the 
umbilicus 
 
The planned incision can be marked by gently scratching the 
skin with an instrument. This step is not mandatory. 
 
3. Incise the skin with a scalpel, down to the level 
of the dermis or subcutaneous tissue.  
 
Incision of the skin through the epidermis alone allows better 
hemostasis, as the dermis with its blood vessels can now be 
divided with diathermy. 
Midline Abdominal Incision 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
 www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
  
4. If the dermis has not been completely divided, 
divide it with the “Cut” setting on the diathermy. 
 
Using the “Cut” setting on the diathermy at this point 
minimizes scarring but controls bleeding from the dermis better 
than cutting straight through with a scalpel blade.   
 
5. Both surgeon and assistant apply direct pressure 
on the cut skin edges while dividing the 
subcutaneous fat, causing it to separate in an even 
manner.  
 
Pulling on both sides of the incision will cause the 
subcutaneous fat to separate more easily under diathermy, until 
the linea alba is reached.  
 
6. The linea alba, the midline between the rectus 
muscles, is incised. If the incision is on the 
midline, the preperitoneal fat is seen. If the 
incision is off midline, one of the rectus muscles 
will appear instead. Try to judge which direction 
to cut in order to return to the midline.  
 
The linea alba has been divided and the preperitoneal fat is 
seen. The peritoneum itself is a variable depth beneath this, 
depending on the patient’s body habitus.  
 
7. Once the preperitoneal space is opened, the 
surgeon can insert a finger into it and bluntly 
dissect the fat posteriorly away from the fascia, 
making division of the fascia easier.  
 
Finger dissection between the fascia and the preperitoneal 
space allows controlled division of the fascia.  
 
Midline Abdominal Incision 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
 www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
8. In patients with scant preperitoneal fat, 
sometimes the peritoneum itself will be entered 
while dividing the linea alba. If this occurs, insert 
a finger into the peritoneum and continue to 
divide the linea alba, preperitoneal fat and 
peritoneum all at once.  
9. In cases of abdominal distention, one must take 
care while entering the peritoneum to not damage 
the intestines underneath. Bluntly dissect through 
the preperitoneal fat until the peritoneum itself is 
seen. Grasp the peritoneum and pull it upwards 
with two hemostats or forceps.  
 
Beneath the preperitoneal fat, the peritoneum will be seen as a 
glistening white structure. Grasp it with two forceps, taking 
care not to grasp any intestines underneath, and elevate it.  
 
10. Cut between the forceps and then widen the 
opening into the peritoneum carefully.  
 
The peritoneum has been cut and the intraperitoneal fat is 
visible underneath.  
 
11. Insert a finger into the peritoneum and use 
diathermy to divide the peritoneum and 
preperitoneal fat.  
 
The peritoneum is divided over the finger of the surgeon’s 
nondominant hand. This finger also feels for any adhesions, 
which can then be visualized and divided if necessary.  
 
12. For maximum exposure in the pelvis, the division 
of the linea alba can extend all the way to the 
Midline Abdominal Incision 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
 www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
pubic symphysis. Bluntly dissect with a finger in 
the prevesical space to be sure the bladder is not 
damaged during entry.  
13. For maximum exposure in the upper abdomen, 
the division of the linea alba can be extended to 
one side of the xiphoid process. During 
subsequent closure, be sure the suture passes 
through the anterior rectus sheath fascia anterior 
to the xiphoid process, rather than encircling or 
piercing the bone itself.  
 
Incise the fascia adjacent to the xiphoid process (Black dot) to 
extend the upper abdominal incision by 2cm. When closing, 
suture only the fascia anterior to the bone and avoid encircling 
or piercing it with the suture.  
 
14. Once the surgery is complete, irrigate the 
abdominal cavity with warm saline. Adding 
antibiotics to the irrigation has not been shown to 
decrease the risk of intra-abdominal infection 
and may increase adhesion formation.  
15. Close the fascia with a running, slowly 
absorbable or non-absorbable suture such as 
polydioxanone 
(PDS) 
or 
polypropylene 
(Prolene.) The surgeon will begin at the end of 
the wound that is most easily reached by their 
dominant hand. Then, the assistant will be 
positioned to begin sewing at the other end. Do 
not close a laparotomy incision by sewing 
straight from one end to the other, because it will 
be difficult to see the needle as the last few 
stitches are placed, placing the patient at risk for 
bowel injury.  
 
The surgeon (Blue) begins sewing at the apex of the wound that 
their dominant forearm is most closely perpendicular to. The 
assistant is shown in Red.  
 
 
The assistant (Red) then begins sewing from the other apex of 
the wound, so that the two sutures can meet in the middle. This 
avoids the unsafe practice of “sewing into a corner.”  
 
16. Begin sewing. Grasp the apex of the incision with 
a Kocher clamp. A wide malleable retractor is 
placed inside the abdomen to hold the intestines 
away from the closure. The assistant retracts the 
skin and subcutaneous tissue with a small 
handheld retractor.  
Midline Abdominal Incision 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
 www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Grasp the apex of the fascial incision with a Kocher clamp. The 
surgeon will hold this in the non-dominant hand while placing 
the first stitch. Protect the viscera from the closure with a wide 
malleable clamp which is repositioned frequently during the 
closure. The assistant retracts the skin and subcutaneous tissue 
with a small retractor to expose the fascia.  
 
17. Stitches are placed every 5-8mm, with bites no 
deeper than 5-8mm. It is tempting to take 
“deeper” bites, which in fact may seem 
“stronger,” but this approach actually leads to a 
higher chance of dehiscence and hernia. Overall, 
the ratio of suture length to wound length should 
be 4:1.  
 
The sutures are placed taking bites of no deeper than 5-8mm, 
and advancing no more than 5-8mm.  
 
 
The total length of each suture will be greater than twice the 
length of the wound to be closed, resulting in a ratio of 4:1 
suture to wound closure length.  
 
 
Bites are taken in the fascia only. Be sure you see the tip of the 
needle at all times. When the anterior and posterior rectus 
fascia have been divided separately, it is acceptable to take only 
the anterior fascia. Recall that below about 3cm caudal to the 
umbilicus, only the anterior rectus fascia should be sutured, as 
the posterior rectus sheath here is not a fascial layer.  
 
Midline Abdominal Incision 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
 www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
18. It is our practice to place nonabsorbable internal 
retention sutures in the fascia every 3-5cm, 
especially 
in 
patients 
who 
are 
obese, 
malnourished, or have other risk factors for poor 
wound healing.  
 
Interrupted internal retention sutures are placed every 3-5cm. 
Again, be sure you see the tip of the needle at all times while 
placing these sutures. The assistant maintains traction on the 
previously placed sutures.  
 
19. The assistant begins a second suture at the 
opposite end of the incision. The two sutures will 
meet in the middle of the incision. This avoids 
placing the last few sutures of the abdominal 
closure at one end of the incision, where poor 
visualization increases the risk of damaging 
viscera with the needle. 
20. The last 5cm of closure is done without traction 
on the sutures, so that the inside of the fascia can 
be seen during their placement. The narrow 
malleable retractor is used to protect the viscera 
during suture placement. 
 
The final stitches, in the center of the incision, are placed 
without the assistant maintaining traction on the previously 
placed sutures. A narrow malleable retractor is inserted, 
perpendicular to the incision, underneath the space where the 
needle will be passing. Following these steps assures that the 
tip of the needle will be seen as every stitch is taken. These loose 
stitches will be pulled tight once the closure is complete.   
 
 
Once the closure is complete, pull the suture tight from both 
ends and then tie the two sutures to each other.  
 
21. Irrigate the subcutaneous space and assure 
hemostasis.  
Midline Abdominal Incision 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
 www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Irrigate the subcutaneous space until it returns clear.  
 
 
Examine the subcutaneous space and cauterize any bleeding 
sites, to prevent blood from accumulating in the wound.  
 
22. The subcutaneous fat is not closed under normal 
circumstances, but if a large space remains after 
resection of a tumor or closure of an incisional 
hernia, the fat in this space can be approximated 
with a few absorbable sutures.  
23. The skin is closed with staples or interrupted 
sutures. Running suture is avoided, in case a part 
of the wound needs to be opened later to treat a 
wound infection.  
 
Special Situations:  
Previous laparotomy: Patients who have already had 
a laparotomy are prone to bowel injury during entry. 
The best way to avoid this situation is to open the 
abdomen in an area it has not already been opened 
before. Make the initial incision about 4cm above or 
below the previous scar and carry the incision 
through 
the 
subcutaneous 
tissue, 
fascia, 
preperitoneal fat and peritoneum as described above. 
Then extend the incision into the previously opened 
space, visualizing the inside of the peritoneum and 
dissecting any adhesions to the planned incision 
before making it.  
 
It is almost always possible to find a part of 
the abdomen that has not been previously opened. 
But if the previous incision has truly gone from 
xiphoid to pubis, enter slowly and carefully, 
dissecting layer by layer, elevating each layer with a 
dissecting forceps before dividing it. When scar 
tissue becomes bowel, attempt to dissect along the 
surface of the bowel to find the plane interior to the 
peritoneum. See the Chapter, Lysis of Adhesions for 
more details.  
 
When performing laparotomy on a patient who has a previous 
laparotomy, begin about 4cm above the scar, leaving enough 
room to open the abdomen in a previously undissected space 
and see inside the peritoneum while extending the incision.  
 
Wound dehiscence: When this occurs, carefully 
consider what the reasons might be. If you are sure 
the cause is a technical error, it is reasonable to close 
again in the manner described above, including 
internal retention sutures.  
Midline Abdominal Incision 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
 www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
One common cause of dehiscence is intra-
abdominal infection, usually accompanied by 
anastomotic leak. When this happens the dehiscence 
will be accompanied by purulent, bilious or feculent 
discharge. The best option in this case is to 
resuscitate, give antibiotics, and then reoperate and 
externalize the anastomosis as an ostomy. If the leak 
is in the stomach, duodenum, or proximal jejunum, it 
must be repaired with an omental patch or drained 
with a roux limb, options that are described 
elsewhere in this Manual. If you do not operate in 
this situation, it becomes an enter-cutaneous or 
entero-atmospheric 
fistula. 
Non-operative 
management of this problem includes total parenteral 
nutrition, bowel rest, and intensive nursing; these are 
scant resources in settings such as ours. The patient 
is better treated with a relaparotomy and attempt to 
close the fistula.  
 
This patient presented to our facility after a laparotomy 
elsewhere and no history available. He was resuscitated, given 
antibiotics, and then explored. After a very difficult dissection, 
a small bowel injury was found and repaired with an omental 
patch.  
 
If the dehiscence is due to patient factors such 
as malnutrition, infection, immunosuppression, or 
something else out of your control, you face a 
difficult decision. One option, if the dehiscence is 
small and there is no infection, is to do nothing. Make 
sure that the skin is completely open so no infection 
can accumulate, and pack the wound gently with 
gauze. A vacuum dressing may help the skin wound 
to contract over the dehiscence, which converts the 
problem to a hernia. Make sure that nutrition is 
optimized in this case. We would strongly consider a 
nasogastric tube and aggressive feeding, as the 
patient has already “failed” nutrition once.  
 
This 80 year old woman with malignant small bowel 
obstruction underwent laparotomy and ileostomy placement. 
Postoperatively she had a wound dehiscence of about 4cm in 
length in the mid-portion of her wound. After assuring there 
was no infection, we used aggressive nutrition and vacuum-
assisted closure to make the wound smaller and more 
manageable at home. She was discharged to home hospice. For 
more information on vacuum-assisted closure, see the Section 
on Wound Care.  
 
If the dehiscence is large and due to patient 
factors, you must reoperate. If there is no intra-
abdominal infection, do not endanger the patient by 
trying to dissect much intra-abdominally. Close the 
fascia with a running non-absorbable suture, using 
the principles above, supplemented with interrupted 
full-thickness retention sutures going through all 
layers of the abdominal wall including the skin. 
These will remain in place for 2-3 months at least. 
Aggressively treat this patient’s malnutrition and any 
other factors that may have contributed to the wound 
dehiscence. If none is apparent consider tuberculosis 
or the Human Immunodeficiency Virus (or both in 
combination!)  
 
Pitfalls 
Midline Abdominal Incision 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
 www.vumc.org/global-surgical-atlas  
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● Visceral injury is possible during opening, 
especially if the bowels are distended. The 
surgeon should be very clear about the 
anatomical layers at the time of incision. For 
emergency surgery, it is important to be speedy, 
but causing a bowel injury will make the 
operation take longer overall.  
● Incisional hernia formation: Risk factors for this 
complication 
include 
emergency 
surgery, 
obesity, steroid use, chronic cough, tobacco use, 
and connective tissue disorders. Patients with 
abdominal aortic aneurysm also have an 
increased risk of postoperative hernia formation. 
Meticulous closure using the principles described 
above will decrease the risk of this complication.  
● Fascial dehiscence in the acute phase is a 
complication 
that 
usually 
requires 
repeat 
operation. Excessive amount of serous fluid 
drainage from the wound is one clue that this has 
occurred. If you suspect wound dehiscence, open 
a small part of the wound at the bedside and 
probe with your finger; most patients can tolerate 
this kind of examination if it is done gently. See 
Chapter, “Closure of Laparotomy Wound 
Dehiscence.” 
● Visceral injury is very possible during closure: 
make sure the tip of the needle is visualized at all 
times as it passes through the fascia.  
● Wound infection after any laparotomy must be 
watched for. Remove the dressing after 48 hours 
and from then on only cover parts of the wound 
that are bleeding or leaking serous fluid. If there 
is any erythema, firmness, or cloudy discharge 
from the wound, remove a few sutures or staples 
and probe the space with a finger to rule out 
fascial dehiscence. The wound must be opened 
enough to allow any open space under it to drain. 
Pack the space with a gauze and change the 
dressing twice daily. It is not necessary to culture 
the wound or to start antibiotics for a small 
wound infection: opening the wound and packing 
it regularly will be enough.  
 
 
 
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital  
Kenya 
 
May 2022 
 
