Transverse abdominal incisions compared with midline incisions for elective infrarenal aortic reconstruction: predisposition to incisional hernia in patients with increased intraoperative blood loss.

PURPOSE: Both midline and transverse abdominal incisions are used for exposing the infrarenal aorta. Transverse incisions are said to cause less pulmonary and systemic complications, but the claimed advantages may be because most transverse incisions are extraperitoneal, whereas midline incisions are intraperitoneal. This study compares intraperitoneal transverse and midline incisions with respect to perioperative and late complications, especially incisional hernia.

METHODS: Three hundred twenty-nine patients undergoing infrarenal aortic reconstruction (239 aneurysms; 90 occlusive disease) were analyzed retrospectively according to whether the abdominal wall incision was midline (154 patients) or transverse (175 patients). In all patients, the subsequent dissection was transperitoneal and not retroperitoneal.

RESULTS: Perioperative survival rates and intraoperative blood loss were comparable, but the transverse incision tended to be followed by a shorter period of postoperative ileus (p = 0.07), perhaps because the small bowel was not always exteriorized during operation with transverse incisions. Mean time spent in the intensive care unit was not different between the groups, but those with transverse incisions remained in hospital 5 days less than those receiving midline incisions (p = 0.0005). When an aortic graft greater than 18 mm in diameter was used, survival was reduced compared with that after smaller grafts (p = 0.028). At 1 to 6 years follow-up in 235 patients (109 midline; 126 transverse), 35 (14.9%) incisional hernias were detected, with no statistical difference according to incision (16.5% midline; 13.4% transverse). Analysis by univariate and multivariate logistic regression showed that blood loss at operation exceeding 1000 ml increased the risk of later incisional hernia by a factor of 3.07. Wound infection increased the risk of hernia by 3.70.

CONCLUSION: Excess blood loss and wound infection exerted this predisposition to incisional herniation independent of other variables.