Pfannenstiel Incision: Evidence‑Based Technique and Clinical Outcomes

Surgical Technique

The true Pfannenstiel incision must remain transverse through the skin, anterior rectus sheath, muscle plane, and peritoneum to preserve its mechanical advantage and achieve lower hernia rates compared with any approach that opens the fascia at the midline. 1
The anterior rectus sheath is opened transversely from lateral to medial, rather than vertically, to maintain the transverse integrity of the incision. 1
Blunt lateral separation of the rectus muscles away from the linea alba is essential; a midline fascial split eliminates the benefit of the transverse approach and increases hernia risk. 1
Transverse peritoneal entry provides access to the lower abdomen while preserving the transverse orientation of the entire wound. [2][3]

The Pfannenstiel approach offers optimal exposure of pelvic organs and lower abdominal structures and is therefore the preferred access for gynecologic surgery, lower‑abdominal/pelvic procedures, left‑colon and rectal resections, and urologic operations such as radical prostatectomy and nephrectomy. [2][3]
For specimen extraction after laparoscopic surgery, a Pfannenstiel incision is strongly preferred over a midline extraction site because it reduces wound complications and improves cosmetic outcome. [3][4]

Hernia prevention: The 2023 World Society of Emergency Surgery (WSES) guidelines issue a strong recommendation (high‑certainty evidence) to avoid midline extraction incisions when a non‑midline alternative such as Pfannenstiel is feasible. [3][4]
Wound integrity: Transverse incisions are associated with significantly lower rates of wound dehiscence and burst abdomen compared with midline laparotomy. (Multiple cohort studies) [2][3]4
Pulmonary function: Patients undergoing transverse Pfannenstiel incisions experience less postoperative impairment of pulmonary mechanics than those with midline incisions. (Prospective comparative data) [2][3]4

The transverse fascia should be closed with a continuous suture to preserve tensile strength and maintain the mechanical benefit of the incision. 1
Subcutaneous tissue ≥ 2 cm thick should be re‑approximated to eliminate dead space and reduce seroma formation. 1
Subcuticular skin suturing is preferred over skin staples for superior cosmetic and wound‑healing outcomes. 1
Suturing the rectus muscles at the midline is unnecessary in a true Pfannenstiel incision and may cause tissue injury; it should be avoided. 1

In hemodynamically unstable patients requiring rapid abdominal exploration, a midline laparotomy remains the incision of choice because it provides the quickest access to all peritoneal organs. [2][3]4
When pre‑operative imaging clearly identifies a localized pathology and the clinical situation permits, a transverse Pfannenstiel incision should be selected to lower the risk of incisional hernia and to enhance postoperative recovery. [2][3]4