We read with interest the article by Chang et al1 in the March 2010 issue of the Archives on the “modified Makuuchi” or “reverse L” incision. We congratulate Chang et al on their detailed and well-illustrated description of this approach, which provides excellent exposure for hepatobiliary and foregut operations. In Ireland and many parts of Europe, the reverse L incision has replaced the Mercedes incision for both liver resection and orthotopic liver transplant. Chang et al also describe an excellent technique for closure. We note their not insignificant hernia rate of 10.9%. However, hernia after liver transplant using a Mercedes incision has been reported as high as 24%2 and it will be interesting to observe if this reduces as more North American surgeons use the reverse L incision.
O’Connor DB, Winter DC. Surgical Innovators Past and Present. Arch Surg. 2010;145(10):1023-1024. doi:10.1001/archsurg.2010.196