Pfannenstiel Incision 
Marianna Frazee, 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 Pfannenstiel Incision derives its name 
from Hermann Johannes Pfannenstiel (1862–1909), 
the German gynecologist who invented the technique 
in 1900. In the UK, the incision was popularized by 
Monroe Kerr, who first used it in 1911, so in English-
speaking countries it is sometimes called the Kerr 
incision or the Pfannenstiel–Kerr incision. Today, 
the Pfannenstiel incision is the most used incision for 
Caesarian Birth as well as urologic, orthopedic, and 
pelvic procedures. For urologic procedures such as 
Suprapubic Prostatectomy or in some instances of 
Ureter Replantation, the incision is placed low 
enough to allow the surgeon to remain outside the 
peritoneum, in the prevesical (extraperitoneal) space, 
as described further below.  
The major drawback of this incision is its 
limited exposure beyond the pelvis: if a patient’s 
intra-abdominal pathology is unknown, a vertical 
midline incision is more appropriate.  
Blood supply in the area includes the inferior 
epigastric vessels, which lie posterior to the rectus 
muscles, moving more laterally towards the external 
iliac vessels as they proceed into the pelvis. The 
superficial epigastric vessels are found just below the 
skin- when the incision is very wide, they must be 
dealt with during the skin incision to prevent 
troublesome bleeding.  
The Pfannenstiel incision is reportedly 
associated with a lower incidence of wound 
complications, including surgical site infection and 
incisional hernia, than midline incisions. 
 
In general, the steps of a Pfannenstiel incision 
are: 
• Transverse lower abdominal skin incision 
• Dissection through subcutaneous fat 
• Anterior rectus sheath division 
• Midline opening rectus muscles 
• Surgical intervention 
• Closure of external oblique layer 
• Skin closure 
 
Steps: 
1. The decision to make a Pfannenstiel incision can 
be surgeon preference, however a variety of 
operations such as caesarian sections have made 
Pfannenstiel incision the standard for that 
procedure. Regardless of the indication, the 
degree of access needed for the surgery should be 
well thought out prior to the time of the operation, 
as this incision cannot be extended cranially if 
unexpected pathology is found.  
2. Anesthesia can be either General or Spinal 
depending on the indication for the incision and 
the overall general condition of the patient. 
3. The patient lies in Supine Position, prepared and 
draped from above the umbilicus to below the 
perineum. For Cesarean Section a right-handed 
surgeon stands on the patient’s right side. For 
prostatectomy a right-handed surgeon generally 
stands on the patient’s left. 
4. Make an incision is made two fingerbreadths 
above the symphysis pubis, about 2-3cm medial 
to the anterior superior iliac spine on both sides. 
 
A transverse incision is made above the pubic symphysis 
extending about 2cm medial to the anterior superior iliac spine 
on both sides. 
 
5. Using diathermy, the incision is extended 
through skin, subcutaneous tissue and eventually 
anterior rectus sheath. Medially, there will be 
only one layer, the anterior rectus sheath itself. 
Laterally, if the incision is wide enough (in most 
cases for Cesarean Section) it will extend into the 
three layers of the lateral abdominal wall.  
Pfannenstiel Incision 
Marianna Frazee, 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  
 
 
The anterior rectus sheath is displayed and then divided to 
expose the bilateral rectus muscles. It is important to clear all 
of the subcutaneous fat off of the anterior rectus sheath at this 
time, to make it easier to identify during closure.  
 
 
If wide exposure is required, such as in a Cesarean Section, the 
incision will go beyond the anterior rectus sheath and into the 
aponeuroses of the lateral abdominal wall muscles. This will be 
important to remember when closing the wound, as described 
below.  
 
6. The fascia is then separated from the rectus 
muscles both superiorly and inferiorly by making 
flaps using both blunt finger dissection and 
diathermy. Occasionally there will be bleeding 
from the anterior surface of the rectus muscle 
during this blunt dissection; this can be 
controlled with diathermy or application of a 
small clamp. The midline, the linea alba, requires 
division with the diathermy or a scalpel blade. 
 
Here, Allis clamps are attached to the anterior rectus sheath 
above both rectus muscles. These are retracted anteriorly by 
the surgeon on the patient’s left. The surgeon on the patient’s 
right bluntly dissects the rectus sheath off the muscles in a 
superior direction. Next, divide the fascia at the midline. 
 
 
This maneuver is repeated inferiorly, with the retraction 
performed by the surgeon on the patient’s right and the 
dissection by the surgeon on the patient’s left. Here, the fascia 
has been divided at the midline (Black arrow) allowing all of 
the anterior sheath to be retracted away from the muscles.  
 
7. Separate the right and left rectus muscles from 
each other in the midline, taking care to not enter 
the peritoneum at this step. If you dissect in the 
true midline between the muscles, you should not 
have to divide any muscle fibers at all during this 
step. For certain procedures, entering the 
peritoneum will be the following step. For others, 
such as many urologic procedures, the goal is to 
remain in the preperitoneal space.  
Pfannenstiel Incision 
Marianna Frazee, 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  
 
 
The surgeon and assistant pull the rectus muscles laterally, 
exposing and dividing the fascial tissue that joins them at the 
midline. Try to find the midline and avoid dividing muscle at 
this point.  
 
 
Once the muscles are free from each other at the midline, they 
can be gently pulled apart. This reveals the transversalis fascia, 
with the peritoneum posterior to this in the upper part of the 
incision. If you intend to enter the peritoneum, do so now. If you 
do not, gently sweep the peritoneum upwards with a gauze; this 
maneuver allows you to bluntly enter the prepelvic space.  
 
8. Perform the operation in question, using a self-
retaining retractor such as the Balfour abdominal 
retractor to hold the rectus muscles laterally. For 
Cesarean 
Section, 
this 
retractor 
with 
a 
removeable bladder blade is very commonly 
used.  
9. For closure of the incision, sutures may be placed 
in the rectus muscles to reapproximate them at 
the midline, however this step is not routinely 
done. Similarly, it is not necessary to close the 
peritoneum if it has been opened.  
10. Start closure by bringing together the external 
oblique layer. Use a non-absorbable or slowly 
absorbable monofilament suture. If your incision 
was wider than the rectus sheath only, as 
described above in Step 5, take care to only grab 
the external oblique layer. Avoid placing deeper 
sutures or performing “mass” closure of all three 
layers of the lateral abdominal wall. This 
maneuver risks causing a nerve injury to the 
ilioinguinal nerve, which passes between the 
external and internal oblique layers. This can lead 
to chronic pain.  
 
Here, suturing lateral to the rectus sheath, the surgeon is being 
careful to only suture the external oblique muscle and not the 
muscles beneath it.  
 
11. Continue to close the external oblique layer with 
the running suture, taking care on both sides to 
only suture the external oblique aponeurosis to 
avoid any nerve injury. 
 
Running monofilament suture reapproximating the external 
oblique aponeurosis 
 
12. Finally close the skin incision with a running 
subcuticular absorbable suture. 
Pfannenstiel Incision 
Marianna Frazee, 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  
 
Pitfalls 
• It is important to not inadvertently enter the 
peritoneum if you intend to operate in the 
preperitoneal space. If you do enter it, there may 
be troublesome herniation of small intestine into 
the field you are trying to operate in, especially if 
the patient is awake under spinal anesthesia. The 
best way to avoid this pitfall is by cautious 
separation of the rectus muscles and not applying 
the diathermy beyond where you are dissecting. 
If you do enter the peritoneum, close it with an 
absorbable suture.  
• Initial dissection and clearing of the external 
oblique aponeurosis will make closure easier and 
will allow visualization and closure of only the 
external oblique layer with better chance of 
avoiding any inadvertent nerve injury. 
• If there is unexpected mid- or upper-abdominal 
pathology, or need for rapid exposure as with 
uterine rupture, this incision can be extended 
laterally and the rectus sheath dissection 
extended further cranially and caudally. If this 
does not provide enough exposure, connect a 
lower midline incision to this one: this is called 
an “Inverted T” incision.  
 
Marianna Frazee MD 
Vanderbilt University Medical Center 
Tennessee, USA 
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
September 2024 
