It is delightful to read and appreciate added insights regarding transverse abdominal incisions in obese pregnant woman. These perceptions are offered by a local colleague, Dr Pymel, and a seasoned and esteemed mentor, Dr Mariona. We graciously acknowledge that the Joel-Cohen technique of abdominal entry was an early description of using a transverse abdominal incision in obese gravidas. It uses the anterior-superior iliac spines as a reference to guide an incision 3-3.5 cm below this imaginary transverse line. In contrast, the “Sokol incision” is made above the hanging pannus without reference to the iliac spines. In some morbidly obese patients, this may fall within the 3-3.5 cm range described by Joel-Cohen, although our observation is that this correlation usually occurs in obese patients with less abdominal wall girth.

The recognition of Krebs’ description of a periumbilical transverse incision in obese patients is likely the first in a gynecologic patient. Since then, this incision technique has also been used in cesarean deliveries. It took almost 25 years before Tixier et al described and evaluated the incision and its outcomes in cesarean deliveries in the morbidly obese pregnant woman. We currently cannot locate an earlier article describing this technique for cesarean delivery.

The literature regarding optimal skin incision sites in the obese pregnant woman who is undergoing cesarean delivery continues to be limited to comparisons of suprapubic transverse and vertical incisions. We have located only a couple of studies that include supraumbilical incisions. However, these were both limited to supraumbilical vertical incisions. Adequate data regarding the utility of the high transverse incision is needed. We concur with Drs Plymel and Mariona that “these techniques must be reviewed thoroughly by the teams who are planning randomized trials that will involve cesarean deliveries in morbidly or extremely obese patients.”