title: Up and down or side to side? A systematic review and meta-analysis examining the impact of incision on outcomes after abdominal surgery.
abstract: BACKGROUND
  The aim of this study was to examine whether midline, paramedian, or transverse incisions offer potential advantages for abdominal surgery.
  
  
  METHODS
  We searched MEDLINE, Embase, Web of Science, and The Cochrane Central Register of Controlled Trials from 1966 to 2009 for randomized controlled trials comparing incision choice.
  
  
  METHODS
  We systematically assessed trials for eligibility and validity and extracted data in duplicate. We pooled data using a random-effects model.
  
  
  RESULTS
  Twenty-four studies were included. Transverse incisions required less narcotics than midline incisions (weighted mean difference = 23.4 mg morphine; 95% confidence interval [CI], 6.9 to 39.9) and resulted in a smaller change in the forced expiratory volume in 1 second on postoperative day 1 (weighted mean difference = -6.94%; 95% CI, -10.74 to -3.13). Midline incisions resulted in higher hernia rates compared with both transverse incisions (relative risk = 1.77; 95% CI, 1.09 to 2.87) and paramedian incisions (relative risk = 3.41; 95% CI, 1.02 to 11.45).
  
  
  CONCLUSIONS
  Both transverse and paramedian incisions are associated with a lower hernia rate than midline incisions and should be considered when exposure is equivalent.
authors.affiliation: University of Medicine and Dentistry of New Jersey, New Jersey School of Medicine, Newark, 07103, USA. bickenka@umdnj.edu
authors.forename: Kai A
authors.initials: KA
authors.lastname: Bickenbach
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Karanicolas
authors.forename: John B
authors.initials: JB
authors.lastname: Ammori
authors.forename: Shiva
authors.initials: S
authors.lastname: Jayaraman
authors.forename: Jordan M
authors.initials: JM
authors.lastname: Winter
authors.forename: Ryan C
authors.initials: RC
authors.lastname: Fields
authors.forename: Anand
authors.initials: A
authors.lastname: Govindarajan
authors.forename: Itzhak
authors.initials: I
authors.lastname: Nir
authors.forename: Flavio G
authors.initials: FG
authors.lastname: Rocha
authors.forename: Murray F
authors.initials: MF
authors.lastname: Brennan
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000701:Analgesics, Opioid / Q000627:therapeutic use; D005541:Forced Expiratory Volume; D046449:Hernia, Abdominal / Q000209:etiology; D006801:Humans; D011183:Postoperative Complications / Q000209:etiology; D016032:Randomized Controlled Trials as Topic; D013514:Surgical Procedures, Operative / Q000379:methods*
chemical_list: D000701:Analgesics, Opioid
keywords: Hernia; Incision; Meta-analysis; Midline incision; Paramedian incision; Transverse incision