The American Journal of Surgery (2013) 206, 400-409

Review

Up and down or side to side? A systematic review

and meta-analysis examining the impact of incision
on outcomes after abdominal surgery
Kai A. Bickenbach, M.D.a,*, Paul J. Karanicolas, M.D., Ph.D.b, John B. Ammori, M.D.b,
Shiva Jayaraman, M.D., M.E.S.C.b, Jordan M. Winter, M.D.b, Ryan C. Fields, M.D.b,
Anand Govindarajan, M.D., M.S.C.b, Itzhak Nir, M.D.b, Flavio G. Rocha, M.D.b,
Murray F. Brennan, M.D.b
a

University of Medicine and Dentistry of New Jersey, New Jersey School of Medicine, 205 South Orange Avenue, G-1222,
Newark, NJ 07103, USA; bDepartment of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
KEYWORDS:
Incision;
Hernia;
Midline incision;
Transverse incision;
Paramedian incision;
Meta-analysis

Abstract
BACKGROUND: The aim of this study was to examine whether midline, paramedian, or transverse
incisions offer potential advantages for abdominal surgery.
DATA SOURCES: We searched MEDLINE, Embase, Web of Science, and The Cochrane Central
Register of Controlled Trials from 1966 to 2009 for randomized controlled trials comparing incision
choice.
METHODS: We systematically assessed trials for eligibility and validity and extracted data in duplicate. We pooled data using a random-effects model.
RESULTS: Twenty-four studies were included. Transverse incisions required less narcotics than midline incisions (weighted mean difference 5 23.4 mg morphine; 95% confidence interval [CI], 6.9 to
39.9) and resulted in a smaller change in the forced expiratory volume in 1 second on postoperative
day 1 (weighted mean difference 5 26.94%; 95% CI, 210.74 to 23.13). Midline incisions resulted
in higher hernia rates compared with both transverse incisions (relative risk 5 1.77; 95% CI, 1.09 to
2.87) and paramedian incisions (relative risk 5 3.41; 95% CI, 1.02 to 11.45).
CONCLUSIONS: Both transverse and paramedian incisions are associated with a lower hernia rate
than midline incisions and should be considered when exposure is equivalent.
2013 Elsevier Inc. All rights reserved.

Surgical access to the abdomen can be achieved through

multiple incision types. The type of abdominal incision can
affect multiple outcomes including operative time, incidence of complications, postoperative pain, pulmonary
The authors declare no conflicts of interest.
* Corresponding author. Tel.: 11-973-972-3115; fax: 11-973-972-3730.
E-mail address: bickenka@umdnj.edu
Manuscript received November 29, 2011; revised manuscript October
19, 2012
0002-9610/$ - see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2012.11.008

function, and length of stay.1 With more than 5 million laparotomies performed each year across the United States,
defining the optimal incision is of great importance.2
Midline incisions are generally preferred by most surgeons because of their ease, speed, and exposure.3 There
are several potential disadvantages with these incisions.
First, these incisions are made along the avascular linea
alba, which may impair wound healing. Second, the contraction of the abdominal wall muscles pulls laterally on

K.A. Bickenbach et al.

Incisions for abdominal surgery

401

the incision, resulting in tension on the closure. Additionally, because the fibers of the aponeurosis cross the midline
obliquely, these fibers are usually cut perpendicularly by a
vertical incision. Transverse (including oblique) incisions
are well vascularized by the muscle bed upon which they
are situated, unlike the avascular tissue of the midline incision.3 Because of the direction of force from the contraction
of the oblique muscles, less tension is placed on the wound
compared with the midline incision, which may result in a
lower hernia rate and less pain.46 Pain may also be reduced because the nerve fibers run parallel to the incision
and are divided less. Finally, the fibers of the aponeurosis
of the abdominal wall musculature are not cut perpendicularly because they are in a midline incision. Paramedian
incisions split the rectus and offer advantages in that they
are situated on a vascular-rich muscle bed, and they also
offer a theoretic shutter mechanism that may contribute to
a lower rate of incisional hernias.7,8 Several studies, including randomized trials, have addressed outcomes after laparotomy with different incisions.3 The majority of these
trials compared midline with transverse incisions. Few trials
have directly compared paramedian with either midline or
transverse incisions. Before embarking on this study, our
hypothesis was that midline incisions would be associated
with an increased risk of hernia but would be less painful.
In this study, we sought to systematically review randomized controlled trials that addressed the optimal incision
for laparotomy. We specifically compared midline, transverse, and paramedian incisions. We report here that midline incisions are associated with an increased risk of
hernia compared with both transverse and paramedian incisions. Transverse incisions are associated less with a decreased postoperative narcotic requirement compared with
midline incisions.

Two investigators conducted a review of articles meeting

the eligibility criteria, rating the methodologic quality of
the primary research. Concealment of allocation, patient
blinding, clinician blinding, outcome assessor blinding, and
completeness of follow-up were assessed to determine the
validity of articles meeting our eligibility requirements. An
agreement between reviewers was measured using the k
statistic. The reviewers discussed any disagreements, and a
consensus was obtained.

Methods

Data extraction

Study selection

Two investigators collected relevant information in

duplicate regarding the patient population, types of surgery,
intervention, and outcomes from each selected article using
a computerized standardized data extraction form. When
possible, we contacted the investigators for any missing
data. When studies reported separate data for different
types of operations, we extracted those datasets separately
rather than combining them.

We searched MEDLINE, Embase, Web of Science, and

The Cochrane Central Register of Controlled Trials from
1966 to 2009 for potentially relevant randomized controlled
trials using the following search terms: transverse, midline,
vertical, oblique, paramedian, abdominal, incision, laparotomy, and hernia. We reviewed the reference lists of all
articles obtained to identify any other missed articles. To
uncover unpublished potentially relevant trials, we searched
the database of registered trials at www.clinicaltrials.gov.
Two reviewers assessed all the abstracts from the articles
obtained to determine whether the articles met our inclusion criteria (Table 1). Full-text articles were obtained
from those abstracts selected and assessed by 2 reviewers
to determine if they met our inclusion criteria. Agreement
between reviewers was measured using the kappa statistic.
The reviewers discussed any disagreements, and a consensus was obtained.

Table 1

Inclusion criteria

Target
population
Intervention

Outcome
measure

Methodological
criteria

Patients undergoing abdominal surgery

through transperitoneal approach
Midline incision
Transverse (including oblique)
Paramedian
1 or more of:
Pain
Narcotic use
Wound complications
Respiratory complications
Incisional hernia
Quality of life
Hospital length of stay
Return to work
Pain
Postoperative complications
Randomized controlled trial
or
Quasi-randomized controlled trial
(patients allocated according to known
characteristics)

Validity assessment

Analysis
When studies reported the median and range, we estimated the mean and standard deviation using the method
described by Hozo et al.9 Data were analyzed using RevMan version 5 (The Cochrane Collaboration, Copenhagen).
For dichotomous outcomes, data were analyzed using
a random-effects model to calculate relative risks (RRs).
For continuous outcomes with the same measure, a
random-effects model was used to provide weighted mean

402

The American Journal of Surgery, Vol 206, No 3, September 2013

differences (WMDs). A P value ,.05 was considered significant. Estimates of the extent of heterogeneity were obtained using the Breslow-Day test and the I2 statistic. We
explored heterogeneity (I2 . 0) with subgroup and
sensitivity analyses based on predetermined hypotheses
(Table 2).
To compare the total amount of analgesics required for
the interventions, we converted the units reported to
milligrams of morphine. This required the assumptions
that 1 mg ketobemidon equals 1 mg morphine and that
1 mg meperidine equals 5 mg morphine. Additionally, for
those studies that reported data as dose per kg of body
weight, doses were calculated by multiplying by the mean
body weight if reported and 70 kg if not reported.
Figure 1

Results

A summary of the trial search and eligibility process.

Characteristics and methodologic quality of

included studies

Comparisons: midline versus transverse

incisions

Our initial search yielded 1,141 abstracts (Fig. 1); 70 of

these articles were selected for full-text review. Two of
these were not available in English, 1 was only available
in abstract form, 1 was duplicated, and 42 articles did not
meet our inclusion criteria. This left 24 randomized controlled trials that were included in our analysis. The reviewers achieved good agreement in the application of
the eligibility criteria (k 5 .71). The characteristics of the
trials are described in Table 3.
The methodologic quality in these studies was generally
poor (Table 4). In only 9 trials was the method of concealment reported as adequate. The majority of these trials were
not blinded, with only 2 trials blinding patients, medical
staff, and outcome assessors. This was accomplished by
the use of dressings designed to cover the entire abdomen,
which were not removed until discharge.

Fourteen trials compared midline with transverse incisions (Table 5). Pain was assessed in 12 of these trials. The
conversion of narcotics to morphine equivalents was possible in 6 trials. The combined data show that patients who
underwent transverse incisions received significantly less
narcotics than those who had midline incisions (WMD 5
23.4 mg morphine per admission; 95% confidence interval
[CI], 6.9 to 39.9). However, there was significant heterogeneity between trials (I2 5 87%) (Fig. 2). The GarciaValdecasas trial contained both emergency and elective
cases.10 If this trial is excluded, the combination of the remaining trials reduces the statistical heterogeneity and still
favors transverse incisions (WMD 5 34 mg morphine per
admission; 95% CI, 29 to 39.1; I2 5 0) (Fig. 3). Combining
data from the 5 trials that reported visual analog scale
(VAS) pain scores on postoperative day (POD) 1 showed
no significant difference (WMD 5 .4; 95% CI, 2.9 to
1.8). Heterogeneity was again significant (I2 5 98%). Sensitivity analyses based on elective or emergency surgery or
the regimen of pain control did not change the results
materially.
The effects of incision choice on pulmonary function
were assessed in 10 trials by various methods. The timing
and method of evaluation were variable between different
trials, making comparisons difficult. The pooling of data on
vital capacity on POD 1 from 5 trials showed no significant
difference (WMD 5 4.7% change from baseline; 95% CI,
210.5 to 1.1). Data from the 4 trials, which evaluated
forced expiratory volume in 1 second (FEV1) on POD 1,
showed that midline incisions had a significantly greater
deterioration of pulmonary function (WMD 5 6.9% change
from baseline; 95% CI, 210.7 to 23.1). Pulmonary complications were similar in the 10 trials that reported them
(RR 5 1.11; 95% CI, .74 to 1.66).
Seven trials reported incisional hernia rates with a
median follow-up from 4 months to 4.4 years. Combining

Table 2

Possible sources of heterogeneity

Population

Intervention

Outcomes

Methodology

Age
Sex
ASA
BMI
Comorbidities
Nature of abdominal operation
Method of fascial closure
Method of skin closure
Cointerventions
Definition/measurement of wound infection
Definition/measurement of narcotic use
Definition/measurement of pain
Definition/measurement of quality of life
Definition/measurement of hernia
Definition/measurement of complication
Components of validity assessment

ASA 5 American Society of Anesthesiologists; BMI 5 body mass

index.

K.A. Bickenbach et al.

Table 3

Incisions for abdominal surgery

403

Study characteristics
Total
sample
size

Elective or
emergency

Operation

Comparison

Outcomes

19

Elective

Cholecystectomy

Midline vs transverse

Armstrong24
GarciaValdecasas10
Halm19

60
129

Elective
Both

Cholecystectomy
Cholecystectomy

Midline vs transverse
Midline vs transverse

123

Elective

Cholecystectomy

Midline vs transverse

Seenu25

181

Elective

Cholecystectomy

Midline vs transverse

Becquemin17

26

Elective

Aortoiliac surgery

Midline vs transverse

Fassiadis11
Massucci26
Lacy27

37
32
50

Elective
Elective
Elective

Aortoiliac surgery
Aortoiliac surgery
Aortoiliac surgery

Midline vs transverse
Midline vs transverse
Midline vs transverse

Brown28

28

Elective

Right hemicolectomy

Midline vs transverse

40
395

Elective
Elective

Right hemicolectomy
Gastrectomy

Midline vs transverse
Midline vs transverse

94

Elective

Gastric or pancreas

Midline vs transverse

Pulmonary complications,
spirometry, PaO2
Pain, spirometry, LOS
Pain, pulmonary complications,
spirometry
Incision length, OR time, pain,
complications, LOS, cosmesis
OR time, LOS, complications, length
of incision
Pulmonary complications, spirometry,
surgical convenience
Hernia rate
Spirometry, PaO2
Pulmonary complications, OR time,
ICU stay, ventilatory time, pain
Pain, LOS, complications, length of
incision
Pain, spirometry
Pain, blood loss, OR time
Complications, incision length
OR time, pain, LOS, mortality,
spirometry, wound complications,
incision length, cosmesis
Blood loss, pulmonary complications,
dehiscence, wound infection, hernia
rate
Pain, pulmonary complications, Wound
infection, dehiscence, hernia rate,
LOS, spirometry
Wound infection, OR time
Pain, OR time, PaO2, complications,
Incision length
Dehiscence, hernia rate, pulmonary
complications, wound infection,
OR time, incision length
OR time, pulmonary complications,
wound infection, dehiscence, hernia
rate
Dehiscence, hernia rate, wound
infection, OR time, mortality
Hernia rate, dehiscence, wound
infection
Wound infection, mortality, hernia
rate, pulmonary complications
Pulmonary complications, wound
infection, hernia rate, pain,
pulmonary complications
Wound infection, dehiscence,
pulmonary complications, hernia

Study
Ali

23

Lindgren29
Inaba30
Proske18

Greenall31,32

572

Both

Abdominal surgery

Midline vs transverse

Seiler33

191

Elective

Abdominal surgery

Midline vs transverse

Stone34
Salonia35

561
69

Both
Elective

Abdominal surgery
Radical prostatectomy

Midline vs transverse
Midline vs transverse

Cox36

329

Unclear

Abdominal surgery

Midline vs paramedian

Guillou37

207

Both

Abdominal surgery

Midline vs paramedian

Kendall38

249

Both

Abdominal surgery

Midline vs paramedian

Ellis39

125

Elective

Abdominal Surgery

Chan40

50

Elective
Both

Peritoneal dialysis
catheter
Cholecystectomy

Midline vs Paramedian
Paramedian vs Transverse
Midline vs paramedian

Emergency

Emergency laparotomy

Halasz41

100

Talwar16

56

Paramedian vs transverse

Paramedian vs transverse

ICU 5 intensive care unit; LOS 5 length of stay; OR 5 operating room.

the data from these studies shows a significant benefit in

favor of transverse incisions (RR 5 1.77; 95% CI, 1.09 to
2.87; Fig. 4). Subgroup analysis including only elective surgery still shows a significant advantage for transverse

incisions (RR 5 2.13; 95% CI, 1.13 to 4.05). There was

no significant difference in incision length, operative
time, wound infections, wound dehiscences, or postoperative length of stay between the 2 groups.

404

The American Journal of Surgery, Vol 206, No 3, September 2013

Table 4

Validity assessment

First author
23

Ali
Armstrong24
Becquemin17
Brown28
Chan40
Cox36
Ellis39
Fassiadis11
Garcia-Valdecasas10
Greenall31,32
Guillou37
Halasz41
Halm19
Inaba30
Kendall38
Lacy27
Lindgren29
Massucci26
Proske18
Salonia35
Seenu25
Seiler33
Stone34
Talwar16

Concealment of allocation
Unclear
Unclear
Unclear
Yes: draw from bag
Unclear
Yes: masked from operating surgeon
determined by random numbers
Unclear
Yes: numbered, opaque envelopes
Unclear
Unclear
Yes: blind card
Yes: drawing cards
Yes: envelopes
Unclear
Yes: blind card system
Unclear
Yes: envelopes
Unclear
Unclear
Unclear
Unclear
Yes: envelopes
Unclear
Unclear

Comparisons: midline versus paramedian

incision
Five trials reported rates of incisional hernia between
patients who underwent midline or paramedian incisions
(Table 6). The follow-up in all 5 trials was 12 months.
Combining the data showed a lower rate of incisional hernia in paramedian incisions (RR 5 3.41; 95% CI, 1.02 to
11.45); however, there was significant heterogeneity between studies (I2 5 68%, Fig. 4). There were insufficient
data to analyze patients as subgroups.
No trials provided data to make comparisons of operative time, incision length, length of stay, pain control, or
pulmonary function. There were no significant differences
in pulmonary complications, wound infections, or rates of
dehiscence.

Comparisons: paramedian versus transverse

incision
We identified 3 trials that compared paramedian with
transverse incisions (Table 6). The available data only allowed comparisons of postoperative complications. There
were no significant differences in the rates of pulmonary
complications, wound infections, or hernia rates although
the follow-up was short (ie, 3 to 12 months). Two trials

Patient
blinding

Clinician
blinding

Outcome
assessor
blinding

Loss to
follow-up
(%)

No
No
No
No
No
No

No
No
No
Some
No
No

No
No
No
Yes
No
No

None
None
None
None
None
.20

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No

520
None
None
,5
520
None
520
520
.20
None
None
None
None
None
None
520
Unclear
Unclear

reported rates of wound dehiscence, with the combined

data favoring transverse incisions (RR 5 4.29; 95% CI,
1.18 to 15.62).

Comments
This systematic review was performed to determine the
optimal incision choice for abdominal operations. The
results of this review show that both transverse and
paramedian incisions offer superior results compared with
midline incisions. Transverse incisions require less narcotic
use than midline incisions. Both transverse and paramedian
incisions have a lower incidence of incisional hernias when
compared with midline incisions.
The combined data suggest that there is lower narcotic
use associated with a transverse incision. Patients with
midline incisions required 23.4 mg morphine more over
their hospitalization period than patients with transverse
incisions. There was significant heterogeneity with this
result. Sensitivity results showed that if emergency surgery
was excluded from the analysis, the significance remained
but the heterogeneity decreased. We believe this is clinically sensible because the disease process in emergency
surgery may have created more pain to mask that of the
incision. For example, it is feasible that the pain of
peritonitis may be greater than the incisional pain. The

K.A. Bickenbach et al.

Table 5

Incisions for abdominal surgery

405

The effectiveness of midline compared with transverse incisions

Outcome or subgroup
Hernia rate
Pulmonary
complications
Wound infection
Wound dehiscence
Total mg morphine
VAS pain score
POD 1
% VC of original on
POD 1
% FEV1 of original on
POD 1
OR time (min)
Cholecystectomy
Right hemicolectomy
Aortoiliac surgery
Incision length (cm)
Cholecystectomy
Right hemicolectomy
Gastric/pancreas
Length of stay (d)
Cholecystectomy
Right hemicolectomy

No. of
participants Midline
Transverse
Relative
(trials)
mean/proportion mean/proportion riskx (95% CI)
1,368 (7)
1,770 (10)

61/697 (9.9)
130/888 (14.6)

2,395
1,903
326
309

124/1,207 (10.2) 136/1,188 (11.4)

15/959 (1.6)
7/944 (.7)
87.6
65.3
4.2
3.8

(11)
(9)
(6)
(6)

30/671 (4.5)
129/882 (14.6)

Absolute
(per 100 patients)
(95% CI)k

Quality of
evidence

1.77 (1.092.87)* 3 more (0 to 8 more)

1.11 (.741.66) 2 more (4 less to 10 more)

Moderate{
Low{,#

.96 (.671.38)
1.71 (.753.89)
d
d

0 less (4 less to 4 more)

0 more (0 less to 2 more)
WMD 5 23.4 (6.939.9)*
WMD 5 .4 (2.9 to 1.8)

Moderate{
Low{,#
Low{,**
Low{,**

263 (5)

50.0

58.4

WMD 5 4.7 (21.1 to 10.5)

Low{,**

244 (4)

43.2

53.0

WMD 5 6.9 (3.110.7)*

Moderate4

d
d
d

WMD 5 1.3 (25.2 to 7.9)

Moderate{
WMD 5 26.2 (218.2 to 5.8) Low{,#
WMD 5 6.5 (237.3 to 50.2) Low{,#

409 (4)
68 (2)
76 (2)

68
95
244

68
102
240

168 (2)
69 (2)
489 (2)

14.3
14.2
18.8

14.3
13.0
24.5

d
d
d

WMD 5 1.2 (21.1 to 3.5)

Low{,**
WMD 5 .7 (2.6 to 2.0)
Low{,#
WMD 5 25.7 (211.6 to .2) Low{,**

370 (3)
68 (2)

4.0
8.5

2.8
7.7

d
d

WMD 5 .7 (2.9 to 2.3)

WMD 5 .9 (2.5 to 2.3)

Low{,#
Low{,#

OR 5 operating time; POD 5 postoperative day; VAS 5 visual analog scale; VC 5 vital capacity; WMD 5 weighted mean differences.
*Statistically significant.

VAS pain scale 1 to 10.

Quality rated from 1 (very low quality) to 4 (high quality).

x
Values .1 favor transverse incision.
k
Values are expected differences if patients undergo midline instead of transverse incisions.
{
Evidence limited by methodological quality of studies.
#
Evidence limited by imprecise data (small sample size or event rate).
**Evidence limited by heterogeneity between studies.

finding of decreased narcotic use with the transverse

incision is contrary to what most surgeons believe. Most
believe that transverse incisions, especially in the upper
quadrants, are more painful than midline incisions. However, these results contradict that belief.
The present study did not show a significant difference
in VAS pain scores on POD 1. However, there was again

Figure 2
incision.

substantial heterogeneity (I2 5 98%). We were unable to

explain the heterogeneity based on subgroup and sensitivity
analysis from our predefined hypotheses (Table 2). The lack
of a difference in VAS pain scores could be explained by
reasoning that patients with midline incisions were administered more narcotics to normalize their VAS pain scores
to those of transverse incisions.

A Forrest plot comparing milligrams of morphine per hospitalization in patients with midline incisions versus transverse

406

The American Journal of Surgery, Vol 206, No 3, September 2013

Figure 3 A Forrest plot comparing milligrams of morphine per hospitalization in patients with midline incisions versus transverse incisions excluding the Garcia-Valdecasas trial.

The combined data show that there is a greater decrease

in FEV1 on POD 1 in patients who have midline incisions.
There is no difference noted in vital capacity between the 2
incision choices. Because of differences in how data were
reported, we were unable to combine data for the later postoperative days, so it is unclear what the effects later in the
admission were. There was no difference in pulmonary
complications with a fairly narrow CI. Therefore, although
there was a difference in pulmonary function, a 6.9%
change in FEV1 on POD 1 may not be clinically significant
in the general population. It is conceivable that this difference could be significant in patients with poor initial pulmonary function.
Our results showed a higher rate of incisional hernia in
midline compared with transverse incisions (Fig. 5). These
data are mainly driven by the Fassiadis trial, which had the
highest rate of incisional hernias.11 However, this trial also
had the longest follow-up of 4.4 years, which is of particular
relevance given the preponderance of data suggesting that
most hernias develop after 1 year from surgery.12,13 Mudge
and Hughes12 showed that less than 50% of hernias develop
in 1 year. This finding was corroborated by Hoer et al,13 who
showed that it takes 2 years for 75% of hernias to develop.
The majority of the trials had a follow-up of 1 year or less,
so it is likely that the Fassiadis trial has a more accurate
rate of detection. The combined data show that paramedian
incisions also have a lower rate of hernias than midline incisions. There was a 3-fold increase in the hernia rate for

Figure 4

patients who had midline incisions. The follow-up in all 5

of these trials was 1 year, so it is possible that the difference
may be more pronounced with a longer follow-up. However,
with the lack of long-term follow-up, it is difficult to draw
conclusions on the long-term effects of incision choice. Irrespective of the type of incision surgeons use, they should adhere strictly to proven methods of incision closure.14,15
It is difficult to draw conclusions when comparing
transverse with paramedian incisions because this study is
underpowered. There was no difference observed in hernia
rates, wound infections, or pulmonary complications between the 2 incisions. There was a higher rate of wound
dehiscence with paramedian incisions when they were
compared with transverse incisions, suggesting that a
transverse incision is superior. However, this finding was
driven mainly by the Talwar study,16 which had an unusually high rate of wound dehiscence (38%). Dehiscence rates
of paramedian incisions ranged from 0% to 1% in the studies that compared paramedian with midline incisions. The
Talwar study was conducted on patients with intestinal perforations from typhoid and had a high incidence of wound
infections (52% transverse and 59% paramedian). It could
be theorized that the high rate of wound infections may increase the dehiscence rate, but there was no statistically significant difference in the wound infection rate between the
2 incisions.
Although we found that the transverse and paramedian
incisions offered some advantages over midline incisions,

A Forrest plot comparing the hernia rate in midline incisions versus paramedian incisions.

K.A. Bickenbach et al.

Figure 5

Incisions for abdominal surgery

A Forrest plot comparing the hernia rate in midline incisions versus transverse incisions.

the adequacy of the incision to expose the operative field is

of crucial importance. The adequacy of exposure was only
addressed in 1 study. In this trial, surgeons subjectively
evaluated the adequacy of the exposure by rating it as
excellent, good, or poor.17 The midline incision was found
to be excellent in 13 cases and good in 2. The transverse
incision was found to be excellent in 7 cases, good in 2,
and poor in only 1 case. This was related to the difficulty
in exposure of the right iliac artery for aortoiliac surgery.
However, there was no difference in operative time in this

Table 6

407

study or any of the other studies, suggesting that the effect

of exposure was minimal. Furthermore, although most surgeons would acknowledge that midline incisions are easier
to open and close than transverse incisions, the similar total
operative times suggests that this difference is not clinically
significant. Future studies should address the difference in
exposure between these incisions.
Another important factor in incision choice is cosmesis.
Cosmesis was only examined in 2 trials. The trial by Proske
et al18 showed a significantly higher patient-rated score for

The effectiveness of paramedian incision

Outcome or
subgroup

No. of
participants
(trials)

Midline

Midline compared with paramedian

Hernia rate
1014 (5)
48/491 (9.8)
Pulmonary
586 (3)
54/240 (22.5)
complications
Wound infections
935 (4)
43/452 (9.5)
Wound
1010 (4)
4/468 (0.6)
dehiscence
Paramedian compared with transverse
Outcome or
No. of
Transverse
Subgroup
participants
(trials)

Paramedian

RR (95% CI)

19/523 (3.6)
3.41 (1.0211.45)* 9 more (0 to 38 more)
71/346 (20.5) 1.04 (.75 1.42)
1 more (9 less to 5 more)

Quality of
evidence
Lowk,#
Lowk,{

49/483 (10.1)
4/452 (.9)

1.09 (.71 1.69)

.90 (.19 4.21)

1 more (3 less to 7 more) Moderatek

0 less (1 less to 3 more) Lowk,{

Paramedian

Relative risk
(95% CI)

Absolute
(per 100 patients)
(95% CI)x

Quality of
evidence

5 less
(13 less to 18 more)
10 less
(14 less to 26 more)
7 more
(4 less to 24 more)
8 less (2 to 10 less)

Very
Lowk,{,#
Lowk,{

Hernia rate

292 (3)

14/127 (11)

29/165 (17.6)

Pulmonary
complications
Wound infection

156 (2)

2/77 (2.6)

11/79 (13.9)

156 (2)

24/77 (31.2)

20/79 (25.3)

1.28 (.83 1.96)

192 (2)

2/77 (2.6)

12/115 (10.4)

0.23 (.06.85)*

Wound
dehiscence

Absolute
(per 100 patients)
(95% CI)x

.7 (.252)
.27 (.02 37.96)

*Statistically significant.

Quality rated from 1 (very low quality) to 4 (high quality).

Values .1 favor paramedian.

x
Values are expected differences if patients undergo midline or transverse instead of paramedian incisions.
k
Evidence limited by quality of studies.
{
Evidence limited by imprecise data (small sample size or event rate).
#
Evidence limited by heterogeneity between studies.

Lowk,{
Lowk,{

408

The American Journal of Surgery, Vol 206, No 3, September 2013

transverse incisions than for midline incisions. This difference was present despite a larger incision length for transverse incisions. The Halm et al trial19 also showed that both
patients and surgeons were significantly more satisfied with
the cosmetic result of transverse incisions compared with
midline incisions. Transverse incisions may offer better
cosmesis because they are situated along the Langer lines
of the skin. This results in less tension on the incision
and may result in a thinner scar. The width of the scar
was only addressed in the Halm et al study, which showed
that midline incisions had significantly thicker scars than
transverse incisions (8.3 vs 3.3 mm, P , .0001).19

Conclusions
Approximately 5 million laparotomies are performed
each year in the United States. This results in approximately 400,000 to 500,000 incisional hernias and close to
200,000 repairs each year.2 Given that the average total
hospital cost for an open incisional hernia repair is US
$7,197 and US $6,396 for a laparoscopic repair, this is a
significant burden on our economy.20 This review shows
that the use of either a paramedian or a transverse incision
as opposed to a midline incision results in a lower hernia
rate. This difference could translate into significant cost reductions for the health care industry.
Strengths of this study include the comprehensive search
for all eligible studies, systematic and explicit application
of the eligibility criteria by duplicate assessment, careful
consideration of the study quality, generation and testing of
a priori hypotheses to explain heterogeneity of the data, and
standardized data extraction. We identified a large number
of studies with a large number of patients and can make
rigorous conclusions.
Limitations to this study include the methodologic
quality of many of the primary studies. In only 9 trials
was the method of concealment adequate. Additionally, in
only 2 trials were the patients, medical staff, and outcome
assessors blinded. This review was also limited by incomplete data reporting in some of the eligible studies and by
the limited follow-up. Another limitation of the study is the
high level of heterogeneity of the studies. A final limitation
is that some of the trials included are dated and should be
treated with caution. Some of the older trials include
operations that are not commonly performed today, such
as open cholecystectomy, which has been replaced by
laparoscopic surgery. However, this should not impact the
results because the choice of incision is being studied and
not the operation performed. A large randomized controlled
trial should be performed to better evaluate incision choice
with modern operations.
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to
assess the overall quality of evidence.21,22 Under this system, trials are rated as high-quality evidence unless they
are limited by serious impairments to study quality,

important inconsistency, uncertainty about directness, imprecise or sparse data, or high probability of reporting
bias. The quality of data was rated as moderate when comparing midline incisions with transverse incisions for the
outcomes of hernia rates, pulmonary complications, and
wound infections. The data were limited by the methodologic quality of the studies. Comparisons regarding pain
were rated as low quality because of the limitations of
the methodologic quality and the heterogeneity between
studies. For the comparison of the hernia rate between midline and paramedian incisions, the quality was rated low because of the methodologic quality and the heterogeneity of
results. The quality of data for all outcomes when comparing paramedian with transverse incisions was rated low because of the limitations of the methodologic quality and the
poor sample sizes.
In summary, transverse incisions are associated with less
postoperative narcotic use than midline incisions. Additionally, both transverse incisions and paramedian incisions
have lower incisional hernia rates than midline incisions.
Based on these results, we recommend that surgeons use
either a transverse or paramedian incision when they are
comfortable with the exposure provided. Future studies
should focus on surgeons ease and adequacy of exposure
and should address the cosmetic results from the patients
perspectives.

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