Preplaced Incision (Fig. 5.3)

A Pfannenstiel incision, which is 5-6 cm in length two to three fingerbreaths above the pubic symphysis pubis, is marked in supine position. A bikini line incision can also be marked in females. The incision is taken once the patient is positioned and prepared. The skin and subcutaneous tissue is incised, and the rectus sheath is opened horizontally and undermined cranially and caudally. Rectus abdominis muscle, pyramidalis muscle, and the midline are identified. The midline is scored with electrocautery, and using an atraumatic forceps and artery forceps, it is split. Preperitoneal fat

Fig. 5.4 Operating room setup. The figure depicts the position of the surgeon, the assistant, and the anesthetist

is now exposed; using atraumatic forceps and artery forceps, this fat is peeled off from the peritoneum, and peritoneum is thus exposed. The incision is packed with wet mop.

Advantage of this incision is that it can be used in any emergency, vascular accident, where surgeon can use his hand to temporize bleeding. It is a muscle-splitting incision, and hence there are less chances of developing hernia and good healing. Cosmetically, it is a very appealing incision. This incision can be used to train surgeons; the surgeons are allowed to do kidney retrievals from this incision in early part of their training, and when they actually start performing this surgery, they can use this incision in salvaging vascular accidents.

A similar incision can be placed in the left iliac fossa; the disadvantage is that it is a muscle-cutting incision, is less cosmetic, and increases chances of incisional hernia. But it is useful in extremely obese patients and in patients with operative history in lower abdomen.