Choice of Incisions: Obese Patient, Multiple Sections, and Abnormal Placentation
Kristy K. Ward
INTRODUCTION
The choice of surgical incision for cesarean section should be individualized for each patient. Every patient and every surgery is different. Many factors direct this incision including surgeon preference, previous scars, placentation, patient habitus, and more. Fortunately, the obstetrical surgeon has many options and factors to consider when choosing an incision for surgical exposure. This chapter presents the different skin and uterine incision techniques and indications to help the surgeon navigate the usual and the unusual situations that come with cesarean delivery.
SKIN INCISIONS FOR CESAREAN SECTION
The transverse incision is the most commonly used incision for cesarean section in the United States. The vertical incision is often used in cases of emergent cesarean sections, known multiple prior surgeries, or preexisting vertical skin incision (Figure 6-1).
Low Transverse Abdominal Incision
The most commonly used low transverse abdominal entry for cesarean section is the Pfannenstiel technique.1
Pfannenstiel Technique
Begin with a semilunar incision 2 to 3 cm above the pubic symphysis approximately 10 to 12 cm across Figure 6-2.
The subcutaneous tissue is incised horizontally in the midline until the fascia is visualized, and then the subcutaneous incision is extended laterally sharply. Many surgeons use a modified technique by bluntly dividing the lateral tissue.
Care must be taken to avoid the superficial epigastric vessels, which run in the subcutaneous tissue just lateral to the rectus muscles (Figure 6-3). They are much easier to cauterize before being cut through as they retract into the subcutaneous tissue when cut.
The fascia is incised horizontally in the midline and extended laterally with scissors, elevating the fascia above the rectus muscle and curving the incision slightly cephalad (Figure 6-4).
The upper fascia is grasped with Kocher or Ochsner clasp and elevated, and the fascia is separated sharply from the rectus muscles for approximately 10 cm to allow mobilization of the rectus muscles laterally). This is repeated inferiorly to separate the rectus and pyrimidalis muscles down to the pubic symphysis (Figure 6-5).
Any perforating vessels encountered should be individually cauterized. If they retract without being properly cauterized, a postoperative rectus hematoma can develop.
The rectus muscles are then separated in the midline and lateralized (Figure 6-6).
The peritoneum is identified at the most cephalad point and entered sharply.
The peritoneal incision is then extended with care taken to avoid the bladder. A modified technique is to enter the peritoneum and extend the opening bluntly.
 FIGURE 6-1 Types of abdominal incisions used for cesarean delivery: vertical or low transverse. The transverse incision is the most commonly used incision for cesarean section in the United States. The vertical incision is often used in cases of emergent cesarean sections, known multiple prior surgeries, or preexisting vertical skin incision. (With permission from Hatfield NT. Introductory Maternity and Pediatric Nursing. 3rd ed. Philadelphia: Wolters Kluwer; 2014.) |
 FIGURE 6-2 Skin incision for Pfannenstiel technique. A semilunar skin incision approximately 2 cm above the pubic symphysis is made. The direction of the incision should aim toward the anterior superior iliac spines. (Reprinted with permission from Jones HW, Rock JA. Te Linde’s Operative Gynecology. 11th ed. Wolters Kluwer; 2015.) |
 FIGURE 6-3 The superficial epigastric vessels run in the lateral subcutaneous tissue just lateral to the rectus muscles. Care must be taken to avoid the superficial epigastric vessels which are often cut or torn during Pfannenstiel incisions. (Reprinted with permission from Agur AM, Dalley AF. Grant’s Atlas of Anatomy. 14th ed. Philadelphia: Wolters Kluwer; 2017.) |
 FIGURE 6-4 Fascial incision for a Pfannenstiel incision. The fascia is cut in a semilunar fashion similar to the skin incision. The lateral edges of the incision can be extended past the length of the skin incision to gain more exposure. (Reprinted with permission from Jones HW, Rock JA. Te Linde’s Operative Gynecology. 11th ed. Wolters Kluwer; 2015.) |
 FIGURE 6-5 Elevating the fascia from the rectus muscle during Pfannenstiel technique. Identify and cauterize the perforating vessels before cutting them to avoid hematoma. (Reprinted with permission from Jones HW, Rock JA. Te Linde’s Operative Gynecology. 11th ed. Wolters Kluwer; 2015.) |
Joel-Cohen Low Transverse Abdominal Entry
Another common low transverse abdominal entry used during cesarean section is the Joel-method. In a Cochrane review, the Joel-incision was found to be associated with less fever, pain and analgesic requirements, less blood loss, and shorter duration of surgery and hospital stay than the Pfannenstiel method.2 The Joel-low transverse technique can be useful in performing stat cesarean sections as the abdomen can be entered in seconds by an experienced obstetrician. In addition, there is a decreased chance of accidentally severing the superficial epigastric vessels and rectus perforating vessels.
 FIGURE 6-6 Dividing the rectus muscles during Pfannenstiel technique. If there is scaring, the rectus muscles may need to be sharply divided. (Reprinted with permission from Jones HW, Rock JA. Te Linde’s Operative Gynecology. 11th ed. Wolters Kluwer; 2015.) |
Technique for Joel-Cohen Low Transverse Abdominal Entry
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