Abdominal incisions and sutures in obstetrics and
Radhae Raghavan MRCOG,a,
* Pallavi Arya,b
Prathibha Arya FRCOG,c
Susnata China MRCOG
Specialty Trainee, Worcestershire Royal Hospital, Charles Hastings Way, Worcester WR5 1DD, UK
Medical Student, University of Nottingham, University Park, Nottingham NG7 2RD, UK
Consultant in Obstetrics and Gynaecology, Alexandra Hospital, Woodrow Drive, Redditch B98 7UB, UK
Consultant Gynaecologist, Worcestershire Royal Hospital, Charles Hastings Way, Worcester WR5 1DD, UK
*Correspondence: Radhae Raghavan. Email: firstname.lastname@example.org
Accepted on 23 April 2013
Selection of any incision must be highly individualised.
Numerous options of skin closure have become available and it is
paramount to choose the method tailored to each patient and
The ideal wound closure device should be easy to use, painless,
provide good cosmesis and be cost-effective.
This article reviews the traditional closure materials as well as
some materials that have recently become available, such as staples
Use of electrosurgery on the skin.
To review the medical literature on this subject.
To outline the anatomical and technical aspects that inﬂuence the
choice of incisions and sutures.
To assess the safety aspects, risks and the appropriate use of various
Is it ethical to allow the selection of an incision dictated by
patient choice to preserve cosmesis if it may compromise the
Is it ethical to subject high-risk women to laparotomy for
diagnostic or therapeutic purposes when laparoscopic
management has demonstrated beneﬁts?
Keywords: closure / electrosurgery / incision / laparoscopy / suture
Please cite this paper as: Raghavan R, Arya P, Arya P, China S. Abdominal incisions and sutures in obstetrics and gynaecology. The Obstetrician Gynaecologist
One of the lasting marks of any abdominal surgery and
most noticeable to the patient is the scar at the site
of incision. In selecting an incision, the surgeon must take
into account the underlying pathology prompting
the surgery, the possibility of adhesions or malignancy,
and comorbidities. In this review we aim to present
the various abdominal incisions, sutures and closure
methods used in obstetrics, benign gynaecology and
The incidence of signiﬁcant wound infections is ≤5% for all
abdominal operations and is related to patient and surgical
Preoperative showering with antiseptics reduces the
infection rate in clean wounds (1.3% versus 2.3%).2
infection rates for depilatory preparations versus no hair
removal are equal (0.6%).3
The reason for hair removal is
to prevent interference with wound approximation in
Incisions of the skin should not be made with a monopolar
electrosurgical device. The same scalpel can safely be used for
superﬁcial and deep incisions.4
Abdominal incisions used for most gynaecological
procedures can be divided into transverse or vertical
incisions. Most of the transverse incisions are identiﬁed by
the name of the surgeon who ﬁrst described them, whereas
the vertical incisions have no such eponyms.
Transverse incisions (Box 1)
Introduced by Pfannenstiel in 1900, this curved incision
is approximately 10–15 cm long and 2 cm above the pubic
symphysis. The skin and rectus sheath are opened
ª 2014 Royal College of Obstetricians and Gynaecologists 13
The Obstetrician Gynaecologist
transversely using sharp dissection. The rectus muscles are
not cut and the fascia is dissected along the rectus muscles.
The K€ustner incision, sometimes incorrectly referred to as
modiﬁed Pfannenstiel incision, involves a slightly curved skin
incision beginning below the level of the anterior superior
iliac spine and extending just below the pubic hairline. The
superﬁcial branches of the inferior epigastric artery or vein
may be encountered in the fat. This incision is more
time-consuming and extensibility is limited.
The Cherney incision involves transection of the rectus
muscles at their insertion on the pubic symphysis and
retraction cephalad to improve exposure. This can be used
for urinary incontinence procedures to access the space of
Retzius and to gain exposure to the pelvic side-wall for
hypogastric artery ligation.
The Maylard incision is a muscle-cutting incision, in which
all layers of the lower abdominal wall are incised transversely
approximately 3–8 cm above the symphysis, depending on
the patient habitus and indication for surgery. The fascia is
not dissected free of the rectus muscles. The peritoneum is
usually entered in a transverse fashion. In a patient with
clinical evidence of impaired circulation in the lower
extremity, a midline incision should be preferred to the
Maylard incision, in view of the risk of lower extremity
ischaemia secondary to inferior epigastric artery ligation.
The Mouchel incision runs at the upper limit of the pubic
hair and is thus lower than the Maylard incision.
The muscles are divided above the openings of the
Professor Joel-Cohen introduced this incision for abdominal
hysterectomy in 1954 and obstetricians have since used
this widely to perform caesarean sections.6
This is a
straight transverse incision through the skin, 3 cm below
the level of the anterior superior iliac spines (higher than
the Pfannenstiel incision; Figure 1). The subcutaneous
tissues and fascia are opened in the midline and extended
laterally with blunt ﬁnger dissection. Blunt dissection is
used to separate the rectus muscles vertically and then open
Vertical incisions (Box 2)
Midline (median) incision
The midline incision is the most versatile incision as it can be
easily extended. The pyramidalis muscle can be a useful
landmark to identify the midline.
Box 2. Advantages and disadvantages of vertical incisions
median incision is least haemorrhagic
minimum nerve damage
rapid entry into abdomen and pelvis with median incision
wound dehiscence and hernia may be more frequent5
poorer cosmetic results
higher infection rates, haemorrhage and operative time with
Figure 1. Joel-Cohen versus Pfannenstiel incisions.
Box 1. Advantages and disadvantages of transverse incisions
best cosmetic results
less interference with postoperative respirations
compromised ability to explore upper abdominal cavity
division of multiple layers of fascia and muscle and nerves, may
result in potential spaces with haematoma or seroma
Earlier studies reported that increased incidence of eviscerations with
vertical incisions might be associated with inappropriate closures.
Recent studies have shown no difference in fascial dehiscence between
transverse and vertical incisions.5
14 ª 2014 Royal College of Obstetricians and Gynaecologists
Abdominal incisions and sutures
The paramedian incision offers the advantage of extensibility,
especially on the side of the pelvis where the incision has
been made. There is no difference in wound infection,
dehiscence or respiratory problems with midline and
Oblique incisions can be used for a transperitoneal or
extraperitoneal approach to abdominal surgery, and include
the Gridiron (muscle-splitting) incision of McBurney and the
Rockey–Davis (or Elliot) incisions.
The Gridiron incision is a downward and inward incision
from the McBurney point. The incision is carried through the
skin and subcutaneous fat to the abdominal wall muscles,
which is split along the direction of the ﬁbres. The
peritoneum may then be reﬂected away from the
abdominal wall inferiorly. This allows extraperitoneal
drainage of abscess, avoiding peritoneal contamination. The
Gridiron incision can be performed on the left lower
quadrant to drain abscess on the left side of the pelvis and
can be varied for appendicectomy in pregnant women.
Rockey–Davis incision is a transverse incision made at the
junction of the middle and lower thirds of the line joining the
anterior superior iliac spine to the umbilicus.
Incisions for caesarean section
Caesarean section is the most frequent major operation
performed on women worldwide. Operative techniques
used for caesarean section vary and some of these
techniques have been evaluated through randomised trials.
Traditionally, vertical incisions were used for caesarean
Many studies have compared the Joel-Cohen with
Pfannenstiel incision and found the former to be superior
for reasons such as less postoperative febrile morbidity, less
analgesia requirements, shorter operating time, less
intraoperative blood loss and adhesion formation,
reduction in hospital stay and in wound infection.9
very obese women, a transverse incision above the umbilicus
has been suggested, but not shown, to decrease morbidity.10
In closure of abdominal incisions, it must be remembered
that tissues need approximation, not strangulation.
Primary suture line
The primary suture is the line of sutures that holds the
wound edges in approximation during healing by ﬁrst
intention. It can either be continuous or interrupted. Other
sutures include buried, purse string and subcuticular sutures.
A continuous suture leaves less foreign body mass in the
wound. It derives its strength from tension distributed evenly
along the full length of suture strand. Interrupted sutures
may be used in the presence of infection: if one suture breaks,
the remaining sutures will hold the wound edges in
approximation. Evidence shows no difference in continuous
versus interrupted closure, with a similar incidence of wound
breakdown and hernia formation.12
Buried sutures are placed so that the knot protrudes to the
inside, under the layer to be closed. Subcuticular sutures are
continuous or interrupted sutures placed in the dermis,
beneath the epithelial layer.
Secondary suture line
The secondary suture line, called retention sutures, is done to
reinforce the primary suture line, eliminate dead space and
prevent ﬂuid accumulation in abdominal wound during
healing by ﬁrst intention. Retention sutures are placed about
2 inches from each edge of the wound. It is the authors’
opinion that if secondary sutures are used in cases of
non-healing, they should be placed in the opposite fashion
from the primary sutures (i.e. interrupted if the primary
sutures were continuous, continuous if primary sutures
If transverse incision is extended laterally beyond the edge of
the rectus muscles and into the substance of the external and
internal oblique muscles, injury to the iliohypogastric and
ilioinguinal nerves can occur, with resulting neuroma.
Hence, with laterally extended transverse incisions, the
extensions should have sutures placed only in the external
Layered versus mass closure
Evidence is in favour of mass closure technique using looped
delayed–absorbable suture, with a wound:suture length ratio
of at least 1:4 (Figures 2 and 3).13
In general, subcutaneous
sutures should be avoided because the subcutaneous tissue
does not provide support.
Figure 2. Jenkins diagram showing geometric use of an individual
stitch, ATB, in a continuous suture closure. AB is the stitch interval and
TD comprises the two tissue bites.
ª 2014 Royal College of Obstetricians and Gynaecologists 15
Raghavan et al.
Principles of suturing skin incisions (Box 3)
The Smead–Jones closure is a mass closure technique of the
anterior abdominal wall using a far–far, near–near approach.
The closure is done using a delayed absorbable suture, to
include all of the abdominal wall structures on the far–far
portion (at least 1.5–2 cm from the fascial edges) and only
the anterior fascia on the near–near portion. This allows
good healing without intervening fat or muscle. This closure
technique can be performed in an interrupted fashion or as a
The fascial dehiscence rate with running
mass closure of the abdomen is 0.4%.3
The Gallup closure technique is the closure of midline
incisions using No. 2 polypropylene suture, placing bites
1.5–2 cm from the fascial edge and including all layers of the
anterior abdominal wall (peritoneum, fascial layers and the
intervening muscle). One suture is started from each end and
tied in the middle with three square knots.15
Box 3. Principles of suturing skin incisions
The primary function of suture is to maintain tissue approximation
Debridement of skin edges should be done if necessary
Avoidance of direct tissue trauma helps ensure best outcomes
Clean passage of the needle following the arc is imperative
Skin sutures that blanch the underlying skin are too tight
Skin edges must just touch each other
Delayed primary closure and secondary closure
Delayed closure should be used for contaminated or dirty
wounds. Staples or monoﬁlament delayed sutures or
non-absorbable sutures can be placed. If the abdomen is
opened for abscess drainage and delayed closure is not used,
copious saline irrigation of all layers should be done.
Incisions and closure for obese patients
Morbid obesity poses problems with incision placement and
closure. Morbid obesity carries a seven-fold increased risk of
patients, it should be far removed from the anaerobic moist
environment of the subpannicular fold. The midline vertical
incision is made by ﬁrst retracting the panniculus inferiorly to
avoid the most anaerobic moist area. Closure is done by
Smead–Jones or running mass closure. An intrafascial drain
should be left in situ until drain is 50 ml/24 hours. The skin is
closed using staples in preference to subcuticular sutures.16
Laparoscopic incisions and closure
It has been suggested that primary incision for laparoscopy
should be vertical from the base, not below the umbilicus.17
Any non-midline port 7 mm and any midline port 10 mm
requires formal deep sheath closure to avoid the occurrence of
port site hernia.17
A laparoscopic wound closure device named V-Loc consists
of a barbed absorbable thread that is self-anchoring and
eliminates the need to tie a knot. This is feasible and appears
to be a promising alternative to frequently used peritoneal
Incisions of the skin must not be made with a monopolar
electrosurgical device as the desiccation effect may cause skin to
blister and heal poorly.19
High electrical current delivered with a
ﬁne electrode of a small surface area generates the most efﬁcient
cutting effects and the least thermal damage. Therefore, to incise
tissue, cut current should be used with a small or thin electrode
that isactivated just beforemaking contact with the target tissue.
Abdominal fat, which has high intrinsic impedance, can be
readily cut using a blade electrode with a coagulation waveform
because of the high current density at the edge of the electrode.
There are no data indicating that using electrosurgery in
pregnancy causes untoward effect on the fetus.
Wound closure materials
Sutures, staples and adhesive tapes are the traditional
methods of wound closure; tissue adhesives have entered
clinical practice more recently.
Figure 3. Relationship between the rise in tension between sutures
and tissues caused by a 30% wound stretch and suture length
(SL):wound length (WL) ratio.
16 ª 2014 Royal College of Obstetricians and Gynaecologists
Abdominal incisions and sutures
In selecting the ideal suture, many factors must be considered
including age of the patient, location of the wound, presence/
absence of infection, and surgeon’s experience in handling a
Three main types of suture include the non-absorbable, slowly
absorbable, and the rapidly absorbable. These can be further
divided into monoﬁlament or braided sutures. The incidence of
wound infection is low with monoﬁlament sutures.20
Characteristics of various sutures (Table 1)
The incidence of wound dehiscence and hernia is similar for
non-absorbable and slowly absorbable sutures. The incidence
of prolonged wound pain and suture sinus is signiﬁcantly
higher with a non-absorbable suture.21
There are two types of staple: non-absorbable and absorbable.
The non-absorbable staple (Proximateâ
; Ethicon Endo-
Surgery, Inc., Blue Ash, OH, USA) is made of stainless steel
and has the highest tensile strength of any wound closure
material. Staples have a low tissue reactivity.22
stapling, it is useful to grasp the wound edges with forceps to
evert the tissue so as to prevent inverted skin edges.
Additionally, contaminated wounds closed with staples
have a lower incidence of infection compared with those
closed with sutures.23
Disadvantages of staples include the
potential for staple track formation, bacterial migration into
the wound bed, and discomfort during staple removal.
The absorbable staple (Insorbâ
; Incisive Surgical, Inc.,
Minneapolis, MN, USA) is a novel device which deploys
U-shaped absorbable staples into the dermal layer of tissue.
These staples contain an absorbable copolymer of
predominantly polylactide and a lesser component of
They maintain 40% of their strength at
14 days and are completely absorbed over a period of months
(tissue half-life of 10 weeks). The Insorb staples are
associated with a signiﬁcantly lower infection rate.25
Tissue adhesives are a valuable alternative for mechanical
tissue ﬁxation by sutures or staples. Box 4 summarises the
classiﬁcation of adhesives and glues.
Box 4. Adhesives and glues
biological: include ﬁbrin-based glues, gelatin-based hydrogels, and
synthetic: cyanoacrylates and polymeric sealants
Ànon-resorbable: limited to surface applications
Àresorbable (biodegradable): deployed for both surface
applications and internal use
genetically engineered protein glues
faster, no need for suture removal
cyanoacrylates have been shown to have antimicrobial properties
(especially against Gram-positive organisms)
Currently, 2-octylcyanoacrylate (Dermabond, Ethicon) is
the only US Food and Drug Administration-approved
surgical adhesive. The cyanoacrylates polymerise upon
Table 1. Characteristics of various sutures
Suture types Filament type
Catgut Twisted Moderate Poor 80 –
Polyglycolic acid (DexonTM
; Covidien Inc., Mansﬁeld, MA, USA) Braided or
Low Good 90–120 –
; Ethicon Inc., Menlo Park, CA, USA) Braided Low Good 60–90 –
Polyglactic 910 (VicrylRapideTM
; Ethicon Inc., Menlo Park, CA, USA) Monoﬁlament Low Good 7–14 –
; Ethicon Inc., Menlo Park, CA, USA) Monoﬁlament Low Greatest 180–210 –
; Ethicon Inc., Menlo Park, CA, USA) Monoﬁlament Low Good 90–120 –
Polytrimethylene carbonate (MaxonTM
; Ethicon Inc., Menlo Park,
Monoﬁlament Low Good 180–210 –
Surgical silk Braided or twisted High Low – Good
Nylon Monoﬁlament Low High – Poor
; Ethicon Inc., Menlo Park, CA, USA) Monoﬁlament Least Good – Poor
; Ethicon Inc., Menlo Park, CA, USA) Braided Low High – Good
; W.L Gore Associates, Inc., Newark, DE, USA)
Monoﬁlament Low High – Excellent
ª 2014 Royal College of Obstetricians and Gynaecologists 17
Raghavan et al.
contact with blood, forming a solid ﬁlm that bridges the
wounds and holds the apposed wound edges together.26
likely that this usage will expand as the technology improves.
The established indication in gynaecology is for closure of
port wounds, while emerging indications include control of
active bleeding during laparoscopic surgery.27
Adhesive strips can be used to approximate wound edges
after buried sutures are placed. This could relieve tension at
the wound edges, improve the aesthetics of the wound and
reduce wound care. One disadvantage is that the tape may
not adhere to moist areas or to mobile areas under tension.23
Laser welding has the potential to become an effective
method for wound closure and healing without sutures.
Closure of skin incisions by laser welding with a combination
of two near-infrared lasers (980 and 1064 nm) has yielded
effective closure with minimum thermal damage. Further
investigations are in progress for clinical use.28
Surgical Skin Closure (3M, St Paul, MN, USA)
The Steri-Strip STM
Surgical Skin Closure is a new wound
closure device with conﬁguration and application
signiﬁcantly different from those of standard Steri-Strips. It
has shown better patient comfort and scar quality when used
on abdominal wounds.29
As scientiﬁc evidence accumulates to refute traditional
dogma, surgical techniques have undergone signiﬁcant
changes. Surgeons should now be able to create and close
abdominal wounds based on scientiﬁc evidence rather than
on the dictum of ‘Do what I always do’.
Disclosure of interests
1 Rock JA, Jones III HW. TeLinde’s Operative Gynecology. 10th ed. revised.
Philadelphia: Lippincott Williams and Wilkins; 2011. p. 285–307.
2 Cruse PJE, Foord R. The epidemiology of wound infection: a 10-year
prospective study of 62,939 wounds. Surg Clin North Am 1980;60:27–
3 Seropian R, Reynolds BM. Wound infections after preoperative depilatory
versus razor preparation. Am J Surg 1971;121:251–4.
4 Hasselgren AO, Harberry E, Malmer H, S€alj€o A, Seeman T. One instead of
two knifes for surgical incision. Arch Surg 1984;118:917–20.
5 Hendrix SL. SchimpV, Martin J, Singh A, Kruger M, McNeeley SG. The
legendary superior strength of Pfannensteil incision: a myth? Am J Obstet
6 Joel-Cohen S. Abdominal and Vaginal Hysterectomy: New Techniques
Based on Time and Motion Studies. London: Heinemann; 1977.
7 Guillou PJ, Hall TJ, Donaldson DR, Broughton AC, Brennan TG. Vertical
abdominal incisions: a choice? Br J Surg 1980;67:359.
8 Myerscough PR. Caesarean section: sterilization:hysterectomy. In:Munro
Kerr’s Operative Obstetrics. 10th ed. London: Bailliere Tindall; 1982. p.
9 Karanth KL, Sathish N. Review of advantages of Joel-Cohen surgical
abdominal incision in caesarean section: a basic science perspective. Med J
10 Houston MC, Raynor BD. Postoperative morbidity in themorbidly obese
parturient woman: supraumbilical andlow transverse abdominal
approaches. Am J Obstet Gynecol 2000;182:1033–5.
11 Ellis H, Heddle R. Does the peritoneum need to be closed at laparotomy? Br
J Surg 1977;64:733.
12 Seiler CM, Bruckner T, Diener MK, Papyan A, Golcher H, Seidlmayer C, et al.
Interrupted or continuous slowly absorbable sutures for closure of primary
elective midline abdominal incisions: a multicenter randomized trial
(INSECT: ISRCTN24023541). Ann Surg 2009;249:576–82.
13 Weiland DE, Bay RC, Del Sordi S. Choosing the best abdominal closure by
metaanalysis. Am J Surg 1998;176:666–70.
14 Morrow CP, Curtin JP. Incisions and wound healing. In: Gynaecologic
Cancer Surgery. New York: Churchill Livingstone; 1996. p. 152.
15 Gallup DG, Talledo OE, King LA. Primary mass closure of midline incisions
with a continuous running monoﬁlament suture in gynaecologic patients.
Obstet Gynecol 1989;73:675–7.
16 Pitkin RM. Abdominal hysterectomy in obese women. Surg Gynecol Obstet
17 Anonymous. A consensus document concerning laparoscopic entry
techniques: Middlesborough, March 19–20 1999. Gynaecol Endosc
18 Patri P, Beran C, Stjepanovic J, Sandberg S, Tuchmann A, Christian H.V-Loc,
a new wound closure device for peritoneal closure—is it safe? A
comparative study of different peritoneal closure systems. Surg Innov
19 Kenady DE. Management of abdominal wounds. Surg Clin North Am
20 Osther PJ, Gjode P, Mortensen BB, Mortensen PB, Bartholin J, Gottrup F.
Randomised comparison of polyglycolic acid and polyglyconate sutures for
abdominal fascial closure after laparotomy in patients with suspected
impaired wound healing. Br J Surg 1995;82:1080–2.
21 Van’t Riet M, Steyerberg EW, Nellensteyn Bonjer HJ, Jeekel J. Meta-analysis
of techniques for closure of midline abdominal incisions.Br J Surg
22 Moy RL, Waldman B, Hein DW. A review of sutures and suturing
techniques. J Dermatol Surg Oncol 1992;18:785–95.
23 Hochberg J, Meyer KM, Marion MD. Suture choice and other methods of
skin closure. Surg Clin North Am 2009;89:627–41.
24 Pineros-Fernandez A, Salopek LS, Rodeheaver PF, Drake DB, Edlich RF,
Rodeheaver GT. A revolutionary advance in skin closure compared to
current methods. J Long Term Eff Med Implants 2006;16:19–27.
25 Shapiro AJ, Dinsmore RC, North JH Jr. Tensile strength of wound closure
with cyanoacrylate glue. Am Surg 2001;67:1113–15.
26 Coulthard P, Esposito M, Worthington HV, van der Elst M, van Waes OJ,
Darcey J. Tissue adhesives for closure of surgical incisions. Cochrane
Database Syst Rev 2002;(3):CD004287.
27 Cuschieri A. Tissue adhesives in endosurgery. Semin Laparosc Surg
28 Hu L, Lu Z, Wang B, Cao J, Ma X, Tian Z, et al. Closure of skin incisions by
laser-welding with a combination of two near-infrared diode lasers:
preliminary study for determination of optimal parameters. J Biomed Optics
29 Kerrigan CL, Homa K. Evaluation of a new wound closure device for linear
surgical incisions: 3M Steri-Strip S Surgical Skin Closure versus subcuticular
closure. PlastReconstr Surg 2010;125:186–94.
18 ª 2014 Royal College of Obstetricians and Gynaecologists
Abdominal incisions and sutures