*5.3.2 Vertical abdominal incisions*

Midline vertical incision was the preferred incision for caesarean section because is faster and ease of entry into the peritoneal cavity with minimal dissection required (**Figure 1**). The incision is useful in situation where high peritoneal access is needed. The incision is made vertically just below the umbilicus to at least 1 cm above the symphysis pubis. The advantage is that it can be extended above the umbilicus if necessary if exposure in the upper part of the abdomen is required. The procedure is undertaken by sharp dissection to the level of the rectus sheath (**Figure 2**).

**Figure 1.** *Abdominal wall incisions.*

**Figure 2.** *Midline subumbilical incision (left) and paramedian subumbilical incision (right).*

Paramedian incisions are made to serve the purpose of the procedure. For caesarean sections paramedian incisions are made 2-5 cm lateral to the midline over the median aspect of bulging convexity of rectus muscles. Closure is theoretically more secure because rectus muscle can act as buttress between the re-approximated posterior and anterior fascial planes (**Figure 2**).

In obese patients the challenges are anaesthetic with difficult intubation [10], extensive subcutaneous tissue leading to prolonged entry time, obscured vision, difficult delivery, increased bleeding, etc. whether a transverse or midline incision is superior for the obese patient remains controversial, but a larger incision is advisable. Retractors should be used to aid with exposure (**Figure 3**).

Bladder flap reflection is not universally as the creation of the flap was not associated with any increase of complications like bladder injury, increased blood loss or prolonged hospital stay [10]. Non flap reflection was associated with reduced operation time [11]. Situation when bladder flap may be advisable is when the fetal head is impacted and in previous caesarean section. The location of the bladder is best delineated by palpating the bladder catheter (**Figure 4**).

#### **Figure 3.**

*A = Transverse subumbilical incision; B = Midline incision extending above the umbilicus; C = Midline subumbilical incision.*

**Figure 4.** *Different abdominal wall incisions.*
