LETTER
the wound apart, thus creating undue tension upon closure. The tension caused by the vertical incision with its multiple tissue trauma increases pain, use of pain management, atelectasis (Department of Anesthesiology, Washington University, St Louis, circa 1975) and a longer hospital stay while decreasing coughing and pulmonary function. In addition to less tension of the transverse incision, the closing sutures lie perpendicular to the tissue planes, creating the strongest closure. The closing sutures of the vertical incision lie parallel to the tissue planes, creating the weakest closure. The rectus muscle heals on its own and simply acts as another transverse tendon. The best closure was shown many years ago to be an interrupted vertical figure of 8 stitches on the fascia and peritoneum with the usual interrupted subcutaneous sutures and a running intracutaneous suture. The resulting scar is far superior to that with the vertical incision. Dr Alex Haller of Johns Hopkins said many years ago at an American College of Surgeons meeting in San Francisco that any operation can be done through the transverse incision.
All Abdominal Incisions Should Be Transverse Larry Lawson, MD, FACS Little Rock, AR In an effort to create thought and introduce a borrowed teaching, I would suggest, to solve Dr Tetsuji and colleagues’ question1,2 regarding the minutiae of how to close the midline incision, that all abdominal incisions should be transverse. Surgeons only need to respect the anatomy and physiology of the abdominal structures. Virtually all the fibers, muscles, nerves, arteries, veins, and lymphatics run transversely. Theoretically, a good transverse incision would cut only 1 of each. A vertical incision cuts hundreds to maybe thousands of these structures. It took a year for Dr Marion DeWeese at the University of Missouri to convince me of this, but after I saw the results, I used this approach for the remainder of my residency and 36 years of private practice. I have no way to publish my statistics, now being 10 years out of practice, but I can recall only 1 dehiscence and no eviscerations. All operations, from hiatal hernias to hysterectomies, including aortic abdominal aneurysms, were approached in this manner. Occasionally one end would have to be swung slightly because of the body habitus. The physiology is quite obvious. With the transverse incision, the major muscles pull laterally bringing the wound together. The vertical incision results in pulling
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
REFERENCES 1. McLeod RS, Brenneman FD, Rotstein OR, et al. Does the size of the stitch length affect surgical site infection? J Am Coll Surg 2013;217:556e559. 2. Fujita T. Choosing a better technique for midline abdominal closure [Letter]. J Am Coll Surg 2014;218:150.
Disclosure Information: Nothing to disclose.
846
http://dx.doi.org/10.1016/j.jamcollsurg.2014.07.001 ISSN 1072-7515/14
the wound apart, thus creating undue tension upon closure. The tension caused by the vertical incision with its multiple tissue trauma increases pain, use of pain management, atelectasis (Department of Anesthesiology, Washington University, St Louis, circa 1975) and a longer hospital stay while decreasing coughing and pulmonary function. In addition to less tension of the transverse incision, the closing sutures lie perpendicular to the tissue planes, creating the strongest closure. The closing sutures of the vertical incision lie parallel to the tissue planes, creating the weakest closure. The rectus muscle heals on its own and simply acts as another transverse tendon. The best closure was shown many years ago to be an interrupted vertical figure of 8 stitches on the fascia and peritoneum with the usual interrupted subcutaneous sutures and a running intracutaneous suture. The resulting scar is far superior to that with the vertical incision. Dr Alex Haller of Johns Hopkins said many years ago at an American College of Surgeons meeting in San Francisco that any operation can be done through the transverse incision.
All Abdominal Incisions Should Be Transverse Larry Lawson, MD, FACS Little Rock, AR In an effort to create thought and introduce a borrowed teaching, I would suggest, to solve Dr Tetsuji and colleagues’ question1,2 regarding the minutiae of how to close the midline incision, that all abdominal incisions should be transverse. Surgeons only need to respect the anatomy and physiology of the abdominal structures. Virtually all the fibers, muscles, nerves, arteries, veins, and lymphatics run transversely. Theoretically, a good transverse incision would cut only 1 of each. A vertical incision cuts hundreds to maybe thousands of these structures. It took a year for Dr Marion DeWeese at the University of Missouri to convince me of this, but after I saw the results, I used this approach for the remainder of my residency and 36 years of private practice. I have no way to publish my statistics, now being 10 years out of practice, but I can recall only 1 dehiscence and no eviscerations. All operations, from hiatal hernias to hysterectomies, including aortic abdominal aneurysms, were approached in this manner. Occasionally one end would have to be swung slightly because of the body habitus. The physiology is quite obvious. With the transverse incision, the major muscles pull laterally bringing the wound together. The vertical incision results in pulling
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
REFERENCES 1. McLeod RS, Brenneman FD, Rotstein OR, et al. Does the size of the stitch length affect surgical site infection? J Am Coll Surg 2013;217:556e559. 2. Fujita T. Choosing a better technique for midline abdominal closure [Letter]. J Am Coll Surg 2014;218:150.
Disclosure Information: Nothing to disclose.
846
http://dx.doi.org/10.1016/j.jamcollsurg.2014.07.001 ISSN 1072-7515/14
