A Historical and Modern Surgical Technique
Developed by the British surgeon Professor James Rutherford Morison in 1896, this technique was originally designed for left-sided access to the sigmoid colon and pelvis. It was particularly useful when a previous midline operation had scarred the area, making repeat midline entry undesirable. The incision's creation was a significant innovation in providing reliable access to the lower abdomen. Since its inception, the application has evolved significantly with advancements in surgical practice.
The Primary Modern Application: Renal Transplant Surgery
While its original use was gastrointestinal, the Rutherford Morrison incision has become most associated with renal transplantation. For this procedure, it provides excellent access to the retroperitoneum, where the new kidney is placed, along with the major vessels (iliac vessels) needed for anastomosis. The incision's lateral placement and muscle-cutting nature allow for a wide surgical field without compromising the abdominal wall's structural integrity as significantly as a midline incision might.
The Anatomical Approach of the Incision
This oblique, curvilinear, muscle-cutting incision is sometimes nicknamed the 'hockey-stick' incision due to its shape. The procedure typically involves:
- Making a primary incision starting roughly 2 cm above the anterior superior iliac spine (ASIS) and extending obliquely down and medially.
- Deepening the incision through subcutaneous tissues.
- Cutting through the three lateral abdominal muscle layers (external oblique, internal oblique, and transversus abdominus) using an electrocautery tool.
- Protecting the peritoneal contents as the transversalis fascia is incised.
The muscle-cutting approach, when done correctly, helps maintain abdominal wall tension better than approaches that rely on muscle splitting or midline division. Surgeons must be cautious of the ilioinguinal and iliohypogastric nerves that traverse this area, as injury can result in chronic pain.
Advantages Over Other Incisional Techniques
One of the main reasons for choosing the Rutherford Morrison incision is its reduced rate of incisional hernia formation compared to midline approaches. This is particularly critical in immunosuppressed patients, such as those undergoing kidney transplantation, where wound healing can be slower and complication rates higher. Its advantages include:
- Lower hernia risk: The oblique, muscle-cutting design distributes tension more evenly and avoids weakening the midline fascia (linea alba).
- Patient-specific suitability: It is particularly advantageous for patients with existing abdominal wall weaknesses, such as diastasis recti, where a midline incision would pose a high risk of future herniation.
- Versatility: The incision can be adapted and extended if more extensive access to the retroperitoneum or colon is needed.
Comparison of Incisions for Lower Abdominal Access
| Feature | Rutherford Morrison Incision | Midline Laparotomy Incision | Pfannenstiel Incision |
|---|---|---|---|
| Access | Excellent for retroperitoneal and lower quadrant access | Excellent and rapid access to the entire abdominal cavity | Primarily used for pelvic cavity access, more limited |
| Hernia Risk | Low due to oblique, muscle-cutting technique | Higher due to division of the linea alba | Very low for pelvic surgery, but difficult to extend |
| Primary Uses | Renal transplantation, colonic resections, ovarian mass excision | Trauma surgery, exploratory laparotomy, extensive abdominal procedures | Gynecologic and obstetric procedures (e.g., C-section) |
| Aesthetics | Can result in visible scarring | Visible longitudinal scar, can be prone to stretching | Transverse, typically concealed by pubic hair line |
Other Notable Applications in General Surgery
Beyond its well-known use in kidney transplants, the Rutherford Morrison incision has other specific applications:
- Difficult Appendectomy: It can be used as an extension of a smaller gridiron incision, particularly when the appendix is retrocaecal or difficult to mobilize.
- Colonic Resection: While its use has shifted, it is still a viable option for resections of the right or left colon, especially when other approaches are not feasible.
- Gynecological Procedures: In some cases, it may be used to access ovarian or adnexal masses, particularly during the second half of pregnancy.
Postoperative Considerations and Potential Complications
While known for a lower hernia rate, the Rutherford Morrison incision is not without risk. Potential complications include:
- Nerve injury: As mentioned, damage to the ilioinguinal or iliohypogastric nerves can cause chronic pain or numbness in the lower abdomen.
- Vascular injury: Injury to the epigastric vessels is a risk, although less common with careful technique.
- Wound healing issues: Like any surgical incision, it is susceptible to seroma (fluid collection), hematoma (blood collection), and infection. Following a doctor’s instructions for post-operative care, including limiting heavy lifting, is crucial for proper healing.
Conclusion
In summary, what is the Rutherford Morrison incision used for? Primarily for renal transplant surgery, offering excellent retroperitoneal access and a low risk of incisional hernia. Its historical use for colonic procedures, coupled with its modern adaptations for a variety of abdominal and pelvic conditions, solidifies its place as an important tool in the surgeon's armamentarium. Its oblique, muscle-cutting design provides a durable alternative to midline approaches, ensuring better long-term outcomes, especially for at-risk patient populations. For more detailed technical specifications, a comprehensive reference can be found at the National Institutes of Health website(https://pmc.ncbi.nlm.nih.gov/articles/PMC10883410/).
