Approach to Abdominal Incisions 
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  
 
Background:  
The choice and performance of an abdominal 
incision will strongly affect how easy, or difficult, 
the operation is. The experienced surgeon, the one 
who seems to make everything look easy, is a master 
at selecting the right type of incision.  
One important factor in any incision is how 
well it adapts to a change in plans. In this regard, the 
midline incision through the linea alba is the best one 
to use in an unknown situation. It affords access to 
all of the abdominal cavity, and it can be extended as 
much as necessary.  
 
Anatomy:  
 
The lateral abdominal wall is made up of 
three layers of muscles. As shown below, each layer 
has its own orientation. This fact allows each layer to 
be identified, allowing safer and more purposeful 
opening and closing during transverse, subcostal and 
retroperitoneal incisions.  
 
Anterior and lateral abdominal wall, superficial. The anterior 
rectus sheath is continuous and meets in the midline at the linea 
alba. The external oblique muscle runs transversely, from 
superolateral to inferomedial and inserts into the lateral rectus 
sheath. The internal oblique muscle lies immediately beneath it.  
 
 
Lateral abdominal wall, middle layer. The internal oblique 
muscle runs transversely, from inferolateral to superomedial. 
The transversus abdominis muscle lies directly beneath it.  
 
Approach to Abdominal Incisions 
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  
 
 
Lateral abdominal wall, deep layer. The transversus abdominis 
muscle runs transversely in a horizontal orientation. The 
extraperitoneal space, not the peritoneum, lies directly beneath 
it. With care, one can transect this muscle without entering the 
peritoneum and then develop the plane laterally to enter into 
the retroperitoneum, as discussed in the chapter “Anterolateral 
Retroperitoneal Incision.”  
 
 
The linea alba is the name of the fascial space 
in between the two rectus muscles. This structure is 
split and then reapproximated during a midline 
laparotomy. Fibers of both the anterior and posterior 
rectus sheath contribute to the linea alba for the upper 
2/3 of its length. At a point 2-3 cm below the 
umbilicus, the posterior rectus sheath ceases to be a 
fascial layer and can not be relied on to hold suture. 
The point where this junction occurs is called the 
linea semicircularis. Below this line, the fibrofatty 
tissue between the posterior rectus muscle and the 
peritoneum is called the transversalis fascia.  
 
 
Cross section of the rectus muscles and linea alba in the upper 
2/3 of the abdomen. Both anterior and posterior rectus sheaths 
are fibrous and strong.  
 
 
Cross section of the rectus muscles and linea alba in the lower 
1/3 of the abdomen. Only the anterior rectus sheath is fibrous 
and strong. The space between the rectus muscle and the 
peritoneum is a fibrofatty layer called the transversalis fascia.  
 
 
Disassembled view of the lower 1/3 of the rectus sheath, 
showing the linea semicircularis, the inferior-most extent of the 
fibrous part of the posterior rectus sheath. The transversalis 
fascia (Red dot) is not fibrous; it has no intrinsic strength and 
will not hold sutures for fascial closure.  
 
Principles:  
Unless dealing with an emergency situation, 
one should always assure hemostasis while making 
an abdominal incision. Cut vessels in the abdominal 
wall and preperitoneal space can continue to bleed 
during an entire surgery, leading to an increased total 
blood loss that is entirely avoidable with a little extra 
care. This is especially true with transverse or 
subcostal incisions that divide the rectus muscles; the 
epigastric vessels or their tributaries can retract 
Approach to Abdominal Incisions 
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  
 
Resource-Rich Settings 
The vast majority of intra-abdominal and retroperitoneal 
surgeries in Resource-Rich settings are done minimally 
invasively, with the laparoscope or the surgical robot. This 
results in less postoperative pain, faster recovery and less 
chance of wound dehiscence or hernia formation. 
Anesthesia providers perform  advanced ultrasound-
guided nerve block techniques to help manage postoperative 
pain.  
The actual act of closing the abdomen securely is not 
dependent on technology, but on meticulous attention to 
detail. There is no reason why your incisional hernia or 
dehiscence rate should be different from that of a surgeon in a 
Resource-Rich setting. Decide to learn how to close 
abdominal incisions safely and well.  
within the muscle and cause troublesome bleeding. 
At the upper or lower abdomen these may be discrete 
vessels that need ligation.  
 
While a smaller incision is certainly less 
painful for the patient, in the end that patient will not 
be served by a surgeon who can’t see what is 
happening during the operation. You will be 
surprised how much difference even a few cm can 
make, so if you find yourself struggling with 
exposure or while suturing, consider extending the 
incision a bit. This is especially true at either end of 
a midline incision, where a tremendous exposure can 
be gained by simply dividing the recti all the way 
down to the pubic symphysis, or up past the xyphoid 
process. You may take pride in doing large 
operations through small incisions, but do not let 
your pride get in the way of what’s best for the 
patient.  
 
Closure of an abdominal incision is 
sometimes left to a junior member of the team while 
the surgeon goes on to more “important things.” This 
is a mistake that the patient sometimes pays for, with 
an incisional hernia, wound dehiscence or visceral 
injury. If you have trainees, take the time to teach 
them the principles of proper abdominal wound 
closure before you leave them alone. In general, 
these principles include:  
● Sutures through fascia, not muscle 
● Layered closure, not mass closure, of the layers 
of the lateral abdominal wall 
● Small bites with short travel, with total suture 
length 4 times that of the wound 
● Visualization of the needle at all times. Pass the 
needle through each side of the fascia separately 
rather than both at once.   
● Starting at each end of a fascial closure and meet 
in the middle, avoiding “sewing into a corner.”  
 
Decision Making: 
Midline incisions can be used for almost 
anything, including procedures that are associated 
with other incisions, such as Cesarean section 
(Pfannenstiel incision) or open cholecystectomy 
(subcostal incision.) Another advantage is that they 
can be made relatively quickly in emergency 
situations. Midline incisions are more useful when 
one does not know what will be found, such as 
laparotomy for trauma or bowel obstruction. 
Conversely, most transverse incisions are useful in 
situations where specific pathology is expected, such 
as cholecystectomy, appendectomy, oophorectomy, 
or elective splenectomy.  
Re-opening a previous laparotomy can be 
tedious if the small bowel is adherent to the incision. 
If you try to enter the abdomen directly through the 
previous incision, there is risk of injuring the 
adherent bowel. Instead, begin the incision beyond 
the scar, entering the abdomen in a previously 
untouched area, and then extend into the previous 
scar while watching or feeling for intra-abdominal 
incisions. This process takes time. Lysis of adhesions 
is described further in its own chapter. 
If the patient with a previous large 
laparotomy presents in hemorrhagic shock and needs 
a laparotomy quickly, do not reopen the same 
incision; this will take too long. If they have a 
previous midline laparotomy scar, make a bilateral 
subcostal or transverse incision so you can quickly 
access the site of bleeding.  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
 
