Vertical compared with transverse incisions in abdominal surgery.

OBJECTIVE To reach an evidence-based consensus on the relative merits of vertical and transverse laparotomy incisions. DESIGN Review of all published randomised controlled trials that compared the postoperative complications after the two main types of abdominal incisions, vertical and transverse. SETTING Teaching hospital, Denmark. SUBJECTS Patients undergoing open abdominal operations. INTERVENTIONS For some of the variables (burst abdomen and incisional hernia) it was considered adequate to include retrospective studies. Studies were identified through Medline, Cochrane library, Embase, and a manual search of relevant journals. The references cited in these studies were reviewed to find out whether any other trials fitted the selection criteria. MAIN OUTCOME MEASURES Early complications including postoperative pain, pulmonary complications, burst abdomen, wound infection, and hospital stay, and late complications (incisional hernia). RESULTS Eleven randomised controlled trials and seven retrospective studies were identified. The transverse incision offers as good an access to most intra-abdominal structures as a vertical incision. The transverse incision results in significantly less postoperative pain and fewer pulmonary complications. Vertical laparotomy, however, is associated with shorter operating time and better possibilities for extension of the incision. The pooled odds ratio for burst abdomen in the vertical incision group was 2.86 (95% confidence interval 1.72 to 4.73, p = 0.0001), and regarding late incisional hernia the pooled odds ratio was 1.68 (95% confidence interval 1.10 to 2.57. p = 0.02). CONCLUSIONS Transverse incisions in abdominal surgery are based on better anatomical and physiological principles. They should be recommended, as the early postoperative period is associated with fewer complications (pain, burst abdomen, and pulmonary morbidity) and there is lower incidence of late incisional hernia after transverse compared with vertical laparotomy. A midline incision is still the incision of choice in conditions that require rapid intra-abdominal entry (such as trauma) or where the preoperative diagnosis is uncertain, as it is quicker and can easily be extended.