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Incisions & Closure

The incision is the first and last decision of every open operation. For the reconstructive urologist, it dictates exposure for the index case, determines where future stomas and re-operations can be sited, and — together with closure technique — drives the dominant delayed complication of abdominal surgery: incisional hernia. Overall incisional hernia incidence in urologic surgery is 4.8%, rising to 7.1% for open midline and 15.1% for parastomal sites, and dropping below 2% for laparoscopic approaches.[1] A 2025 meta-analysis of abdominal wall closure trials reinforces what the 2022 European and American Hernia Societies (EHS/AHS) guideline already codified: small-bites continuous closure with slowly absorbable monofilament is the reference standard, and it is the single modifiable factor with the largest effect on long-term wound integrity.[2][7]

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

Open Incisions — A Urologist's Atlas​

Midline Laparotomy​

Anatomy. Linea alba — avascular fusion of the rectus sheaths — from xiphoid to pubic symphysis. Divided into upper (xiphoid to umbilicus), lower (umbilicus to pubis), or full.

Use. Workhorse for radical cystectomy with urinary diversion, retroperitoneal lymph node dissection, large renal tumors with IVC thrombus, and any operation requiring bilateral or multi-quadrant access.

Pros. Fastest entry, maximum exposure, easily extended, bloodless plane along the linea alba.

Cons. Highest incisional hernia rate (7.1%) of open urologic incisions.[1] Maximum postoperative pain. Poor cosmesis.

Pfannenstiel Incision​

Anatomy. Transverse curvilinear skin incision ~2 fingerbreadths above the symphysis, 10–15 cm wide. Subcutaneous fat, Scarpa's fascia, and anterior rectus sheath are divided transversely; the rectus muscles are retracted laterally (the inferior epigastric vessels run on the posterior sheath); the peritoneum is entered vertically.

Use. Extraperitoneal access to the bladder and retropubic space (open RP, simple prostatectomy, diverticulectomy, autologous pubovaginal sling harvest), specimen extraction site in robotic cases, and cesarean section.

Pros. Superior cosmesis, lower hernia rate than midline, preserves linea alba for future access.

Cons. Limited cephalad exposure. Iliohypogastric and ilioinguinal nerves at risk laterally — entrapment or neuroma causes chronic groin pain.

Gibson (Lower-Quadrant Oblique) Incision​

Anatomy. Oblique skin incision 2 cm above and parallel to the inguinal ligament, from lateral border of rectus toward the ASIS. External oblique aponeurosis, internal oblique, and transversus abdominis are split in the direction of their fibers; peritoneum is swept medially to expose the iliac vessels and lower ureter retroperitoneally.

Use. Distal ureterectomy, ureteral reimplantation (Lich-Gregoir, psoas hitch, Boari flap), iliac node dissection, and the standard renal transplant incision (extraperitoneal placement onto the iliac vessels).

Pros. Extraperitoneal — ileus-sparing, ideal for transplant. Lower hernia rate (4.7%) than midline.[1]

Cons. Limited upper-abdominal extension. Ilioinguinal nerve injury risk.

Flank Incision (11th or 12th Rib)​

Anatomy. Patient in full lateral decubitus with break over the iliac crest. Skin incision over the bed of the 11th or 12th rib, extending obliquely toward the umbilicus. Latissimus dorsi and external oblique are divided; the rib is resected subperiosteally or incision is made between ribs. Pleura and peritoneum are swept away; Gerota's fascia is entered retroperitoneally. Intercostal neurovascular bundle runs along the inferior margin of each rib — preserve by staying on the superior border.

Use. Open radical nephrectomy, nephroureterectomy, adrenalectomy, pyeloplasty, large renal stone surgery.

Pros. Direct retroperitoneal access, no bowel mobilization, spares the peritoneal cavity.

Cons. Flank bulge from intercostal nerve injury (subcostal / iliohypogastric denervation of lateral abdominal wall musculature) — a pseudohernia distinct from true fascial dehiscence. Pleural injury if the incision extends above the 11th rib. Positioning-related rhabdomyolysis and brachial plexus stretch.

Subcostal and Chevron / Mercedes / Makuuchi Incisions​

Anatomy. Subcostal: skin incision 2–3 cm below and parallel to the costal margin, dividing anterior rectus sheath, rectus muscle, and posterior sheath; can be unilateral or extended across midline as a Chevron. Adding a vertical xiphoid extension converts Chevron into a Mercedes (three-pointed) incision. The Makuuchi ("reverse-L" / "J") incision — a right subcostal with a vertical midline xiphoid extension — was developed for hepatobiliary resection and is invoked in urology for complex right retroperitoneal / IVC tumor thrombus cases when combined hepatic mobilization is anticipated.

Use. Open radical nephrectomy (especially right-sided with IVC thrombus), bilateral adrenalectomy, donor nephrectomy (historical), complex retroperitoneal sarcoma, combined liver-kidney exposure.

Pros. Excellent upper abdominal exposure, direct access to IVC and renal hilum with hepatic mobilization option.

Cons. Two rectus sheath layers to close with increased hernia risk at the midline junction ("Mercedes point"), significant postoperative pulmonary morbidity.

Thoracoabdominal Incision​

Anatomy. Extension of a subcostal or flank incision through the 8th, 9th, or 10th interspace across the costal margin. Diaphragm is divided radially (preserving phrenic branches at the central tendon); pleura entered; combined thoracic-abdominal cavity. Chest tube at closure.

Use. Giant upper-pole renal tumors, adrenal cortical carcinoma, IVC thrombus extending into the atrium, large retroperitoneal sarcoma.

Pros. Unmatched exposure for cephalad retroperitoneal pathology.

Cons. Highest morbidity open incision in urology — pulmonary complications, diaphragmatic hernia, chronic intercostal neuralgia, costochondritis.

Dorsal Lumbotomy​

Anatomy. Patient prone. Vertical paraspinal skin incision from the 12th rib to the iliac crest, lateral to the paraspinal muscles. Latissimus dorsi and posterior layer of thoracolumbar fascia divided; quadratus lumborum retracted medially or divided; Gerota's fascia entered posteriorly.

Use. Open pyeloplasty, pyelolithotomy, ureterolithotomy, and nephrectomy for benign disease — particularly pediatric.[3][4]

Pros. No muscle division in many variants, rapid recovery, minimal postoperative pain, excellent cosmesis.

Cons. Very limited exposure — cannot manage vascular injury or extend to renal hilum. Almost entirely displaced by laparoscopic/robotic approaches outside pediatric practice.

Perineal Approach​

Anatomy. Patient in exaggerated lithotomy or prone jackknife. Curvilinear or inverted-U skin incision anterior to the anus. Central tendon of the perineum divided; rectourethralis fibers separated; Denonvilliers' fascia entered to reach the posterior urethra, prostate, or rectum.

Use. Bulbar and posterior urethroplasty (the dominant urethral reconstructive approach), rectourethral fistula repair, perineal prostatectomy (historical), York-Mason rectal approach (prone).

Pros. Direct access to the urethra and prostatic apex without abdominal entry. Excellent for salvage post-radiation when the abdominal field is hostile.

Cons. Lithotomy-position complications (well-leg compartment syndrome, peroneal nerve palsy, rhabdomyolysis). Sexual function sequelae (pudendal neurovascular injury). Limited exposure cephalad to the prostate.

Lateral/Inguinal Port Extraction Sites​

A technique consideration rather than an incision: where to extract a laparoscopic or robotic specimen. Midline extraction after minimally invasive nephrectomy carries a 23% incisional hernia rate vs ≤10% for off-midline extraction, an effect large enough that it should drive planning.[5] Pfannenstiel extraction is the lowest-hernia-rate choice for large specimens.

Videos​

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

Fascial Closure — The Evidence That Matters​

The evidence base for abdominal closure technique is unusually strong, built on two landmark trials and a recent transatlantic guideline.

The STITCH Trial (Deerenberg, Lancet 2015)​

Multicenter RCT, 560 patients, elective midline laparotomy. Small-bites closure (5 mm × 5 mm, continuous, 2-0 slowly absorbable monofilament) vs traditional large-bites (10 mm × 10 mm, 1 PDS). At 1 year, incisional hernia occurred in 13% of small-bites vs 21% of large-bites patients (p=0.022) — no increase in surgical site infection or operative time.[6] This trial is the reason small-bites is now guideline-directed care.

The 2022 EHS/AHS Guideline (updated 2024–2025)​

The European and American Hernia Societies published a joint updated guideline for abdominal wall closure.[7] Subsequent 2025 systematic review data support the recommendations unchanged.[2]

Core recommendations for elective midline laparotomy:

  • Continuous, single-layer, small-bites fascial closure with slowly absorbable monofilament suture.
  • Tissue bites 5–8 mm from the wound edge; stitches spaced 5 mm apart.
  • Aponeurosis only — do not include rectus muscle or peritoneum.
  • Suture-to-wound length ratio ≥4:1 — the single most audited technical marker.
  • USP 2/0 suture on a small (~26 mm) needle.
  • Low tension — approximate, do not strangulate.

Suture material:

  • Slowly absorbable monofilament (e.g., PDS) retains >50% tensile strength at 6 weeks vs only 25% at 4 weeks for fast-absorbing sutures — the fascia has not regained strength by the faster timeline.[7]
  • Monofilament reduces incisional hernia vs multifilament (RR 0.76).[8]
  • Non-absorbable sutures achieve equivalent hernia rates but increase chronic wound pain and suture sinus formation.[7]

What not to do:

  • Do not close the peritoneum separately. No wound-outcome benefit.[9]
  • Do not place retention sutures prophylactically. No benefit in elective closure and increased pain; reserve for the rare damage-control / dehiscence scenario.[9]]
  • Do not place subcutaneous sutures or drains routinely to prevent hernia or seroma.[9]

Overall Effect Size​

Meta-analysis of small-bites vs conventional technique shows approximately 50% relative reduction in incisional hernia (RR ≈ 0.49).[7] No other modifiable closure variable approaches this magnitude.

Incisional Hernia — Rates and Risk Factors​

Rates by Approach[1]​

ApproachIncisional hernia rate
Retroperitoneal0.9%
Laparoscopic1.9%
Open, off-midline (Gibson, flank)4.7%
Open midline7.1%
Parastomal15.1%

Procedure-Specific Rates​

  • Radical cystectomy with diversion: 18.7% incisional + 23% parastomal.[10]
  • Minimally invasive radical prostatectomy: 5.3% (vs 1.9% for open).[11]
  • MIS nephrectomy with midline extraction: 23%.[5]

Independent Risk Factors[5][7][10]​

  • Surgical site infection — OR 8.55
  • Diabetes — OR 6.68
  • Smoking — OR 3.93
  • COPD — HR 2.35
  • Obesity — HR 1.74
  • Immunosuppression — OR 2.5
  • Male sex, advanced age
  • Incision length, midline location
  • Higher BMI / fat mass index

The large SSI effect is a reminder that infection control is hernia prevention.

Prophylactic Mesh in High-Risk Closure​

For elective midline laparotomy in high-risk patients (the canonical candidates: BMI ≥30, prior laparotomy, COPD, AAA repair), the EHS/AHS guideline suggests prophylactic synthetic permanent mesh augmentation in the onlay or retromuscular position, with a relative hernia reduction of ~65% (RR 0.35).[7] Risk-stratification tools (HERNIA score) help identify candidates. Complication rates — seroma, infection, mesh-related pain — are small but not zero.

In urology this is most relevant after open radical cystectomy and in patients with prior radiation or multiple prior abdominal operations.

Port-Site Closure in Laparoscopy and Robotics​

  • Close fascia at all trocar sites ≥10 mm, and consistently at the umbilical and SILS sites regardless of caliber.[7]
  • Occult radiographic port-site hernias are detected in 6.7% of patients after robotic urologic surgery — most commonly at 12 mm ports and extended extraction sites; specimen weight >40 g and wound infection are independent risk factors.[12]
  • Extraction-site selection is the single most impactful hernia-prevention choice in MIS urology: avoid midline extraction when a Pfannenstiel or off-midline option is available.[5]

Practical Takeaways​

  1. Match incision to exposure need, then to downstream operability — a transplant candidate gets a Gibson; a cystectomy patient gets a midline because diversion dictates it.
  2. Small-bites, 4:1 ratio, 2-0 slowly absorbable monofilament is the default closure for every midline laparotomy — this is the evidence-based intervention with the largest effect size.
  3. Do not close the peritoneum and do not use retention sutures prophylactically.
  4. Prophylactic mesh for elective high-risk midline closure — especially post-cystectomy.
  5. Avoid midline extraction after minimally invasive nephrectomy; Pfannenstiel or off-midline extraction cuts hernia rate by more than half.
  6. Infection is hernia — SSI carries a >8-fold hernia risk and is the single largest modifiable driver outside closure technique.

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. Henriksen NA, Deerenberg EB, Antoniou GA, et al. "Updated Evidence on Closure of Abdominal Wall Incisions — Systematic Review and Meta-Analysis." BJS Open. 2025;10(1):zraf150. doi:10.1093/bjsopen/zraf150

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.

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