1446 In the late 1800s, when 3 of 4 patients died during or after surgery, the pelvic surgeon focused on overcoming the obstacle of operative death. As patient survival im- proved, attention shifted to refining surgical technique, with the goal of lowering surgical morbidity. Because of the high mortality associated with surgical wound dehis- cence, techniques to secure a more permanent closure of the abdomen were a high priority. In 1896 Kustner, a German gynecologist, and Rapin, a Swiss gynecologist, began using and recommending the transverse lower abdominal incision. 1 In 1900 Pfannen- stiel 2 presented his experience with 51 pelvic operations and described the advantages of the combined transverse and longitudinal incision in the lower abdomen. One ad- vantage, boasted Pfannenstiel, was the elimination of in- cisional hernias. In 1907 Maylard 3 advocated the additional feature of cutting the rectus muscles and incising the peritoneum transversely with the transverse lower abdominal inci- sion to improve exposure. His logic was based on anatomic and physiologic rationale, with an emphasis on his own case series of 18 patients. A conclusion made by Maylard 3 in his landmark article that is relevant to this study was, “More permanently secure cicatrices result from transverse than vertical incisions.” In his final argument he recognized those who preceded him in this theory, including Lewis A. Stimson and “foreign surgeons,” seemingly a reference to Pfannenstiel. May- lard 3 reinforced the concept of the superior strength of the transverse incision stating that it afforded “appar- From the Division of Gynecology, Department of Obstetrics and Gynecol- ogy, Wayne State University–Hutzel Hospital. Central Prize Award Paper, presented at the Sixty-seventh Annual Meet- ing of The Central Association of Obstetricians and Gynecologists, Maui, Hawaii, October 24-27, 1999. Reprint requests: Susan L. Hendrix, DO, Department of Obstetrics and Gynecology, Wayne State University/ Hutzel Hospital, 4707 St Antoine, Detroit, MI 48201. Copyright © 2000 by Mosby, Inc. 0002-9378/ 2000 $12.00 + 0 6/ 6/ 106849 doi:10.1067/ mob.2000.106849 The legendary superior strength of the Pfannenstiel incision A myth? Susan L. Hendrix, DO, Veronica Schimp, DO, Joy Martin, Amarpreet Singh, Michael Kruger, PhD, and S. Gene McNeeley, MD Detroit, Michigan OBJECTIVE: This study was undertaken to determine whether there is a difference in the frequency of fas- cial dehiscence between midline vertical lower abdominal and Pfannenstiel incisions among women under- going obstetric and gynecologic operations. STUDY DESIGN: A case-control study of 48 cases of fascial dehiscence complicating 17,995 major opera- tions (8950 cesarean deliveries and 9405 gynecologic procedures) during a 6-year period at Wayne State University Hutzel Hospital, Detroit, was performed. Univariate analysis identified significant independent vari- ables related to fascial dehiscence. Stepwise logistic regression analysis then identified those risk factors that were independently associated with fascial dehiscence. RESULTS: Among the 48 patients who underwent repair of fascial dehiscence after a major obstetric or gy- necologic operation, 27 were from the obstetric service and 21 were from the benign and cancer gynecologic services. Wound dehiscence occurred in 10 vertical incisions and 17 Pfannenstiel incisions among the ob- stetric patients and in 12 vertical and 9 Pfannenstiel incisions among the gynecologic patients. The risk for dehiscence with vertical lower abdominal incisions was not increased with respect to that associated with Pfannenstiel incisions (P = .39, 2-tailed). This finding was true for all patients (odds ratio, 1.3; 95% confi- dence interval, 0.7-2.6), obstetric patients (odds ratio, 1.3; 95% confidence interval, 0.5-3.4), and gyneco- logic patients (odds ratio, 1.5; 95% confidence interval, 0.5-4.0). Forty-seven of the 48 case patients had doc- umented wound infections, compared with 1 of the 144 control subjects ( P < .0001, odds ratio, 37.8; 95% confidence interval, 14.8-96.8). CONCLUSION: Wound infection was the most important risk factor for fascial dehiscence among women who underwent major obstetric and gynecologic operations. Our results do not support the long-held belief that Pfannenstiel incisions are stronger than lower abdominal vertical incisions and reduce the risk for fascial dehiscence. (Am J Obstet Gynecol 2000;182:1446-51.) Key words: Abdominal wound dehiscence, fascial dehiscence, gynecologic surgery, Pfannenstiel incision, surgical wound dehiscence, wound healing, wound infection