Compared to midline,Transverse Incision has lower incidence of Incisional Hernia

A transverse specimen extraction site has a lower incidence of an Incisional Hernia compared to midline with longer follow-up but with worse cosmesis, according to a study published in the journal Annals of Surgery.

A small midline laparotomy remains the most commonly used incision for specimen extraction in laparoscopic colorectal surgery, but the rate of Incisional Hernia (IH) after midline laparotomy may be as high as 20%, of which an important proportion are symptomatic.

L.Lee and his associates conducted a study to compare the incidence of an incisional hernia (IH) between midline and transverse specimen extraction site in patients undergoing laparoscopic colectomy.

The study conducted was a single-center, parallel-arm, nonblinded, superiority randomized trial.

The study participants were aged 18 years or older and had elective laparoscopic right hemicolectomy, left hemicolectomy, or rectosigmoid resection for the malignant or benign disease. Exclusion criteria involved patients who were undergoing surgery for inflammatory bowel disease, emergency surgery, mid- to low-rectal resection, transverse colectomy, single incision laparoscopic surgery, planned stoma and if they had prior abdominal surgery. Patients were randomly assigned to a midline versus transverse extraction site.

The primary outcome was the proportion of patients with IH at 1 year. IH was defined as a spontaneous or Valsalva-induced protrusion through a palpable fascial defect at the extraction site. Secondary outcomes included the incidence of IH over the total follow-up period, perioperative outcomes such as 30-day morbidity and mortality, in particular, surgical site infections (SSIs), and patient-reported outcomes (PROs).

A total of 180 patients were enrolled, of which 165 were randomly assigned to transverse (n = 79) or midline (n = 86) extraction specimen extraction site.

The study found that:

• Patient, tumor, surgical data, and perioperative morbidity were similar.


• Pain scores were similar on each postoperative day.


• On intention-to-treat analysis, there was no difference in the incidence of IH at 1 year (transverse 2% vs midline 8) or after mean 30.3-month follow-up (6% vs 14%). In the per-protocol analysis, there were more IH after midline incision with longer follow-up (15% vs 2%,).


• On intention-to-treat analysis, SF-36 domains body pain and social functioning were improved after transverse incision.


• Cosmesis was higher after midline incision on per-protocol analysis, but without affecting body image.

The study concluded that patients receiving a transverse specimen extraction incision had a lower incidence of IH compared to those undergoing midline incision with longer follow-up. However Transverse incisions resulted in worse cosmesis. On the other hand, ITT analysis did not show a significant difference in IH between midline and transverse incisions at 1 year, although there was a trend toward fewer IH in the transverse group.