Abdominal entry

Choice of Abdominal Incision

The skin incision from any surgical procedure is a “mark for life,” worn by the patient long after the operation is over. The technique selected mostly depends on the surgeon's experience, preference and the clinical condition of the patient. Most women with severe placenta accreta spectrum (PAS) are subjected to midline laparotomy due to clinician concerns about surgical access, risk of catastrophic hemorrhage and poor patient outcomes. 

Our original paper demonstrated non-inferiority of the transverse SAC incision to a midline vertical incision for anatomical access and immediate surgical morbidity in severe PAS (FIGO grade 3). Our subsequent follow-up paper demonstrated a significant increase in long-term cosmetic satisfaction with the SAC transverse incision and a trend towards less scar concerns in terms of stiffness and colour. This finding is consistent with the anecdotal evidence. Allied to this, we believe that a vertical incision is unnecessarily morbid and disfiguring, resulting in further negative psychological impact for patients already at high risk of post-traumatic stress disorder (PTSD). However, some patients reported a usually transient, alteration in skin sensation with the SAC incision, which was not seen with the midline laparotomy. 

We offer this detailed description of our abdominal entry technique as supplementary material to our two papers to enable clinicians to offer the transverse SAC incision for their surgery. Care should be taken to warn women about the risk of altered skin sensation allowing them to make an informed decision regarding their choice of incision. 

The SAC Incision 

For a more detailed surgical description with diagrams see here

The SAC technique achieves excellent surgical access for the vast majority of cases via a novel hybrid transverse/vertical abdominal entry. The modification from Maylard is not cutting the muscles thereby decreasing the morbidity of the incision. Adequate access is gained by a large curvilinear incision in the rectus sheath and then reflecting the sheath off the recti muscles to the level of the umbilicus and vertically dividing the inner sheath midline.   

SAC abdominal entry 

1.  A curvi-linear transverse incision 25-30cm long from anterior superior iliac spine (ASIS) to ASIS, passing 5-6 cm above the pubic symphysis in the centre line is made in the skin.

2.  The subcutaneous layers are opened in the routine manner (with monopolar diathermy to reduce blood loss).

3.  A large curvi-linear transverse incision is made in the external layer of the rectus sheath.

4.  The abdominal wall muscles are then carefully reflected off the inner layer of the rectus sheath.

5.  Vertical division of the inner rectus sheath layer (midline) starting from the arcuate ligament and extending up to the umbilicus allows access to the uterine fundus.

Advantages of SAC incision

• Less risk of incisional hernia

• Improved healing

• Cosmetically pleasing

Disadvantages of SAC incision

• Potential risk of needing vertical extension in an emergency

• Risk of nerve trauma if operator is not fully aware of the anatomy 

Monopolar Diathermy

Regardless of choice of skin incision made, we recommend performing the initial skin cut with cold scalpel; followed by the use of monopolar energy (settings 35:35 - blend:spray) to open the abdomen in layers with haemostatic control; before reverting to cold opening of the peritoneum