Recommendations for Incision Technique in Kidney Surgery

Incision Selection

A true Pfannenstiel incision consists of a transverse suprapubic skin cut, transverse opening of the anterior rectus sheath, blunt lateral separation of the rectus muscles (not at the linea alba), and a transverse peritoneal entry【1】【2】【3】.
The 2023 World Society of Emergency Surgery guidelines strongly recommend against using a midline fascial separation when a non‑midline alternative is feasible (Strong recommendation, High‑certainty evidence)【1】【2】【3】.

Incisional hernia rates are significantly lower after non‑midline (transverse) incisions compared with midline approaches【1】【2】【3】.
Transverse incisions are associated with less impairment of pulmonary function, lower rates of wound dehiscence, reduced burst abdomen, and decreased postoperative pain relative to midline laparotomy【1】【2】【3】.
Performing the fascial opening at the linea alba (midline) increases the risk of postoperative hernia regardless of the skin incision orientation【1】【2】【3】.
A transverse skin incision alone does not confer structural benefit if the fascia is opened vertically (midline)【2】.
Midline fascial separation nullifies the mechanical advantages of transverse, muscle‑sparing techniques【1】【2】【3】.
Misalignment between a transverse skin cut and a midline fascial cut can increase wound‑related complications【2】.

Using a true Pfannenstiel technique (transverse skin, fascia, and muscle separation) preserves the lower hernia rates demonstrated for transverse incisions【1】【2】【3】.

The transverse fascia should be closed with a continuous suture to maintain tensile strength【1】【2】.
Subcutaneous tissue ≥ 2 cm thick should be re‑approximated to reduce dead‑space and seroma formation【4】.
Subcuticular suturing of the skin is preferred over staples because it yields superior wound outcomes【4】.
Suturing the rectus muscles at the midline is unnecessary in a true Pfannenstiel incision and may cause tissue damage【4】.