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Lower Midline Incision: Surgical Steps and Wound Closure

Urologic Indications

In urology, a lower midline incision is used for an extraperitoneal approach to the prostate, bladder, distal ureters, and pelvic lymph nodes. In unexpected intraoperative findings, a lower midline incision can be easily extended.

Patient Positioning:

The patient is in a supine position with slight hyperextension of the lumbar spine.

Lower midline incision.

Surgical Technique of a Lower Midline Incision

See fig. lower midline incision for the skin incision.
Cut through the subcutaneous fat tissue and expose the rectus sheath
Division of the linea alba and fascia transversalis. Blunt dissection of the Retzius' space.
Using blunt dissection, the peritoneum is pushed superiorly and medially to expose the iliac vessels, spermatic cord and ureter. The posterior lamina of the rectus sheath may be divided to the umbilicus and further cranially for better exposure.

**Lower midline incision from the surgeon's point of view:** Preparation of the anterior lamina of the rectus sheath (1) and transection of the linea alba (2). Preparation of the posterior lamina of the rectus sheath (3) between both rectus muscles.
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**Lower midline incision from the surgeon's point of view:** The incision is extended until the symphysis and a retractor is used, the filled bladder is exposed (4).
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Wound Closure of Midline Incision

Wound closure is best done with the short stitch technique; continuous running suture (monofilament, elastic, slowly absorbable, suture size USP 0 or 2-0), tissue bites of 5 mm and intersuture spacing of 4–5 mm are applied exclusively to the fascia (linea alba) (Deerenberg et al., 2015). See also the section wound closure of transperitoneal midline laparotomy.

Urologic Surgery

Index

Pfannenstiel incision

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

References

E. B. Deerenberg et al., “Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial.,” Lancet, vol. 386, no. 10000, pp. 1254–1260, 2015, doi: 10.1016/S0140-6736(15)60459-7.

J. A. Smith, S. S. Howards, G. M. Preminger, and R. R. Dmochowski, Hinman’s Atlas of Urologic Surgery Revised Reprint. Elsevier, 2019.

Deutsche Version: Mediane Laparotomie