Assessed as up to date: 2011/02/02

Background
The choice of surgical incision in the abdomen is determined by access. It has been suggested that other parameters such as recovery and complication rate may be influenced by utilising a transverse or oblique rather than a midline incision. However, there is little consensus in the literature as to whether a particular incision confers any advantage.

Objectives
To determine whether a midline incision or a transverse incision (including oblique incision) confers any recovery advantage to the patient.

Search strategy
Search terms include randomised trials containing combinations of the following: 'abdominal', 'incisions', 'horizontal', 'transverse', 'vertical', 'midline', 'laparotomy'

Selection criteria
All prospective randomised trials comparing midline with transverse incisions for abdominal surgery were included. Caesarian sections were excluded.

Data collection and analysis
Two reviewers assessed the methodological quality of potentially eligible trials and independently extracted data from the included trial. A wide range of outcome measures were considered.

Main results
Due to the differences in the method of assessment, the variability of data and the heterogeneity of the participant groups it was difficult to pool some of the outcome data. Despite these limitations and potentially significant biases related to methodological quality there was evidence to suggest that a transverse or oblique incision has less impact on pulmonary function particularly in the early post-operative period and is less prone to rupture (wound dehiscence/incisional hernia). The data on pain is less clear and should be interpreted with caution but some data suggests a transverse incision is less painful. There was no difference seen in other early or late post-operative complications and recovery times were similar although the transverse incision may be cosmetically more acceptable.

Authors' conclusions
The analgesia use and the pulmonary compromise may be reduced with a transverse/oblique incision but this does not seem to be significant clinically as pulmonary complication rates and recovery times were the same. The likelihood of wound dehiscence and rupture appears to be reduced with a transverse incision and a transverse incision may look better. The methodological and clinical diversity and the potential for bias also mean that the results in favour of a transverse/oblique incision (particularly with regard to analgesic use) should be treated with caution. The optimal incision for abdominal surgery still remains the preference of the surgeon.

Author(s)
Brown Steven R, Tiernan Jim