Surgical Innovators Past and Present—Reply

In reply

We thank Drs O’Connor and Winter for providing perspective on our technique article on the “modified Makuuchi” or “reverse L” incision.¹ We have read with interest the excellent 100-year-old seminal works of Prof G. C. Perthes,² Dr H. M. W. Gray,³ and Dr H. M. Lyle.⁴ It is interesting that these first descriptions meticulously detail the distinct advantages of the approach, which include (1) preservation of the innervation of the rectus muscle, (2) an excellent exposure of the liver without crossing the midline, (3) a 2-layer reconstruction, which should minimize the risk of hernia, and (4) ready access to the right lower quadrant. In the Perthes and Gray articles, the vertical incision was not along the midline but a paramedian incision with opening of the rectus sheath along its full length vertically. The posterior rectus sheath was divided obliquely along the course of the right costal margin after the anterior rectus sheath was reflected en bloc with the rectus muscle superiorly. Regardless of these small differences between the previously described techniques and our current technique, it is clear that the reverse L incision has stood the test of time. In our experience, it provides a window to the right upper quadrant with access to the right lower and left upper quadrants without need for left-sided abdominal extension of the incision. We thank Drs O’Connor and Winter for placing the “reverse” L incision in historical perspective.