The single biggest disaster that can possibly take place is directly opening the abdomen through a transverse incision, especially when the diagnosis is uncertain, or when the preoperative clinical assessment and imaging reports are only suggestive and not confirmative about the nature of the adnexal mass, or when there is a disparity between clinical examination findings and imaging findings. Even if another more experienced colleague is called midway during surgery, the disadvantage of having taken the wrong incision remains.

Per rectal examination in a woman with a pelvic/abdomino-pelvic mass is often forgotten mainly because its importance is underestimated. No doubt per vaginal examination yields more information. But the information that can be got by a per rectal examination is immense—the nodularity and fixidity of the adnexal mass, whether rectal mucosa is involved or not, whether the pelvic mass is primarily of intestinal origin, should upper and/or lower GI endoscopy be done to confirm the exact nature of the mass, whether the ovarian tumor is malignant and is neoadjuvant chemotherapy preferable to staging laparotomy, whether the endometriosis involves the rectum—these are the points that can be fairly well determined by a per rectal examination. The information that can be got by the tactile sensation on our fingertips is something that no imaging modality can replace. This information is something that becomes more accurate with increasing years of experience.

Opening the abdomen through a transverse incision in an emergency situation can be justified in cases of ectopic pregnancy (laparoscopy would be ideal) and emergency caesarean section, no matter how complicated. Even when the presenting part is deeply engaged, when a classical caesarean section is planned or has to be done due to surprise finding of dense lower segment adhesions or leiomyoma, or multiple previous surgeries, when there is postpartum hemorrhage for which internal iliac artery ligation, or if caesarean hysterectomy has to be done, one can easily accomplish everything through a transverse incision by asking for general anesthesia and by converting the Pfannenstiel incision to a larger Maylard incision. If there is a surprise finding of an adnexal mass or an abscess during caesarean section, a transverse incision is still the rule since the additional procedure can be done through the same incision (if it is an emergency procedure like abscess drainage) or can be deferred to a later date with proper planning and preparation (like presence of a large leiomyoma or an ovarian tumor which requires staging).

Transverse incision for elective surgeries can be taken directly if one is very sure of the diagnosis—a straightforward elective caesarean section with nothing to suggest otherwise, hysterectomy for leiomyoma, adenomyosis, DUB, etc. But when the nature of adnexal mass is not known (the commonest disaster being finding an ovarian tumor in a patient opened up for a leiomyoma), or in cases of endometriosis—a condition which can be extensive despite the patient having no symptoms (indication for surgery could be for infertility), when there is a possibility of malignancy (sarcoma, ovarian tumor), when PID is suspected or is certain (there can be extensive adhesions involving the bowel), if the patient has had multiple previous surgeries, has received radiation or chemotherapy in past—directly opening the abdomen through a transverse incision is strongly discouraged. If one is lucky, then one might well be able to accomplish the surgery by requesting for general anesthesia (the surgery may have started with patient under spinal anesthesia) and by converting the incision to a much larger Maylard incision. If the condition requires staging or if upper regions of the abdomen are involved, then one might still be able to complete the case but one may have to confront a lot of complications a few days later. Bowel, bladder, and ureteric injuries can occur due to poor visualization and excessive retraction.

Small serosal injuries or a small cautery burn may heal by itself [1]. The patient may have to be kept nil orally for a longer period of time. Oral sips should be started only after complete recovery of bowel motility, that is, passage of flatus. The urinary catheter should be removed only after hematuria resolves completely, that is, urine microscopy should rule out microscopic hematuria. However, if larger injuries are missed, the patient may still be stable for the first day or two, but will deteriorate eventually. Bile or fecal matter may appear in the drain (if it has been placed) and the patient will develop peritonitis if a bowel injury has been missed. A urinary fistula will form if a ureteric or a bladder injury has been missed, and the patient will develop trickling of urine a week after the surgery [2, 3]. The appearance of blood in urine about 5 days after the surgery is a harbinger of this complication. Excessive retraction through a small incision will also affect would healing due to ischemic injury and pressure necrosis of the abdominal wall.

Bleeding vessels may be missed due to the same reason. The patient will have to be taken up for exploration in the very first postoperative day, if there is internal bleeding. Complications like rectus sheath hematoma are also known to occur because of excessive retraction of the abdominal wall [4]. In most cases hemostasis occurs due to the normal coagulation mechanism, the patient may still develop anemia in the postoperative period due to a missed bleeding vessel requiring transfusions, and this will result in escalation of treatment costs.

So when one encounters such a situation-abdomen opened through a transverse incision when a vertical incision would have been appropriate, the choice is between taking a vertical incision, which results in patient having an inverted T incision, or closing and deferring the case to a later date. The choice depends on the condition which has been discovered on table and whether the condition is an emergency. For example, for multiple pelvic abscesses which cannot be deferred to a later date, one has to proceed by taking a vertical incision and thoroughly drain the entire peritoneal cavity.

So what should be the correct incision? In the age of laparoscopy, we must use laparoscopy more often and as a diagnostic tool as well. Insert a laparoscope—it will provide an excellent panoramic view, and then decide how to go ahead—proceed laparoscopically, or take a transverse incision or a vertical incision.

One must remember that surgery is the ultimate diagnostic tool. Many conditions require exploration, which means we are opening to explore, to find out, and if possible to treat the condition that exists in the patient. One has to choose laparoscopy over laparotomy wherever possible, and one should never be embarrassed when a laparoscopic surgery gets converted into a laparotomy, especially if the exact nature and extent of the disease gets confirmed only after having inserted a laparoscope. Even in cases of large lesions, in patients with history of multiple previous surgeries, one can (and should) successfully insert a laparoscope through the open method and then insert the side ports under vision. Initial inspection by laparoscopy can be done even in cases where the patient has had one or more previous suboptimal surgeries.

So far the author has been able to successfully operate on all patients referred with a diagnosis of being inoperable. This is solely because a vertical incision was taken, while the primary surgeon attempted the same through a transverse incision. Both, midline vertical and paramedian incision are similar when it comes to exposure and ease of closure. However, midline vertical incision is cosmetically superior, if the incision needs to be extended above the umbilicus. One must skirt around the umbilicus if the incision needs to be extended. This is because umbilicus is a region rich in skin commensals, and infection of the wound around this region is very painful and disfiguring.

Paramedian incision involves cutting of the nerves, and this can lead to a slightly higher incidence of incisional hernia as compared to midline vertical incision. Midline vertical incision by virtue of being in the midline receives lesser blood supply and can heal poorly as compared to transverse and paramedian incisions [5].