Subcostal 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 subcostal incision is most useful for 
situations where the location of the pathology is to 
one side of the midline. Examples on the left side 
include adrenalectomy, splenectomy and trans-
abdominal nephrectomy. Examples on the right side 
include cholecystectomy, limited hepatic resections, 
adrenalectomy and nephrectomy. A bilateral 
subcostal incision gives excellent access to all of the 
upper abdomen, such as for major hepatic resections. 
Some surgeons prefer a central subcostal incision for 
the abdominal part of esophagectomy. 
The subcostal incision involves division and 
repair of all layers of the central and abdominal wall, 
so an understanding of this anatomy is important for 
both opening and closure. The anatomy is explained 
further in “Approach to Abdominal Incisions.”  
 
The subcostal incision opening and closure 
proceeds in the following steps:   
● Make the incision down to the external oblique 
fascia and the anterior rectus sheath 
● Divide the anterior rectus sheath, crossing over 
the midline.  
● Puncture the preperitoneal fat and peritoneum 
between the two rectus muscles.  
● Divide the rectus muscle, slowly to assure 
hemostasis. 
● With a finger in the peritoneum, divide the 
posterior rectus sheath and the lateral abdominal 
muscles.  
● Close the posterior rectus sheath and the inner 
lateral wall muscles starting at each end of the 
incision and meeting in the middle 
● Close the anterior rectus sheath and the external 
oblique muscle. 
 
Steps: 
1. Measure a space two fingerbreadths below the 
palpable costal margin. This assures that you will 
have enough tissue to suture on the cranial side 
of the wound when you close.  
 
The muscle incision should be two fingerbreadths below the 
costal margin, assuring that there is enough tissue on the 
cranial side when you close the wound. These pictures were 
taken from a left subcostal incision for adrenalectomy.  
 
2. Make an incision parallel to the costal margin 
crossing over the midline by 1cm. Carry the 
incision through the subcutaneous fat. 
3. Divide all the subcutaneous fat evenly to expose 
the anterior rectus sheath and the external oblique 
aponeurosis. 
 
Clear the subcutaneous fat off the fascia for the length of the 
incision before dividing any of the fascia.  
 
4. Divide the anterior rectus sheath, crossing over 
the midline slightly. As you cross the midline, 
you divide the single layer of the linea alba 
horizontally. You will see the preperitoneal fat 
below it.  
Subcostal 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  
 
 
Incise the fascia near the midline, exposing the vertical fibers 
of the rectus muscle.  
 
 
Carry your incision slightly over the midline (in this case, to the 
patient’s right) dividing the linea alba transversely. In the 
midline, the fascia is one layer thick, and the preperitoneal fat 
will appear in between the two exposed rectus muscles.  
 
5. Insert your finger through the linea alba and 
perforate the peritoneum bluntly with your 
fingertip. 
 
Enter the peritoneum bluntly at the transversely divided linea 
alba. 
 
6. Insert a large Kelly clamp (or your finger) in 
between the rectus muscle and the posterior 
sheath. Elevate the rectus muscle and divide it 
slowly with diathermy. There will be some points 
of bleeding here; the superior epigastric artery 
and vein usually are several branches running 
within the upper rectus muscle rather than one 
discrete large vessel.  
 
Slide a clamp or your finger between the rectus muscle and the 
posterior rectus sheath. Elevate the muscle anteriorly and 
divide it slowly with diathermy. Take time to control any 
bleeding that appears as you do this.  
 
7. Insert your finger into the peritoneal cavity and 
divide the posterior rectus sheath. As you 
proceed more laterally this will become more 
Subcostal 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  
 
muscular and fuse with the internal oblique and 
transversus abdominis.  
 
The posterior rectus sheath is divided separately, after the 
rectus muscle has been divided. Note that the lateral aspect of 
the rectus muscle has not been completely divided- its division 
will be finished before dividing the remaining posterior rectus 
sheath. 
 
 
With your fingers still inside the abdomen, make the transition 
from posterior rectus sheath to all 3 layers of the lateral 
abdominal wall 
 
8. Continue laterally, dividing all three layers with 
the diathermy until you reach the edge of the 
incision.  
 
While your assistant retracts the skin and subcutaneous tissue, 
divide all 3 layers of the lateral abdominal wall to the edge of 
the skin incision.  
 
9. Proceed with the operation.  
10. To close, begin laterally. With proper retraction, 
visualize all three layers of the lateral abdominal 
wall. Place retractors so that they are retracting 
the external oblique fibers only, so that the 
internal oblique and transversus abdominis are 
accessible.  
 
The lateral part of the wound. The two retractors are holding 
back the external oblique aponeurosis. The divided edges of 
internal oblique (Blue dots) and transversus abdominis (Green 
dots) can be seen.  
 
11. Place a wide malleable retractor to protect the 
bowels and close the transversus abdominis and 
internal oblique layers together. Continue until 
you are near the middle of the incision.  
Subcostal 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  
 
 
Close the internal oblique (Blue dot) and transversus 
abdominis (Green dot) muscles while the external oblique 
muscle (Black arrow) is avoided.  
 
12. Now close the incision beginning medially. 
Reapproximate the rectus sheath and the linea 
alba on the side opposite your incision, where 
you crossed over the midline previously.  
 
The incision into the fascia covering the contralateral rectus 
muscle must be closed as well (in this case it is the right rectus 
muscle.) It is acceptable to close only the anterior sheath, cross 
the linea alba, then transition onto the posterior sheath. 
 
The suture line is begun on the anterior sheath of the 
contralateral rectus muscle.  
 
 
The closure continues, approximating the horizontally divided 
linea alba.  
 
13. Continue laterally, transitioning to close only the 
posterior rectus sheath.  
Subcostal 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  
 
 
Transitioning from the linea alba to the posterior rectus sheath. 
The rectus muscle, anterior to the sheath, is shown by a Yellow 
dot. It is not necessary to suture the muscle itself, only the 
posterior rectus sheaths is closed.   
 
14. Note the point where the posterior rectus sheath 
transitions into the internal oblique and 
transversus abdominis muscles as you suture in a 
lateral direction.  
 
Continuing laterally on the posterior rectus sheath, you will 
make the transition to the internal oblique and transversus 
abdominis muscles. The rectus muscle is shown by a Yellow dot.  
 
15. As you approach the opposite suture, instruct 
your assistant to stop providing traction on the 
suture as you place it. These last few stitches 
must be directly visualized.  
 
As in all abdominal closures, the last stitches are taken without 
tension on the sutures. A narrow malleable retractor is inserted 
perpendicular to the closure for each individual stitch.  
 
16. Tie the sutures together.  
 
The two sutures have closed the inner layer of the wound, the 
posterior rectus sheath medially and the internal oblique and 
transversus abdominis laterally. The sutures meet in the middle 
of the wound and are tied there.  
 
17. Close the anterior rectus sheath and the external 
oblique aponeurosis. You may suture straight 
from one side of the incision to the other, 
beginning at either side, as there is no longer a 
danger of injuring bowel.  
Subcostal 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  
 
 
The inner layer has been closed. The transition can clearly be 
seen between the muscular part of the external oblique (Black 
arrows,) the aponeurotic part of the external oblique (Gray 
arrows) and the anterior rectus sheath (Yellow arrows.)  
 
 
One continuous running suture closes the outer layer of the 
incision, starting at either end: in this case the surgeon started 
medially, closing the anterior rectus sheath first.  
 
As the closure continues laterally, the transition is made to the 
external oblique aponeurosis and muscle.  
 
18. Irrigate 
the 
subcutaneous 
space, 
assure 
hemostasis, and close the skin.  
 
Before closing the skin, irrigate and assure hemostasis, as 
blood in the wound can increase the risk of infection.  
 
Pitfalls 
● Poor visualization of the lower abdomen: use this 
incision only if you are certain where the 
pathology is. Otherwise, a midline incision is 
more appropriate. It is acceptable to extend a 
subcostal incision in either direction if you need 
to.  
● Ongoing 
bleeding 
during 
surgery, 
or 
postoperatively, from the branches of the 
superior epigastric vessels that run through the 
rectus muscle. Take time to coagulate each one 
with diathermy as you divide the muscle. If you 
do not have diathermy, apply a hemostat and 
ligate each branch individually.  
Subcostal 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  
 
● Visceral injury during closure: be sure to see the 
needle at every point as it passes through the 
muscle and fascia. Do not close the inner layer of 
the fascia from one end of the wound to the other, 
begin at both ends and meet in the middle so that 
the needle can be seen during the final stitches.  
● Placing the wound too close to the costal margin: 
this makes closure more difficult and incisional 
hernia more likely. Be sure that you start the 
incision two fingerbreadths below the costal 
margin to leave enough tissue on the cranial side 
of the wound.  
● Incisional hernia: This is usually the result of a 
technical error during closure, especially failure 
to see and close the individual layers as described 
here. Alternatively, the risk of an incisional 
hernia increases when closure is done with a 
rapidly absorbable suture such as polyglycolic 
acid (Vicryl®.)  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
