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Incisions & Closure

Choose an incision that provides adequate exposure while preserving options for future reconstruction, stomas and reoperation. Incisional hernia risk depends on the operation, patient, incision, infection prevention and closure technique. For elective midline laparotomy, the EHS/AHS guideline suggests continuous small-bites closure with slowly absorbable suture.[7] This is a weak recommendation supported by low-certainty evidence; newer reviews support a reduction in hernia, with less consistent evidence for other wound outcomes.[2][7][13][14]

See also: The Abdominal Wall, Wound Healing, Plastic Surgery Principles, Laparoscopic Access.

Open Incisions — A Urologist's Atlas​

These are exposure options, with variants determined by anatomy and the planned reconstruction.

Midline Laparotomy​

Plane and use. Access through the linea alba can be extended for bilateral or multiple-quadrant exposure. It is commonly used for open cystectomy with diversion and complex abdominal reconstruction.

Tradeoff. Exposure is versatile, but comparative abdominal-surgery evidence favors avoiding a midline incision when another incision provides equally appropriate access.[7]

Pfannenstiel Incision​

Plane and use. A low transverse skin and anterior fascial incision with separation of the rectus muscles can provide retropubic access or an extraction site. Peritoneal entry is optional, according to the operation; extraperitoneal bladder work does not require it.

Tradeoff. Cephalad exposure is limited. Preserve the inferior epigastric vessels on the deep surface of the rectus and avoid lateral iliohypogastric/ilioinguinal nerve injury or entrapment. Do not assume a posterior rectus sheath is present below the arcuate line. A fascial-harvest incision for an autologous sling requires its own donor-site plan.

Gibson (Lower-Quadrant Oblique) Incision​

Plane and use. Lower-quadrant extraperitoneal exposure allows access to the iliac vessels and distal ureter, including transplantation and selected ureteral reconstruction. Abdominal-wall division and muscle separation depend on the incision variant; the three lateral layers are not all simply split in one shared fiber direction.

Tradeoff. Upper-abdominal extension is limited. Protect the peritoneum, nerves and vascular structures. The cited hernia rate pools off-midline incision types.[1]

Flank Incision​

Plane and use. A flank or rib-related approach provides retroperitoneal access to the kidney, proximal ureter and collecting system. Rib resection, muscle division and patient positioning vary with the required exposure.

Tradeoff. Pleural injury can occur during upper flank exposure, including near the 12th rib. Protect intercostal/subcostal nerves and vessels; denervation can produce a flank bulge without a true fascial hernia. Avoid excessive table flexion and pressure on dependent tissues.

Managing an opened pleura. A recognized pleurotomy can be repaired by evacuating pleural air through a small catheter while suturing the defect.[20] In an operative teaching variant, pass a small (12 Fr) red rubber catheter through the defect into the pleural cavity, place an absorbable purse-string suture around it, immerse the free end in saline, position the patient in Trendelenburg, ask anesthesia for repeated positive-pressure breaths until bubbling stops, and remove the catheter while tying the purse-string. After a recognized pleural tear, obtain a recovery-room chest radiograph to assess for pneumothorax; repeat imaging or place a chest tube according to the radiograph and respiratory findings.[19][20] Excise the 11th rib when the exposure requires it: incise the intercostal-muscle fibers at the superior rib border with cautery, use a periosteal elevator in a medial-to-lateral brushing motion to clear periosteum above and below the rib and deflect the neurovascular bundle away from it, free the rib posteriorly with a costal elevator, cut it with a rib cutter while a clamp stabilizes it, and apply bone wax to the cut surface.

Subcostal, Chevron and Extended Upper-Abdominal Incisions​

Plane and use. Unilateral or bilateral subcostal incisions and selected vertical extensions provide upper-abdominal or combined retroperitoneal exposure. Named variants differ in their geometry; choose the actual exposure required.

Tradeoff. Muscle division, intersecting fascial incisions, pain and pulmonary recovery require attention. Thoracoabdominal access additionally requires a planned pleural/diaphragmatic opening and repair with appropriate expertise; a generic incision description is insufficient for that operation.

Dorsal Lumbotomy​

Plane and use. A posterior approach can expose the kidney or proximal ureter for selected procedures, including pediatric pyeloplasty. Muscle-sparing variants are described in historical urologic series.[3][4]

Tradeoff. The working space and ability to extend exposure are limited. Plan how wider exposure and vascular control would be obtained if necessary; avoid assuming the approach either guarantees minimal morbidity or makes hilar access categorically impossible.

Perineal Approach​

Plane and use. Perineal exposure is central to bulbar/posterior urethral reconstruction and selected fistula repairs. Positioning and dissection vary substantially with the target and previous treatment.

Tradeoff. Routine bulbar urethroplasty does not require division of the perineal body, rectourethralis or entry into Denonvilliers' fascia. York–Mason is a distinct posterior transsphincteric approach. Use the relevant urethral reconstruction technique for operative planes. Protect the rectum, neurovascular structures and limbs during prolonged positioning.

Specimen Extraction​

Plan extraction before placing ports. An off-midline or Pfannenstiel incision is reasonable when it permits safe specimen removal and the intended reconstruction. A 2025 observational nephrectomy cohort associated midline extraction with more hernias; in a separate surgeon-selected robotic-prostatectomy cohort, extraction-site hernias occurred in 2/347 after Pfannenstiel versus 83/1118 after periumbilical extraction, so neither cohort establishes a universally best site.[5][23] A randomized prostatectomy trial comparing transverse and vertical supraumbilical extraction incisions found no significant 15-month hernia difference (100/482 versus 97/512 assessed; 362/1356 lacked outcome data); it did not compare Pfannenstiel with periumbilical extraction.[24]

Reopening a Prior Incision​

When feasible, extend the incision and enter through an unviolated area rather than the scarred field: planes are often more anatomic and adhesions fewer away from the prior wound. Identify organs adherent to the old incision early and take them down under direct, careful dissection. When substantial adhesions are anticipated — after cystectomy with urinary diversion, abdominal trauma, or prior bowel surgery — consider involving an experienced general surgeon for entry and closure.[15]

Fascial Closure — The Evidence That Matters​

STITCH: what was actually compared​

STITCH randomized 560 patients undergoing elective midline laparotomy. At one year, the primary analysis included 545: hernia occurred in 35/268 (13%) with small bites versus 57/277 (21%) with large bites; adjusted OR 0.52 (95% CI 0.31–0.87). Closure took 14 versus 10 minutes, respectively. Other complication rates did not differ significantly.[6]

This was a technique package: the small-bite arm used approximately 5-mm bites/spacing, 2-0 PDS Plus II and a 31-mm needle; the large-bite arm used bites of at least 10 mm with 10-mm spacing and USP 1 double-loop suture with a 48-mm needle. Emergency laparotomy was excluded.[6]

In a 2026 long-term STITCH analysis, estimated cumulative incisional-hernia incidence at 13 years was 34% with small bites versus 49% with large bites (HR 0.61, 95% CI 0.43–0.86; median time to censoring eight years); hernia repair rates were similar.[16] In the separate ESTOIH trial, five-year hernia incidence was 9.14% versus 13.90% among 362 analyzed patients, a difference that did not reach statistical significance (p = 0.155).[17]

EHS/AHS 2022 guidance and subsequent evidence​

The joint guideline is dated 2022. Later systematic reviews are additional evidence, not a new society guideline.[7]

EvidencePractical interpretation
EHS/AHS 2022 guidelineSuggests continuous small-bites closure using slowly absorbable suture for elective midline incisions; recommendation strength is weak.
Comprehensive closure review, 2025Supports lower hernia risk with small bites; heterogeneous materials and techniques limit claims about the best isolated component.[2]
Morarasu review, 2025Hernia benefit persisted in the randomized-trial analysis, while infection and dehiscence differences did not reach significance. Highlights bias, different technique packages and fragility of some trial results.[14]
SUBITE, 2026Twelve studies (7 randomized, 5 comparative nonrandomized; 5,886 participants) supported lower hernia, infection and fascial dehiscence odds with small bites. Overall hernia OR was 0.47 (95% CI 0.38–0.58), infection OR 0.53 (0.42–0.67) and dehiscence OR 0.60 (0.38–0.93); the authors report randomized estimates comparable to nonrandomized ones. Much of the evidence overlaps earlier reviews.[13]

These results support a consistent elective-midline closure technique. For emergency midline laparotomy, the WSES 2023 guideline weakly suggests small-bites closure (grade 2C), extrapolating from elective trials.[18] The pooled elective-midline results have uncertain applicability to emergency, severely contaminated, transverse or complex reoperative wounds and to other slowly absorbable products.

Elective midline closure principles​

  • Take small aponeurotic bites, approximately 5–9 mm from the edge, spaced about 5 mm apart; avoid incorporating muscle or subcutaneous fat.
  • Use a continuous slowly absorbable monofilament and an appropriate small needle. Common studied packages use 2-0; needle sizes differ between trials.
  • Aim for a suture-to-wound length ratio of at least 4:1, with low tension and approximation rather than tissue strangulation.
  • Inspect tissue quality and the full closure, including the ends. Adapt the plan when viable fascia cannot be approximated safely.[6][7]

Exact strength-retention timelines depend on the material, product and caliber. The 2017 Cochrane review did not establish one best material–technique combination and excluded trials comparing only small versus large bites. Nonabsorbable sutures can cause persistent pain or sinus problems.[7][8]

Routine separate peritoneal closure has no established wound-outcome benefit. Retention sutures, subcutaneous closure and drains answer different problems; they are not routine substitutes for sound fascial closure or universal hernia-prevention measures. Selected contaminated or disrupted wounds require a specific management plan.[9]

Incisional Hernia — Interpreting Rates​

Surveillance method, follow-up, procedure and denominator explain much of the variation.

Source and populationReported outcomeLimitation
Urologic systematic review, 84 studiesOverall mean proportion across 84 studies 3.8% (95% CI 3.1–4.6%); case-series subgroup 4.8% (95% CI 3.7–6.2%); open midline 7.1%, off-midline 4.7%, laparoscopic 1.9%, retroperitoneal 0.9%; parastomal hernia 15.1%.[1]Marked heterogeneity; categories overlap different operations and are not randomized comparisons. Parastomal hernia is a separate outcome.
USC cystectomy cohortIncisional hernia 125/670 (18.7%); parastomal hernia 21/92 ileal-conduit patients (23%).[10]Different denominators and median follow-up: 57 months for the incisional analysis and 34 months for the conduit subgroup.
SEER–Medicare prostatectomy cohortIncisional hernia repair in 5.3% after minimally invasive versus 1.9% after open prostatectomy.[11]Older patients; follow-up differed.
Imaging-selected MIS nephrectomy cohort, 494 patientsTwo-year hernia incidence 23% with midline versus ≤10% with other extraction sites.[5]Observational association; selection and incision choice may confound the comparison.
CT-selected robotic urology series, 104 patientsSeven patients (6.7%) had occult port-site hernias; 8/564 ports (1.4%).[12]Patient-level and port-level incidence are different.

Discuss smoking, obesity, diabetes, pulmonary disease, immunosuppression, prior incisions and infection risk.[7]

Prophylactic Mesh in High-Risk Closure​

The EHS/AHS guideline states that prophylactic mesh can be considered after elective midline laparotomy. If chosen, permanent synthetic mesh in an onlay or retromuscular position is suggested. These are weak recommendations; benefits, seroma, infection and the implications of a permanent implant should be considered together.[7]

The incremental benefit over a well-performed modern small-bites closure remains uncertain. Incisional-mesh and parastomal-mesh decisions are separate. The 2022 EHS/AHS guideline made no recommendation for prophylactic mesh in emergency laparotomy because evidence was insufficient at that time.[7] PREEMER stopped early after 109 randomizations; among 72 patients who received an allocated intervention, it did not detect a two-year hernia advantage for retrorectus mesh over 4:1 small-stitch closure. One mesh patient developed a fistula requiring mesh removal.[21] A 2026 synthesis of seven heterogeneous emergency-laparotomy RCTs (643 patients) found fewer incisional hernias with mesh through 24 months and more seromas; the overall wound-complication difference appeared in a sensitivity analysis, not the main pooled analysis.[22]

Port-Site Closure in Laparoscopy and Robotics​

The EHS/AHS guideline suggests fascial closure of trocar defects ≥10 mm, especially umbilical and single-incision laparoscopic sites. Evidence is very limited, and no particular closure method or material is established as superior.[7]

Assess the final fascial defect, including enlargement for extraction and stretching during manipulation. The guideline does not mandate closure of every umbilical port regardless of caliber. Close under adequate visualization to avoid entrapping bowel or injuring abdominal-wall vessels.

Practical Takeaways​

  1. Match access to exposure, reconstruction, extraction and future operations.
  2. Use a reproducible small-bites, slowly absorbable closure for suitable elective midline wounds; document the technique.
  3. Choose off-midline extraction when clinically appropriate, recognizing the limitations of urology-specific observational evidence.
  4. Consider prophylactic mesh selectively and distinguish incisional from parastomal prevention.
  5. Prevent infection and address patient risk factors; no closure technique eliminates hernia risk.

Videos​

Abdominal incisions
Open incision atlas and exposure
Small-bites fascial closure
STITCH technique demonstration

References​

1. Calcerrada Alises E, Antón Rodríguez C, Medina Pedrique M, et al. "Systematic Review and Meta-Analysis of the Incidence of Incisional Hernia in Urological Surgery." Langenbecks Arch Surg. 2024;409(1):166. doi:10.1007/s00423-024-03354-4

2. van den Berg R, Visscher L, Menon AG, Deerenberg EB, Tanis PJ. "Suture Techniques and Materials for Fascial Closure of Abdominal Wall Incisions: A Comprehensive Meta-Analysis." Ann Surg Open. 2025;6(1):e548. doi:10.1097/AS9.0000000000000548

3. Orland SM, Snyder HM, Duckett JW. "The Dorsal Lumbotomy Incision in Pediatric Urological Surgery." J Urol. 1987;138(4 Pt 2):963–6. doi:10.1016/s0022-5347(17)43472-0

4. Novick AC. "Posterior Surgical Approach to the Kidney and Ureter." J Urol. 1980;124(2):192–5. doi:10.1016/s0022-5347(17)55369-0

5. Lone Z, Harper S, Shin D, et al. "Association Between Midline Extraction Incision and Increased Risk of Incisional Hernia After Minimally Invasive Radical Nephrectomy." J Urol. 2025. doi:10.1097/JU.0000000000004649

6. Deerenberg EB, Harlaar JJ, Steyerberg EW, et al. "Small Bites Versus Large Bites for Closure of Abdominal Midline Incisions (STITCH): A Double-Blind, Multicentre, Randomised Controlled Trial." Lancet. 2015;386(10000):1254–60. doi:10.1016/S0140-6736(15)60459-7

7. Deerenberg EB, Henriksen NA, Antoniou GA, et al. "Updated Guideline for Closure of Abdominal Wall Incisions From the European and American Hernia Societies." Br J Surg. 2022;109(12):1239–1250. doi:10.1093/bjs/znac302

8. Patel SV, Paskar DD, Nelson RL, Vedula SS, Steele SR. "Closure Methods for Laparotomy Incisions for Preventing Incisional Hernias and Other Wound Complications." Cochrane Database Syst Rev. 2017;11:CD005661. doi:10.1002/14651858.CD005661.pub2

9. Pearl ML, Rayburn WF. "Choosing Abdominal Incision and Closure Techniques: A Review." J Reprod Med. 2004;49(8):662–70. PMID 15457857

10. Movassaghi K, Shah SH, Cai J, et al. "Incisional and Parastomal Hernia Following Radical Cystectomy and Urinary Diversion: The University of Southern California Experience." J Urol. 2016;196(3):777–81. doi:10.1016/j.juro.2016.03.150

11. Carlsson SV, Ehdaie B, Atoria CL, Elkin EB, Eastham JA. "Risk of Incisional Hernia After Minimally Invasive and Open Radical Prostatectomy." J Urol. 2013;190(5):1757–62. doi:10.1016/j.juro.2013.05.036

12. Christie MC, Manger JP, Khiyami AM, et al. "Occult Radiographically Evident Port-Site Hernia After Robot-Assisted Urologic Surgery: Incidence and Risk Factors." J Endourol. 2016;30(1):92–6. doi:10.1089/end.2015.0431

13. Golling M, Baumann P, Kuger F, Fortelny RH. "Impact of the SUture BIte TEchnique on clinical outcomes after midline laparotomy closure: SUBITE—a systematic review and meta-analysis." Hernia. 2026;30:221. doi:10.1007/s10029-026-03700-z

14. Morarasu S, Lunca S, O’Brien L, et al. "Small-bites versus large-bites closure of midline laparotomies: A systematic review and meta-analysis." Colorectal Dis. 2025;27:e70073. doi:10.1111/codi.70073

15. Lundy M, Ashburn JH. "Management of the Hostile Abdomen." Clin Colon Rectal Surg. 2022;35(3):169-176. doi:10.1055/s-0041-1740043

16. van den Berg R, van Egmond S, Smits F, et al. "Small Bites vs Large Bites for Closure of Abdominal Midline Incisions: A Randomized Clinical Trial." JAMA Surg. 2026;161(6):566–573. doi:10.1001/jamasurg.2026.0618

17. Fortelny RH, Baumann P, Hofmann A, et al. "5-year clinical outcome of the ESTOIH trial comparing the short-bite versus large-bite technique for elective midline abdominal closure." Hernia. 2025;29(1):263. doi:10.1007/s10029-025-03459-9

18. Frassini S, Cobianchi L, Fugazzola P, et al. "ECLAPTE: Effective Closure of LAParoTomy in Emergency—2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings." World J Emerg Surg. 2023;18(1):42. doi:10.1186/s13017-023-00511-w

19. Latchamsetty KC, La Rochelle JC, Hoeksema J, Coogan CL. "Is routine postoperative chest radiography needed after open nephrectomy?" Urology. 2005;65(2):256–259. doi:10.1016/j.urology.2004.09.011

20. Atmaca AF, Canda AE, Serefoglu EC, Altinova S, Ozdemir AT, Balbay MD. "The incidence and management of pleural injuries occurring during open nephrectomy." Adv Urol. 2009;2009:948906. doi:10.1155/2009/948906

21. Mäkäräinen E, Tolonen M, Sallinen V, et al. "Prophylactic Retrorectus Mesh Versus Small-Stitch Closure After Emergency Midline Laparotomy: 2-Year Results of a Randomized Controlled Trial." J Abdom Wall Surg. 2025;4:15500. doi:10.3389/jaws.2025.15500

22. Hindawi MD, Kalmoush AF, Mohamed MG, et al. "Role of prophylactic mesh in emergency midline laparotomy: a systematic review and meta-analysis." World J Emerg Surg. 2026;21(1):29. doi:10.1186/s13017-026-00697-9

23. Van Horn CM, Jabeer M, Felice MD, et al. "Pfannenstiel Extraction Site Reduces Postoperative Extraction Site Hernias after Robotic Radical Prostatectomy." J Endourol. 2025;39(4):364–369. doi:10.1089/end.2024.0506

24. Gaffney CD, Vertosick EA, Laudone V, et al. "Randomized Trial of Transverse vs Vertical Extraction Site Incision After Robotic Radical Prostatectomy." J Urol. 2024;212(3):401–408. doi:10.1097/JU.0000000000004066