Understanding the Kustner Incision Technique
The Kustner incision is a surgical procedure that involves a specific two-part approach to open the lower abdomen. It begins with a horizontal or slightly curved skin incision made approximately 5 cm above the pubic symphysis, positioning it just below the anterior iliac spine. This initial cut is similar to the skin incision used in a Pfannenstiel procedure, giving it a potentially good cosmetic result. The surgeon then separates the subcutaneous fat tissue up to the midline to expose the linea alba, a fibrous band that runs vertically down the middle of the abdomen. A vertical incision is then made through the linea alba itself, allowing access to the abdominal cavity.
This combination of a transverse skin cut and a vertical fascial opening is what makes the Kustner incision unique. Unlike a Pfannenstiel incision, which involves a transverse cut through both the skin and the rectus fascia, the Kustner technique aims to provide access to the pelvis while minimizing the transverse disruption of the rectus muscles. Historically, this was seen as a way to avoid the trauma associated with median-line incisions and reduce the risk of postoperative hernia.
Comparison with Other Common Incisions
To better understand the Kustner incision, it is helpful to compare it to other abdominal surgical approaches. The choice of incision is determined by factors such as the required surgical exposure, cosmetic outcome, and patient anatomy. Here is a comparison of the Kustner, Pfannenstiel, and midline incisions:
| Feature | Kustner Incision | Pfannenstiel Incision | Midline Incision |
|---|---|---|---|
| Skin Incision | Transverse | Transverse and curvilinear | Vertical |
| Fascial Incision | Vertical | Transverse | Vertical |
| Surgical Access | Limited, primarily pelvic | Good, but more limited than midline | Excellent, for wide abdominal access |
| Cosmetic Result | Favorable | Very favorable (often called the "bikini line" incision) | Least favorable due to vertical scarring |
| Extensibility | Poorly extensible; difficult to lengthen | Moderate; can be extended laterally | Highly extensible, can be lengthened superiorly or inferiorly |
| Recovery Pain | Potentially less than midline, but possibly more painful than transverse fascial cuts | Generally less painful than midline incisions | Can be more painful, especially with greater tension on the abdominal wall |
| Complication Risk | Risk of bleeding from epigastric vessels during dissection | Low risk; good healing | Higher risk of dehiscence (wound separation) and incisional hernia |
Advantages and Disadvantages of the Kustner Approach
While largely superseded by modern techniques, the Kustner incision does have some notable characteristics. Some surgeons who have used it found it satisfactory for specific cases of benign gynecologic diseases, and even for more radical procedures in certain young women. Proponents have argued that, for a given skin incision length, the Kustner technique could offer better intraoperative exposure than a Pfannenstiel incision, particularly for deep pelvic work. Additionally, it was originally developed to minimize the high rates of postoperative hernia and shock associated with midline incisions at the time.
However, the Kustner incision also comes with several key disadvantages. The process of dissecting the subcutaneous tissue to expose the linea alba can be time-consuming. This creates a large, undermined flap of tissue, which some sources suggest increases the risk of wound infection and seroma formation. Its limited extensibility is another major drawback, as the vertical opening of the fascia cannot be easily lengthened if more surgical exposure is needed during the procedure. This inflexibility makes it unsuitable for complex or unexpected surgical situations. The modern Pfannenstiel approach is often preferred because it offers a good balance of cosmetic outcome, adequate exposure for many pelvic procedures, and lower operative complexity.
Modern Clinical Relevance
In contemporary general and gynecological surgery, the Kustner incision is considered less common and has limited utility compared to other abdominal incisions. The American College of Obstetricians and Gynecologists (ACOG) notes that it is infrequently used and not widely considered a valuable technique in modern practice. The Pfannenstiel incision has largely become the standard for procedures like C-sections and hysterectomies because it offers excellent cosmetic results and sufficient pelvic access without the added risks and complexities of the Kustner technique.
For most surgeons, the primary considerations for choosing an incision are clear and rapid access, minimal blood loss, low complication rates, and an acceptable cosmetic outcome. The Kustner incision's drawbacks, particularly its limited extensibility and potentially higher risk of wound complications, have made it less favorable in an era where alternative methods are more efficient and safer. Despite its historical significance, it remains a less-practiced option today. For more information on various surgical access methods, consult medical literature from respected institutions, such as the National Institutes of Health.
