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Invited Critique
March 2010

Foregut Surgery by the Letter: Is J Better Than Inverted T or V?Comment on “Modified Makuuchi Incision for Foregut Procedures”

Author Affiliations

Author Affiliation: Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota.

Arch Surg. 2010;145(3):285. doi:10.1001/archsurg.2010.4

The advent of minimally invasive surgery has underscored the importance of the abdominal incision in postoperative morbidity and length of stay in patients undergoing foregut surgery. Therefore, it is appropriate for those procedures requiring a traditional open surgical approach to use techniques that minimize postoperative pain and incisional wound-healing problems. The modified Makuuchi incision theoretically maintains innervation and blood supply to the skin and rectus muscle, thereby decreasing skin numbness, muscle atrophy, postoperative pain, and perhaps incisional infection/hernia. Although the authors report their infection and hernia rates to be quite low, they present no data to prove that this incision is superior to other standard incisions chosen for foregut surgery, such as midline, bilateral subcostal, or bilateral subcostal with xiphoid extension. That said, the theoretical advantages noted are most attractive. Unlike bilateral subcostal incisions (my preference for pancreatoduodenectomy or right hepatectomy), which are symmetrical and lend themselves to basic fixed abdominal retractors such as the “third arm,” the asymmetrical modified Makuuchi incision requires a much more sophisticated abdominal retraction system. Fortunately, these have now become widely available, and one example is nicely illustrated in the authors' article. Although the exposure with the bilateral subcostal incision is superb, division of intercostal nerves does result in infraincisional numbness and muscle atrophy.

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