Incisional Hernia – Midline Vs Low Transverse Incision: What Is the Ideal Incision for Specimen Extraction/hals?

Purpose: This study was designed to compare the rates of incisional hernia associated with a standard midline laparotomy (open surgery), a midline incision of reduced length (laparoscopic/hand-assisted surgery) and a Pfannenstiel incision (hand-assisted surgery).

Methods: A retrospective review of a prospectively maintained database was performed to identify and evaluate all patients undergoing a pure laparoscopic, hand-assisted or open colorectal procedure between March 2004 and July 2007, at a single institution. Patients in whom post operative follow up was not possible (e.g. in-house death), open procedures not involving a laparotomy (e.g. stoma reversal), and laparoscopic procedures not involving an incision for specimen retrieval/hand assistance (e.g. APR) were excluded. Depending on the type of incision, the remaining 512 patients were grouped into three groups open, midline and Pfannenstiel. Demographic variables, incidence of incisional hernia, and risk factors for hernia were compared among the groups. A hernia was defined as a palpable defect at the site of incision or a defect detected on CT scan performed for any indication. Trocar site and stoma related hernias were excluded.

Results: There were 142, 231 and 139 patients in the open, midline and Pfannenstiel groups respectively. Procedural break up is presented in table 1. All three groups were comparable with respect to age, gender, steroid use, diabetes, number of patients with cancer and duration of follow up (17-21 months). The Pfannenstiel group had a higher mean BMI (p=0.015) and the open group had a higher rate of wound infection (28.2%) as compared to the other groups. There was no difference in the rate of incisional hernia between the open and midline groups (19.71% and 16.01%, p=0.36). Not a single patient with a Pfannenstiel incision developed an incisional hernia (p<0.001). On univariate analysis, duration of follow up, BMI, wound infection and diabetes were significantly associated with incisional hernia. BMI (p=0.019), follow up (p<0.001) and type of incision (p<0.001) remained significant on multivariate analysis.

Conclusions: With the exception of APR, the majority of colorectal procedures even when performed laparoscopically, require an incision for intact specimen retrieval. This fact has been used to evolve hand-assisted laparoscopic techniques to overcome the technical challenges faced with standard laparoscopy. A Pfannenstiel incision offers excellent access to the pelvis and can be used to supplement laparoscopy with open techniques especially for rectal dissection, transection and anastomosis, which are challenging to accomplish laparoscopically. As the Pfannenstiel incision is also associated with the lowest rate of incisional hernia, it should be the incision of choice for hand assistance/specimen extraction in minimally invasive colorectal resections wherever applicable.

Table 1. Procedural break up

ProceduresOpen n=142Midline n=231Pfannenstiel n=139
Small bowel resection1720
Left hemicolectomy861
Right hemicolectomy231460
Segmental colectomy211
Modified MACEprocedure100
Anterior resection4756119
Completion proctectomy +IPAA9215
Hartman reversal200
Ileostomy reversal (ileo-proctostomy)400
Exploratory laparotomy1100

Session: Podium Presentation

Program Number: S002

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