Global Survey Reveals Surgeons Split on Closing the Same Abdominal Incision

When a surgeon cuts into the lower abdomen, the layers of the abdominal wall must be opened in a specific sequence and then restored in reverse order. It sounds like a standardized procedure, but a new international survey shows that what happens between the first cut and the final suture varies dramatically depending on which surgical specialty holds the scalpel. The findings, published in the Journal of Abdominal Wall Surgery, suggest that two surgeons operating on the same anatomical region may follow entirely different protocols for entry and closure, and that these differences could influence one of the most common postoperative complications in surgery: the incisional hernia.

The study, led by researchers at the University of Edinburgh, set out to characterize contemporary global practice in lower abdominal transverse incisions, or LATIs. These are the horizontal cuts made just above the pubic bone, used almost universally for caesarean sections and increasingly adopted by general surgeons and urologists for other abdomino-pelvic procedures. Using an anonymised online questionnaire distributed through professional networks, the team collected responses over a ten-month period from January to October 2025. After removing duplicates and ineligible respondents, 231 surgeons from 31 countries across six continents were included in the final analysis.

The respondent pool was dominated by general surgeons, who accounted for 68.4 percent of the sample, followed by obstetricians and gynaecologists at 26.4 percent and urologists at 5.2 percent. This distribution matters because the three groups bring very different levels of experience with the incision type. Obstetricians and gynaecologists performed a dramatically higher annual volume of LATI procedures, with 60.7 percent reporting more than fifty cases per year, compared with just 6.5 percent of general and urological surgeons. The median consultant experience also differed, with general and urological surgeons reporting a median of sixteen years in independent practice versus nine years for obstetricians and gynaecologists.

The first major divergence appeared at the point of entry into the abdominal wall. General surgeons and urologists predominantly used diathermy, an electrosurgical tool that cuts tissue while simultaneously coagulating blood vessels, to open the fascia, the tough fibrous layer enveloping the rectus muscles. In contrast, most obstetricians and gynaecologists favoured a combination of dissection modalities, blending blunt and sharp techniques. The differences extended deeper into the wound. When it came to opening the peritoneum, the thin serous membrane lining the abdominal cavity, 62.3 percent of obstetricians and gynaecologists used blunt dissection, compared with just 7.6 percent of the other group, who more commonly relied on sharp dissection with scissors or a blade.

The direction of the peritoneal opening also split along specialty lines. Obstetricians and gynaecologists most frequently opened the peritoneum transversely, in line with the modified Joel-Cohen technique popularised for caesarean sections roughly three decades ago, an approach designed to avoid injury to the bladder. General surgeons and urologists, by contrast, most commonly opened the peritoneum longitudinally, a practice more consistent with the traditional Pfannenstiel incision described in 1900 or with abdominal entry through a midline incision. These differences in technique likely reflect the distinct operative exposures required by each specialty, as well as the underlying pathology being treated and the potential need for more urgent access in obstetric surgery.

The second major divergence emerged at closure. Obstetricians and gynaecologists left the peritoneum unsutured in 77.0 percent of cases, whereas 75.9 percent of general and urological surgeons routinely closed it. This non-closure practice aligns with current guidelines from the UK’s National Institute for Health and Care Excellence and the PROSPECT recommendations, which suggest that leaving the peritoneum open reduces operating time and postoperative analgesic requirements. The two largest randomised controlled trials addressing this question, CAESAR and CORONIS, demonstrated equivalence between closure and non-closure across most considered outcomes, including infection, bleeding and pain. However, some potentially important outcomes such as adhesion and hernia formation remain under-explored, and a systematic review has suggested that non-closure may be associated with an increased risk of adhesions.

Re-approximation of the rectus muscles also differed between groups. Obstetricians and gynaecologists were less likely to bring the muscles back together, with only 36.1 percent doing so, compared with 58.2 percent of general and urological surgeons. Urologists had the highest rates of muscle re-approximation across all groups at 83.3 percent. Interestingly, country income status appeared to influence this practice as well, with surgeons in upper-middle and lower-middle income countries more likely to re-approximate the rectus muscles than their counterparts in high-income countries. The reasons for this geographic variation are unclear but may relate to differences in training traditions, suture availability or perceived risk of wound complications.

Fascial closure technique revealed perhaps the most striking inter-specialty difference. The small bites technique, which involves placing sutures closer together with smaller tissue bites, has been recommended by the European and American Hernia Societies for closure of midline abdominal incisions based on evidence that it reduces hernia rates. General surgeons and urologists overwhelmingly adopted this approach, with 85.3 percent using it, while only 42.6 percent of obstetricians and gynaecologists did so. More than half of the obstetric group employed large bites instead. Across all groups, continuous rather than interrupted closure was predominant, and slowly absorbable sutures were the preferred suture material, with no significant difference between specialties in this regard.

The survey also explored surgeons’ experience with hernias related to these incisions. General surgeons were far more likely to have encountered a LATI hernia, with 85.4 percent reporting at least one, compared with 41.7 percent of urologists and 42.6 percent of obstetricians and gynaecologists. The types of hernias seen also differed. General surgeons commonly encountered a mix of total and partial inter-parietal hernias, the latter remaining clinically occult within the abdominal wall layers, while urologists and obstetricians predominantly reported partial hernias. Most general surgeons also reported finding LATI hernias incidentally during laparoscopy, at 62.0 percent, whereas far fewer urologists and obstetricians reported this finding.

Perhaps most tellingly, 84.0 percent of all respondents agreed that LATI hernias are underreported, with the proportion rising to 91.1 percent among general surgeons. This consensus suggests that the true prevalence of hernias following these incisions may be substantially higher than current clinical recognition implies. The authors caution that the survey’s open, network-based dissemination means no response rate could be calculated and that voluntary participation may have introduced selection bias. The questionnaire also did not distinguish between elective and emergency contexts, which may obscure clinically relevant differences within specialties. Nevertheless, the findings highlight a clear need for further outcome-focused research and standardisation of LATI techniques, particularly regarding the relationship between entry and closure methods and the development of incisional hernias, which could ultimately inform guidelines that currently rest almost exclusively on evidence from obstetric populations.

Subject of Research: International survey of surgical practice in lower abdominal transverse incision entry and closure techniques across specialties

Article Title: Contemporary global practice in dissection and closure techniques for lower abdominal transverse incisions: a cross-sectional survey

Article References: Brown, L. R., Adegoke, H., Gardner, E., Drake, T. M., Lucocq, J., & Zanellato, A. (2026). Contemporary global practice in dissection and closure techniques for lower abdominal transverse incisions: a cross-sectional survey. Journal of Abdominal Wall Surgery, 5, Article 17006. https://doi.org/10.3389/jaws.2026.17006

Image Credits: AI Generated

DOI: 10.3389/jaws.2026.17006

Keywords: lower abdominal transverse incision, LATI, surgical technique, incisional hernia, caesarean section, peritoneal closure, fascial closure, small bites technique, cross-sectional survey, abdominal wall surgery, inter-specialty variation, Joel-Cohen technique