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

Lower abdominal transverse incisions, or LATIs, are the horizontal cuts made across the lower belly to reach the uterus, bladder, pelvic organs and lower bowel. They are the standard approach for caesarean section, which alone accounts for nearly 30 million births each year worldwide, and they are equally routine in gynaecology, urology and general surgery. Because these incisions heal with a low rate of the full-thickness hernias seen after vertical midline cuts, they have long been considered forgiving. The Edinburgh group’s narrative review, which combed MEDLINE and PubMed from database inception to March 2025 and included translated non-English literature, suggests that this reputation has allowed a subtler problem to hide in plain sight.

The crux of the argument is anatomical. When a midline incision fails, the whole thickness of the abdominal wall gives way and bowel or omentum pushes straight through to lie under the skin. Transverse lower abdominal incisions, however, open the wall in layers: skin transversely, fascia in a separate manoeuvre, muscle and posterior sheath according to the specific technique. When healing fails, it often fails in only one of those layers. The result is an interparietal hernia, in which abdominal contents slip between the planes of the wall itself rather than through it, creating a defect that can be large internally yet nearly invisible externally.

These hernias are frequently swept into large series of generic incisional hernias, where their distinctive anatomy is lost. The authors describe them as typically a mix of a sizeable posterior defect with smaller defects in the more superficial layers, a pattern quite different from other incisional hernias. Because the bulge may be contained within the wall, patients can present with chronic pain, unexplained pelvic symptoms or intermittent bowel complaints rather than an obvious lump. The review notes that such hernias can progress to bowel obstruction and bowel ischaemia, making delayed recognition genuinely dangerous.

The terminology problem is historical. Interparietal hernias, in which the sac is trapped between the layers of the abdominal wall, were described as early as the seventeenth century and systematically characterised in the eighteenth and nineteenth by anatomists and surgeons including Petit, Cloquet and Hesselbach. Sir Astley Cooper’s detailed dissections in the 1800s established that these were not curiosities but the consequence of specific anatomical constraints, and by the early twentieth century classifications distinguishing properitoneal, interstitial and superficial interparietal hernias were already in place. Early series reported high mortality, largely because the diagnosis was made only at operation or autopsy, often in patients with strangulated bowel.

Historically, interparietal hernias were strongly associated with congenital anomalies, particularly undescended testes, which is one reason they faded from surgical consciousness as imaging improved and attention shifted elsewhere. But reports in women and in men with normally descended testes pointed to a multifactorial origin involving mechanical forces and acquired weaknesses of the wall. The Edinburgh authors argue that the iatrogenic version, produced by the surgeon’s own incision, deserves its own category rather than being treated as a rare congenital curiosity.

The story of the incisions themselves explains why the naming matters. Johannes Pfannenstiel popularised the suprasymphysarial fascial cross-section for caesarean section in 1900, praising its speed, cosmesis and low hernia rate, though he acknowledged modifying Otto Küstner’s 1896 technique, in which the skin is opened transversely but the fascia longitudinally. Alfred Maylard described a higher transverse incision cutting all layers including rectus muscle in 1907, and Leonid Cherney proposed in 1941 dividing the rectus at its tendon close to the pubic bone. Joel-Cohen introduced a higher straight incision in 1972, and Michael Stark modified it in the 1990s with sharp dissection and non-closure of the peritoneum. These techniques differ markedly in which anatomical planes are divided and how they are closed, yet all their hernias are colloquially lumped together as Pfannenstiel or caesarean-section hernias.

That habit, the authors contend, obscures the link between technique and complication. Because the wall is opened transversely in layers, herniation after a LATI is usually not full thickness; a single compromised layer is enough to create an interparietal defect. Currently it is impossible to connect any particular incision type to a specific presentation, which is precisely why the authors favour a generic umbrella term that can be refined by future research rather than perpetuating a name that describes only one of several operations.

Diagnosis compounds the problem. Computed tomography can detect clinically occult abdominal hernias, though some ventral hernias disappear when the patient lies supine. Dynamic ultrasound is a useful alternative but may lack specificity, and diagnostic laparoscopy is sometimes required. One reported series described interstitial hernias found only at laparoscopic exploration of the abdominal wall in patients with incision-site pain and negative ultrasound scans. The authors add from their own experience that LATI-Hs are frequently misreported radiologically as divarication of the recti, diastasis, intraparietal lipoma or simple omental adhesion to fascia, because radiologists’ eyes are trained to look for herniation through the whole wall rather than between its layers.

Confusion extends to neighbouring entities. Lateral LATI-Hs, arising where the incision extends beyond the lateral border of the rectus sheath, are often reported as Spigelian hernias. The two look similar in location and morphology, but Spigelian hernias are primary defects through the Spigelian fascia between the transversus abdominis and internal oblique aponeuroses, whereas lateral LATI-Hs are iatrogenic, occurring when posterior muscular layers are left open or closed inadequately. Mislabelling them, the authors argue, prevents accurate reporting and stalls the development of management guidelines.

The practical stakes are considerable. Estimated hernia rates after caesarean section range from zero to 5.6 percent in the literature, which, applied to tens of millions of procedures, implies a substantial global burden concentrated in young women, many of whom may have their chronic pelvic symptoms attributed to other causes. Standardised terminology, the authors argue, is the prerequisite for everything that follows: consistent documentation, rational design of clinical trials, core descriptor and outcome sets, and ultimately evidence-based strategies for prevention and repair. Without a defined disease, patients cannot be recruited to studies, and without studies, surgical practice cannot improve.

The proposal is deliberately simple. Call these hernias what they are, lower abdominal transverse interparietal or incisional hernias, and record which incision produced them. That single change in vocabulary, the team argues, would transform an overlooked complication of some of the world’s most common operations into a researchable, preventable and treatable condition, and give a name at last to the many patients whose pain has never had one.

Subject of Research: Proposal of the term LATI-H for hernias following lower abdominal transverse incisions

Article Title: Why LATI-H must enter the surgical lexicon

Article References: Zanellato, A., Lucocq, J., Brown, L., Drake, T. M., Berrevoet, F., & Wigmore, S. J. (2026). Why LATI-H must enter the surgical lexicon. Journal of Abdominal Wall Surgery, 5, Article 16806. https://doi.org/10.3389/jaws.2026.16806

Image Credits: AI Generated

DOI: 10.3389/jaws.2026.16806

Keywords: LATI-H, incisional hernia, interparietal hernia, caesarean section, Pfannenstiel incision, abdominal wall surgery, hernia diagnosis, surgical nomenclature, Spigelian hernia, abdominal wall anatomy, postoperative complications, hernia repair

The intervention, known as ARC/S, or Augmented Reality for Safe Caesarean Section, was implemented by the international non-profit Jhpiego in partnership with the World Federation of Societies of Anesthesiologists and the Makueni County Department of Health. It layered the Proximie digital platform onto an existing Obstetric Safe Surgery program that had been running in the county since 2020. The platform allows a remote mentor to watch an operation through live video streams from multiple camera angles in the operating theater, and to draw augmented reality annotations directly onto the surgeon’s field of view. Every case is also recorded and uploaded to a secure cloud-based library, where it can be reviewed asynchronously for training and quality assurance purposes.

The scale of the surgical workforce problem the technology addresses is staggering. The Lancet Commission on Global Surgery and the World Health Organization have recognized timely access to safe and affordable surgical care as a fundamental component of universal health coverage, yet nearly five billion people, three-quarters of the global population, lack access to essential surgical services. In low- and middle-income countries, more than 90 percent of the population remains underserved. The distribution of specialists is even more skewed: only 12 percent of the world’s specialist surgical workforce serves Africa and Southeast Asia, despite those regions being home to a third of humanity. In Kenya, medical officers staffing district hospitals are supposed to receive ongoing mentorship from specialists, but those specialists are concentrated in a small number of urban facilities, and the travel distances involved make regular in-person support impractical.

Makueni County illustrates the geography of the problem. The five high-volume public hospitals participating in the study are separated by substantial distances: Makueni County Referral Hospital lies 69 kilometers from the Mbooni Sub-county Hospital it supports, while Makindu Sub-county Hospital must travel 60 kilometers to reach Sultan Hamud and 24 kilometers to reach Kibwezi. A single in-person mentoring visit was estimated to consume eight hours of a mentor’s time, including travel, at a total cost of 25,396 Kenyan shillings once travel expenses were added. A virtual mentoring session on the platform, by contrast, averaged 1.22 hours including feedback time and cost just 3,056 shillings per event.

Between February and October 2022, the technology supported 191 virtual mentorship sessions across the five hospitals, complemented by 17 in-person sessions. A total of 180 elective and emergency caesarean sections were carried out with the platform’s support, and 142 surgical providers were trained on its use. Of the recorded procedures, 125 were successfully reviewed for adherence to safe surgery standards; the remaining 55 recordings were excluded because intermittent internet connectivity produced incomplete files. The platform-generated data, cross-referenced with operational records, gave the research team an unusually objective picture of how the digital tool was actually integrated into surgical service delivery, capturing session durations, participant attendance, mentorship roles, and clinical checklists for each case.

The acceptability results were strikingly positive across every group surveyed. All 60 mentees reported that the platform improved provider and team performance in adhering to best practices, 98 percent felt it improved patient safety, and 92 percent found it easy to use during live procedures and said it enhanced team confidence in the operating theater. All nine mentors believed the technology strengthened the existing mentorship model, and all seven information and communications technology personnel reported that surgical teams were ready to use the platform for every caesarean section. Patients were equally receptive: 90 percent of the 125 post-caesarean mothers surveyed said they had been adequately informed about the use of cameras in the operating theater, and 89 percent said they would recommend the approach to other mothers.

The recorded cases also revealed uncomfortable truths about baseline surgical quality. Direct observation by expert mentors, using the World Health Organization Surgical Safety Checklist as a rubric, found variable adherence to critical safety practices. Correct completion and use of the checklist met standards in only 39.2 percent of the 125 reviewed cases, while timely administration of antibiotic prophylaxis met standards in 53.6 percent. Adherence to proper surgical scrubbing and appropriate use of personal protective equipment met standards in 45.6 percent of cases. The authors note that these quality gaps, detectable only because the platform enabled systematic video review, would likely have gone unnoticed through traditional audits, opening the door to targeted refresher training and site-specific quality improvement initiatives.

The economic analysis, while deterministic and based on a single county, proved robust to most sensitivity tests. Doubling ongoing training costs, increasing feedback time, or raising the discount rate from 3.5 to 10 percent each produced only small reductions in the benefit-to-cost ratio. The most consequential assumption was the time required for an in-person mentoring visit: halving it from eight hours to four cut the ratio to 4.85, still a substantial return. Conversely, assuming two mentors attended half of all in-person visits pushed the ratio up to 12.78. The authors emphasize that the efficiency gains represent potential value as programs expand rather than immediate budgetary savings, and that virtual mentoring is designed to complement, not replace, hands-on in-person training, which remains essential for complex cases and direct supervision.

The study’s technical findings offer a practical roadmap for other regions considering similar programs. The platform requires a stable connection of at least 5 to 7 megabits per second for each high-definition video stream, with 20 to 30 megabits per second of dedicated bandwidth preferable when multiple feeds run simultaneously. Standard laptops with at least 8 gigabytes of memory or mobile devices from 2020 onward are sufficient, and a wired network connection consistently outperformed 4G and 5G backups. Yet the researchers found that success depended far more on basic infrastructure and staffing than on device specifications: reliable power, protected outlets, at least one designated ICT focal person, and established workflows for permissions and data governance mattered more than hardware. Intermittent electricity, limited bandwidth, and absent leadership support pose greater barriers in lower-readiness sites than the technology itself.

The authors are candid about the pilot’s limitations. Clinical outcomes were not assessed, so no conclusions can be drawn about improvements in maternal or neonatal outcomes attributable to the intervention. The technology was embedded within an existing capacity-building program, making it difficult to disentangle its independent effects, and social-desirability bias may have inflated survey responses. The single-county setting, with relatively strong digital infrastructure and committed local government, may limit generalizability. Framed through Kirkpatrick’s four-level evaluation model, most outcomes measured learner reaction rather than objective learning or sustained behavior change. Still, the study demonstrates that in a geographically dispersed surgical network, combining onsite training with augmented reality-enabled virtual mentorship is feasible, acceptable to clinicians and patients alike, and dramatically more efficient than travel-dependent models, offering health systems in low- and middle-income countries a credible path toward decentralizing surgical expertise and strengthening workforce capacity.

Subject of Research: Augmented reality-enabled virtual surgical mentorship for building surgical workforce capacity in resource-limited settings

Article Title: Virtual surgical mentorship: a cost-efficient solution for building workforce capacity in resource limited settings

Article References: Mallender, J., Ferenchick, E., Worku, T. A., Shibata-Germanos, S., Varallo, J., Muthengi, M., Kiiru, S., Mbithi, D., Ruto, D., Nyaga, F. K., Mwatha, S., Muia, C., Bertram, M., Musila, P., Ndolo, S., Mwanthi, C. K., & Hachach-Haram, N. (2026). Virtual surgical mentorship: a cost-efficient solution for building workforce capacity in resource limited settings. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 125. https://doi.org/10.1007/s44186-026-00490-x

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00490-x

Keywords: augmented reality, surgical mentorship, global surgery, caesarean section, Kenya, telementoring, health workforce, low- and middle-income countries, digital health, obstetric surgery, cost-efficiency, surgical training