Incisional hernia, midline versus low transverse incision: what is the ideal incision for specimen extraction and hand-assisted laparoscopy?
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Minimally invasive surgery is associated with smaller surgical incisions than those of traditional midline laparotomy. However, most colorectal resections and all hand-assisted procedures require an incision either for specimen retrieval or insertion of the hand-assist device. The ideal site of this incision has not been evaluated with respect to the incidence of incisional hernia. This study compares the rates of incisional hernia associated with a standard midline laparotomy, a midline incision of reduced length, and a Pfannenstiel incision.
From March 2004 to July 2007, 512 consecutive patients were identified from a prospectively maintained database according to predefined inclusion and exclusion criteria. Patients were divided into three groups depending on the type of incision (open, midline, and Pfannenstiel). Demographic variables, rate of incisional hernia, and risk factors for hernia were compared among the groups.
There were 142, 231, and 139 patients in the open, midline, and Pfannenstiel groups, respectively. All three groups were comparable with respect to age, gender, steroid use, diabetes, number of patients with malignancy, and duration of follow-up. The Pfannenstiel group had a higher mean BMI (p = 0.015) and the open group had a higher rate of wound infection (28.2%) compared to the other groups. Incidence of incisional hernia was similar for the open and midline groups (19.7 and 16%, p = 0.36). At a mean follow-up of 17.5 months, not a single patient with a Pfannenstiel incision developed an incisional hernia (p < 0.001). BMI (p = 0.019), follow-up (p < 0.001), and Pfannenstiel incision (p < 0.001) were found to be predictors (protectors) of incisional hernia on multivariate analysis.
A Pfannenstiel incision is associated with the lowest rate of incisional hernia and should be the incision of choice for hand assistance and specimen extraction in minimally invasive colorectal resections wherever applicable.
KeywordsIncisional hernia Laparoscopy Colorectal surgery Pfannenstiel incision Hand-assisted laparoscopy Specimen extraction
The authors thank Ms. Nancy Davis, MA, Director of Research Services, Department of Research, Advocate Health Care, for her contribution with the statistics for this study.
Leela Prasad has received an honorarium from Intuitive Surgical; an honorarium and fellowship grant from Ethicon; and an honorarium and fellowship grant from Covidien. Ashwin deSouza has received salary from Ethicon while pursuing a Fellowship in Laparoscopic and Minimally Invasive Colon and Rectal Surgery, University of Illinois at Chicago. Bastian Domajnko, John Park, Slawomir Marecik and Herand Abcarian have no conflicts of interest or financial ties to disclose.
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