Sensory Impact of Bilateral Subcostal Incision in Long Term Survivors After Whipple Surgery

Sensory Impact of Bilateral Subcostal Incision in Long Term Survivors After Whipple Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sensory Impact of Bilateral Subcostal Incision in Long Term Survivors After Whipple Surgery Anuradha Naligama, Suchintha B Thilakarathne, Mahiman B Gunathilake, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7362975/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Whipple surgery needs adequate surgical exposure. The bilateral subcostal incision (BSI) is one of the traditional preferred approaches. However, the long-term sensory impairment following BSI in survivors has not been thoroughly investigated. Methods Out of 196 patients who underwent Whipple surgery with bilateral subcostal incision, 39 patients who completed 6 months follow up (median 43 months) were included in the study. The area of sensory impairment (SI) was measured using pin prick method and the Nottingham Sensory Assessment (NSA) scale and factors affecting the sensory impairment were evaluated. Factors influencing sensory impairment were analyzed, and correlations were determined Results The median age was of the cohort was 51 yrs (range 16-78 yrs) with 61% (n =23) being male. The median area of sensory loss was 109.27 cm 2 and 97.3 % (n=36) had grade NSA 1/0 SI. In univariate analysis incision angle (p=0.050), length of the right limb (p = 0.019), Body mass index (p = 0.021) and distance from subcostal margin (p=0.029) had a significant association with SI. In multivariate analysis, the distance from the subcostal margin had a significant association (p=0.037) with SI and it showed a significant negative correlation. Conclusion There is a consistent area of sensory impairment in long-term survivors after Whipple surgery. This can potentially be minimized when an incision is placed furthest away from the subcostal margin. Outcomes Pancreatectomy/methods Pancreas Treatment Figures Figure 1 Figure 2 Introduction Whipple surgery has a historical association with poor perioperative outcomes. Nevertheless, over the years, these adverse outcomes have been significantly mitigated resulting in increased life expectancyfor patients prompting a shift in focus towards long-term results 1 . Adequate surgical exposure is crucial for optimal surgical outcomes. Among the various types of surgical incisions utilized in Whipple surgery, the bilateral subcostal (rooftop) incision stands out. Positioned over the upper abdomen parellel to the subcostal margin, this incision impacts a region primarily innervated by the ventral rami of the T6 to T10 intercostal nerves, which emerge from the subcostal margin and traveres the intermuscular plane. As these mixed nerves contain both sensory and motor fibers such an incision may sever these nerves on either side of the abdomen leading to both sensory and motor deficits in the latter anatomical regions. Nerve injury can result in complete sensory loss, impairment, or hyperesthesia. These alterations are dynamic and eveolve over time due to the overlapping nature of dermatomes and the healing process. Typically, a period of six months is required for stabilization 2 . These enduring changes can impact daily functionality of the patients as their quality of life gradually returns to normal post major medical interventions like Whipple surgery. Therefore, an objective assessment is crucial to select the surgical approach that yields the optimal long-term outcomes.There is currently little, if any, data on the sensory repercussions following bilateral upper abdominal incisions. Hence the aim of this prospective study was to examine a cohort of 39 longterm survivors who underwent Whipple surgery at a single institution and investigates the long-term sensory impairment they experience. Method Study design and setting A total of 39 patients out of 196, who underwent Whipple surgery at the Colombo North Center for Liver Diseases, Sri Lanka from 2011 March to 2023 December were chosen for this prospective study. All such patients underwent bilateral subcostal incisions during the surgical procedure. We reviewed the historical patient records of these patients. The inclusion criteria for the study were: those who completed a six months minimum period of follow-up, with no surgical complications (e,g. wound infections, pancreatic leak and re-laparotomy); patients who did not receive chemotherapy over the immediate six months, and those who did not have recurrence of the original disease. Ethical considerations All subjects were informed of the study procedure, the purpose of the study, known risks and obtained written consent. The study protocol was reviewed and approved by the Ethical review committee, Faculty of Medicine, University of Kelaniya, Sri Lanka (Ref No: P/14/02/2024) Variables and measurement Patient’s demographic data and anterior abdominal wall parametrics were collected using a pre formed data collection rubric. The following parameters were defined and evaluated in the study. Subcostal angle – The meeting point of the lines joining 7th to 10th costal cartilages on right and left sides. This angle was traced on to a transparent paper and measured using a protractor. Length of the right limb of incision - length from the right edge of incision to the apex. Length of the left limb of incision - length from the left edge of incision to apex. Distance to costal margin – vertical distance between the incision and costal margin at the level of the 9th costal cartilage. Sensory impairment (SI) - Graded using Nottingham sensory assessment score (NSA) and the area calculated as described below. Standard area of sensory impairment (SSI) – This standardized metric was computed by dividing the sensory impairment area by the body surface area. This parameter aimed to mitigate any potential bias related to the area of sensory loss caused by variations in body habitus. Sensory impairment in all patients was measured by an experienced, senior, clinician. The degree of sensory impairment was graded according to the NSA scale 3 , with Grades 0 and 1 being classified as sensory impairment. The following method was used to evaluate the sensory impairment: The anterior abdominal wall was examined with the pinprick using a previously described technique (3,4). A blunt pin was employed for the pinprick examination, starting just above the incision angle and progressing inferiorly and laterally. Patients were instructed to indicate when sensation transitioned from abnormal to normal during the pin prick assessment. This specific point was denoted with a skin marking pen. Additional points were identified within 1 cm range from the initial point extending both inferiorly and laterally from the incision to delineate the total area of sensory impairment (SI). The marked points were connected with short lines. A piece of transparent paper of suitable dimensions was then placed over the marked area, and the markings were transferred onto it. Subsequently. The transparent paper was placed on a square grid paper, and the sensory impaired area was calculated with precision to one decimal point. Statistical analysis SPSS for Windows (SPSS 17.0) software was used for statistical analysis. Univariate and multivariate analyses were used to determine the association between factors and area of sensory impairment. For each variable p valve was calculated to determine the significance of the association. P valve of < 0.05 was considered statistically significant. Results The demographic data of the evaluated cohort were as follows: 23/16 (60.5/29.5%) males/females; median age 52 (16–78) years; Median BMI 20.6 (13.7–28.5) and the body surface area (BSA) 1.58 m 2 (1.27–2.10) ;15 (58.5) % diabetics. Overall, 19 had Whipple surgery for pancreatic cancer, 7 for peri-ampullary cancer, and 13 for other indications; 28.2% had received chemotherapy following surgery. Median time since the surgery was 43 months. The median total incision length was 27.3 cm (17.5–41.0) the left limb being 11.4 cm and the right limb 15.3 cm. The distance from the subcostal angle was 8.9cm (range 4.0-13.5). The median incision angle was 148 0 and the median subcostal angle was 90.5 0 . Out of 39 subjects, 37 (96.7%) had an NSA 1/0 sensory impairment. The median area of sensory impairment in them was 107.2 cm 2 (19.7-530.6). The standard sensory impairment (SSI) was 67.9 (Table 1 ). The sensory impairment was mainly dispersed in the midline (Fig. 1 ). The median vertical (Cranio-caudal) length of SI was 10.59 cm (5-17.8). The median maximum right extension of SI was 7.78cm (0-18.2). The median maximum left extension of SI was 6.66 cm (0–12). Table 1 – Univariate and multivariate analysis of factors affecting area of sensory impairment Variable (median) Area of SI – p value SSI – p value Univariate multivariate Univariate Multivariate Total Incision length (27.3 cm) 0.177 0.777 0.406 0.825 Left limb (11.4 cm) 0.558 0.740 0.827 0.985 Right Limb (15.3 cm) 0.019 0.756 0.069 0.693 Subcostal angle (90.5 0 ) 0.055 0.654 0.115 0.374 Incision angle (148 0 ) 0.079 0.229 0.063 0.165 Distance from rib cage (8.9 cm) 0.029 0.037 0.023 0.029 BMI – (20.6) 0.021 0.697 0.109 0.904 Body surface area (1.58 m 2 ) 0.063 0.978 0.383 0.828 Interval after surgery (48 months) 0.615 0.829 0.366 0.820 Chemotherapy in 0.163 0.925 0.275 0.965 Univariate analysis was done to assess the effects of incision length, incision angle, subcostal angle, distance from subcostal angle, chemotherapy following surgery, interval after surgery and gender on SI and SSI (Table 1 ). On univariate analysis, SI had a significant association with the length of right limb (p = 0.019), subcostal angle (p = 0.055), distance from rib cage (p = 0.029) and BMI (p = 0.029). On multivariate analysis only the distance from the ribcage has a significant association (p = 0.037). When evaluating the SSI with the factors, only the distance from the rib cage had a significant association in univariate (p = 0.023) and multivariate analysis (p = 0.029). Figure 2 shows a scatterplot of distance from the subcostal angle against the SI and SSI. which demonstrates a negative significant correlation (r 2 = − 0.393) between the incision distance from the subcostal line and the SI. Discussion In our cohort of Whipple surgery patients, 96% exhibited NSA 1 sensory impairment. Limited published data exists on the long-term sensory impact of transverse upper abdominal incisions. Balogh et al. evaluated sensory and motor impairment following unilateral subcostal incisions subsequent to open cholecystectomy 4 . In their cohort 95% of patients displayed some degree of sensory impairment. However, they did not investigate long term outcome nor provide data on the degree and dispersion of sensory impairment. Our findings indicate that 96% of patients exhibited 107.2 cm 2 (19.7–530.6 cm 2 ) area of sensory impairment. Postoperative sensory loss is a much-discussed topic that has medico-legal undertones, particularly in non-spine orthopedic surgeries and in anesthesia, related to patient positioning 5 , 6 . However, sensory impairment following abdominal incisions has not been widely debated, possibly due to the to the limited functional implications of trunk involvement. None of the patients in our cohort initially presented with the sensory impairment as a primary complaint. However, upon specific inquiry all acknowledged experiencing sensory impairment. Although this sensory loss did not have significant functional consequences for our patients, it should be recognized as an adverse effect of the surgery 7 . The consistent sensory loss we observed in our study should be considered an expected outcome rather than a surgical complication. Therefore, it is imperative that patients are informed about this potential outcome during preoperative counseling, especially when a bilateral subcostal incision is planned for the surgery. Midline and subcostal incisions have been compared in previous studies. For instance, Qian et al. compared different incisions in terms of surgical exposure, surgical time, blood loss, peri-operative complications, and concluded that subcostal incisions yield superior outcomes 8 . Another study focusing on perioperative outcomes found that transverse incisions carried a higher risk of infections, although postoperative pain, morbidity, and mortality were similar 9 . Additional studies have also compared midline and transverse incisions 10 – 12 . Hence the superiority of one type of incision over the other is arguable. While midline incisions are theoretically, less likely to result in the sensory loss as observed in our study, none of our patients presented sensory impairment as a primary complaint. Therefore, the choice of incision should be based on the surgeon's preference and experience, aiming to achieve the best possible perioperative outcome. Our data revealed a significant negative correlation between sensory impairment and the distance of the incision from the costal margin. This relationship can be explicable in anatomical terms. Placing the incision higher up risks dividing the main trunks of 8th, 9th, and 10th subcostal nerves, while a lower placement poses a minimal risk, perhaps to only the smaller branches. On the other hand, placing the incision too low may compromise access to the porta hepatis, particularly in patients with a narrow subcostal angle. An alternative approach in such a scenario, would be to combine a right subcostal incision and a midline incision so as to optimize access. With the advancement of robotic and laparoscopic techniques, many of the traditional complications associated with surgical incisions is likely to be minimized in future 13 . Until then, the choice of an open surgical approach should be carefully tailored based on the surgeon’s preference and individual patient factors to achieve the best possible outcomes. In conclusion, bilateral subcostal incisions lead to consistent regions of sensory impairment in long-term survivors of Whipple surgery. This anticipated outcome should be communicated to patients during preoperative counseling. Placing the subcostal incision further away from the rib cage may help mitigate the extent of sensory impairment. The choice of the optimal surgical approach should be individualized, considering the surgeon's preferences and patient-specific factors. Declarations Ethics approval and consent to participate The study protocol was reviewed and approved by the Ethical review committee, Faculty of Medicine, University of Kelaniya, Sri Lanka (Ref No: P/14/02/2024). Informed written consent was obtained from all participants. Consent for publication Not applicable Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to unit policy but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding None Authors' contributions AN – Formal analysis and Investigation ST – Data Curation MG - Supervision NR – Project administration SN – Writing – original draft SG - Formal analysis and Investigation RC – Conceptualization, Writing – review and editing Acknowledgements Authors acknowledge professor L P Samaranayake (Professor Emeritus University of Hong Kong, Hong Kong, Editor-in-Chief International Dental Journal) for the assistance given in language editing and reviewing the article. We thank Miss Esheli Ranawaka for the assistance given in coordinating the study. References Strasberg SM, Drebin JA, Soper NJ. Evolution and current status of the Whipple procedure: an update for gastroenterologists. Gastroenterology. 1997; 113: 983-94. Bai L, Han YN, Zhang WT, Huang W, Zhang HL. Natural history of sensory nerve recovery after cutaneous nerve injury following foot and ankle surgery. Neural Regen Res. 2015; 10: 99-103. Lincoln NB, Jackson JM, Adams S. Reliability of the Revised NSA. Physiotherapy. 1998; 84: 358-65. Balogh B, Zauner-Dung A, Nicolakis P, Armbruster C, Kriwanek S, Piza-Katzer H. Functional impairment of the abdominal wall following laparoscopic and open cholecystectomy. Surg Endosc. 2002; 16: 481-6. Huang H, Yao D, Saba R, et al. A contemporary medicolegal claims analysis of injuries related to neuraxial anesthesia between 2007 and 2016. J Clin Anesth. 2019; 57: 66-71. Kent CD, Stephens LS, Posner KL, Domino KB. What Adverse Events and Injuries Are Cited in Anesthesia Malpractice Claims for Nonspine Orthopaedic Surgery? Clin Orthop Relat Res. 2017; 475: 2941-51. Anderson OA, Wearne IM. Informed consent for elective surgery--what is best practice? J R Soc Med. 2007; 100: 97-100. Qian LM, Huang JM. Impact of bilateral subcostal rooftop incision combined double lifting retractor on recent surgical outcomes of obese patients with advanced gastric cancer. Eur Rev Med Pharmacol Sci. 2016; 20: 2792-8. Seiler CM, Deckert A, Diener MK, et al. Midline versus transverse incision in major abdominal surgery: a randomized, double-blind equivalence trial (POVATI: ISRCTN60734227). Ann Surg. 2009; 249: 913-20. Brown SR, Goodfellow PJ, Adam IJ, Shorthouse AJ. A randomised controlled trial of transverse skin crease vs. vertical midline incision for right hemicolectomy. Tech Coloproctol. 2004; 8: 15-8. Lohsiriwat V, Lohsiriwat D, Boonnuch W, et al. Comparison between midline and right transverse incision in right hemicolectomy for right-sided colon cancer: a retrospective study. J Med Assoc Thai. 2009; 92: 1003-8. Junker S, Jacobsen A, Merkel S, et al. Transverse Incision for Pancreatoduodenectomy Reduces Wound Complications: A Single-Center Analysis of 399 Patients. J Clin Med. 2023; 12: 2800. Shyr YM, Wang SE, Chen SC, Shyr BU, Shyr BS. Robotic pancreaticoduodenectomy for pancreatic head cancer and periampullary lesions. Ann Gastroenterol Surg. 2021; 5: 589-96. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":30061,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDispersion of the sensory impairment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA - The median vertical (Cranio-caudal) length, B- The median maximum left extension, C - The median maximum right extension\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7362975/v1/eaca949ebbd613c579d049ca.jpg"},{"id":92478620,"identity":"03869676-e411-47ba-b294-072fee901e99","added_by":"auto","created_at":"2025-09-30 07:34:43","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":35082,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of sensory impairment against the distance from the subcostal line\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7362975/v1/3a68b7c5aae2bb6bcaf7de09.jpg"},{"id":93700755,"identity":"d10c51a2-df4e-4fce-9506-c26de68cb5ad","added_by":"auto","created_at":"2025-10-16 15:32:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":629754,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7362975/v1/3ce777ea-a9a3-43ed-a3ac-cfbf4182c450.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sensory Impact of Bilateral Subcostal Incision in Long Term Survivors After Whipple Surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWhipple surgery has a historical association with poor perioperative outcomes. Nevertheless, over the years, these adverse outcomes have been significantly mitigated resulting in increased life expectancyfor patients prompting a shift in focus towards long-term results \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAdequate surgical exposure is crucial for optimal surgical outcomes. Among the various types of surgical incisions utilized in Whipple surgery, the bilateral subcostal (rooftop) incision stands out. Positioned over the upper abdomen parellel to the subcostal margin, this incision impacts a region primarily innervated by the ventral rami of the T6 to T10 intercostal nerves, which emerge from the subcostal margin and traveres the intermuscular plane. As these mixed nerves contain both sensory and motor fibers such an incision may sever these nerves on either side of the abdomen leading to both sensory and motor deficits in the latter anatomical regions.\u003c/p\u003e\u003cp\u003eNerve injury can result in complete sensory loss, impairment, or hyperesthesia. These alterations are dynamic and eveolve over time due to the overlapping nature of dermatomes and the healing process. Typically, a period of six months is required for stabilization\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. These enduring changes can impact daily functionality of the patients as their quality of life gradually returns to normal post major medical interventions like Whipple surgery. Therefore, an objective assessment is crucial to select the surgical approach that yields the optimal long-term outcomes.There is currently little, if any, data on the sensory repercussions following bilateral upper abdominal incisions. Hence the aim of this prospective study was to examine a cohort of 39 longterm survivors who underwent Whipple surgery at a single institution and investigates the long-term sensory impairment they experience.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and setting\u003c/h2\u003e\u003cp\u003eA total of 39 patients out of 196, who underwent Whipple surgery at the Colombo North Center for Liver Diseases, Sri Lanka from 2011 March to 2023 December were chosen for this prospective study. All such patients underwent bilateral subcostal incisions during the surgical procedure.\u003c/p\u003e\u003cp\u003eWe reviewed the historical patient records of these patients. The inclusion criteria for the study were: those who completed a six months minimum period of follow-up, with no surgical complications (e,g. wound infections, pancreatic leak and re-laparotomy); patients who did not receive chemotherapy over the immediate six months, and those who did not have recurrence of the original disease.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e All subjects were informed of the study procedure, the purpose of the study, known risks and obtained written consent. The study protocol was reviewed and approved by the Ethical review committee, Faculty of Medicine, University of Kelaniya, Sri Lanka (Ref No: P/14/02/2024)\u003c/p\u003e\n\u003ch3\u003eVariables and measurement\u003c/h3\u003e\n\u003cp\u003ePatient\u0026rsquo;s demographic data and anterior abdominal wall parametrics were collected using a pre formed data collection rubric. The following parameters were defined and evaluated in the study.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eSubcostal angle \u0026ndash; The meeting point of the lines joining 7th to 10th costal cartilages on right and left sides. This angle was traced on to a transparent paper and measured using a protractor.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eLength of the right limb of incision - length from the right edge of incision to the apex.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eLength of the left limb of incision - length from the left edge of incision to apex.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDistance to costal margin \u0026ndash; vertical distance between the incision and costal margin at the level of the 9th costal cartilage.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSensory impairment (SI) - Graded using Nottingham sensory assessment score (NSA) and the area calculated as described below.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStandard area of sensory impairment (SSI) \u0026ndash; This standardized metric was computed by dividing the sensory impairment area by the body surface area. This parameter aimed to mitigate any potential bias related to the area of sensory loss caused by variations in body habitus.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eSensory impairment in all patients was measured by an experienced, senior, clinician. The degree of sensory impairment was graded according to the NSA scale\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e, with Grades 0 and 1 being classified as sensory impairment. The following method was used to evaluate the sensory impairment: The anterior abdominal wall was examined with the pinprick using a previously described technique (3,4).\u003c/p\u003e\u003cp\u003eA blunt pin was employed for the pinprick examination, starting just above the incision angle and progressing inferiorly and laterally. Patients were instructed to indicate when sensation transitioned from abnormal to normal during the pin prick assessment. This specific point was denoted with a skin marking pen. Additional points were identified within 1 cm range from the initial point extending both inferiorly and laterally from the incision to delineate the total area of sensory impairment (SI).\u003c/p\u003e\u003cp\u003eThe marked points were connected with short lines. A piece of transparent paper of suitable dimensions was then placed over the marked area, and the markings were transferred onto it. Subsequently. The transparent paper was placed on a square grid paper, and the sensory impaired area was calculated with precision to one decimal point.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eSPSS for Windows (SPSS 17.0) software was used for statistical analysis. Univariate and multivariate analyses were used to determine the association between factors and area of sensory impairment. For each variable p valve was calculated to determine the significance of the association. P valve of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe demographic data of the evaluated cohort were as follows: 23/16 (60.5/29.5%) males/females; median age 52 (16\u0026ndash;78) years; Median BMI 20.6 (13.7\u0026ndash;28.5) and the body surface area (BSA) 1.58 m\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (1.27\u0026ndash;2.10) ;15 (58.5) % diabetics. Overall, 19 had Whipple surgery for pancreatic cancer, 7 for peri-ampullary cancer, and 13 for other indications; 28.2% had received chemotherapy following surgery. Median time since the surgery was 43 months.\u003c/p\u003e\u003cp\u003eThe median total incision length was 27.3 cm (17.5\u0026ndash;41.0) the left limb being 11.4 cm and the right limb 15.3 cm. The distance from the subcostal angle was 8.9cm (range 4.0-13.5). The median incision angle was 148\u003csup\u003e0\u003c/sup\u003e and the median subcostal angle was 90.5\u003csup\u003e0\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOut of 39 subjects, 37 (96.7%) had an NSA 1/0 sensory impairment. The median area of sensory impairment in them was 107.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (19.7-530.6). The standard sensory impairment (SSI) was 67.9 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The sensory impairment was mainly dispersed in the midline (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The median vertical (Cranio-caudal) length of SI was 10.59 cm (5-17.8). The median maximum right extension of SI was 7.78cm (0-18.2). The median maximum left extension of SI was 6.66 cm (0\u0026ndash;12).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u0026ndash; Univariate and multivariate analysis of factors affecting area of sensory impairment\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable (median)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eArea of SI \u0026ndash; p value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eSSI \u0026ndash; p value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnivariate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003emultivariate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUnivariate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMultivariate\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Incision length (27.3 cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.177\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.777\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.406\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.825\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft limb (11.4 cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.558\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.740\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.827\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.985\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight Limb (15.3 cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e0.019\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.756\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.069\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.693\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubcostal angle (90.5\u003csup\u003e0\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e0.055\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.654\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.115\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.374\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncision angle (148\u003csup\u003e0\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.079\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.229\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.063\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.165\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistance from rib cage (8.9 cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.023\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI \u0026ndash; (20.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.697\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.904\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody surface area (1.58 m\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.063\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.978\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.383\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.828\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterval after surgery (48 months)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.615\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.829\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.366\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.820\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChemotherapy in\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.163\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.925\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.275\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.965\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eUnivariate analysis was done to assess the effects of incision length, incision angle, subcostal angle, distance from subcostal angle, chemotherapy following surgery, interval after surgery and gender on SI and SSI (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). On univariate analysis, SI had a significant association with the length of right limb (p\u0026thinsp;=\u0026thinsp;0.019), subcostal angle (p\u0026thinsp;=\u0026thinsp;0.055), distance from rib cage (p\u0026thinsp;=\u0026thinsp;0.029) and BMI (p\u0026thinsp;=\u0026thinsp;0.029). On multivariate analysis only the distance from the ribcage has a significant association (p\u0026thinsp;=\u0026thinsp;0.037). When evaluating the SSI with the factors, only the distance from the rib cage had a significant association in univariate (p\u0026thinsp;=\u0026thinsp;0.023) and multivariate analysis (p\u0026thinsp;=\u0026thinsp;0.029). Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows a scatterplot of distance from the subcostal angle against the SI and SSI. which demonstrates a negative significant correlation (r\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.393) between the incision distance from the subcostal line and the SI.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our cohort of Whipple surgery patients, 96% exhibited NSA 1 sensory impairment. Limited published data exists on the long-term sensory impact of transverse upper abdominal incisions. Balogh et al. evaluated sensory and motor impairment following unilateral subcostal incisions subsequent to open cholecystectomy\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. In their cohort 95% of patients displayed some degree of sensory impairment. However, they did not investigate long term outcome nor provide data on the degree and dispersion of sensory impairment.\u003c/p\u003e\u003cp\u003eOur findings indicate that 96% of patients exhibited 107.2 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (19.7\u0026ndash;530.6 cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e) area of sensory impairment. Postoperative sensory loss is a much-discussed topic that has medico-legal undertones, particularly in non-spine orthopedic surgeries and in anesthesia, related to patient positioning \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. However, sensory impairment following abdominal incisions has not been widely debated, possibly due to the to the limited functional implications of trunk involvement.\u003c/p\u003e\u003cp\u003eNone of the patients in our cohort initially presented with the sensory impairment as a primary complaint. However, upon specific inquiry all acknowledged experiencing sensory impairment. Although this sensory loss did not have significant functional consequences for our patients, it should be recognized as an adverse effect of the surgery\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. The consistent sensory loss we observed in our study should be considered an expected outcome rather than a surgical complication. Therefore, it is imperative that patients are informed about this potential outcome during preoperative counseling, especially when a bilateral subcostal incision is planned for the surgery.\u003c/p\u003e\u003cp\u003eMidline and subcostal incisions have been compared in previous studies. For instance, Qian et al. compared different incisions in terms of surgical exposure, surgical time, blood loss, peri-operative complications, and concluded that subcostal incisions yield superior outcomes\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Another study focusing on perioperative outcomes found that transverse incisions carried a higher risk of infections, although postoperative pain, morbidity, and mortality were similar\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Additional studies have also compared midline and transverse incisions\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Hence the superiority of one type of incision over the other is arguable. While midline incisions are theoretically, less likely to result in the sensory loss as observed in our study, none of our patients presented sensory impairment as a primary complaint. Therefore, the choice of incision should be based on the surgeon's preference and experience, aiming to achieve the best possible perioperative outcome.\u003c/p\u003e\u003cp\u003eOur data revealed a significant negative correlation between sensory impairment and the distance of the incision from the costal margin. This relationship can be explicable in anatomical terms. Placing the incision higher up risks dividing the main trunks of 8th, 9th, and 10th subcostal nerves, while a lower placement poses a minimal risk, perhaps to only the smaller branches. On the other hand, placing the incision too low may compromise access to the porta hepatis, particularly in patients with a narrow subcostal angle. An alternative approach in such a scenario, would be to combine a right subcostal incision and a midline incision so as to optimize access.\u003c/p\u003e\u003cp\u003eWith the advancement of robotic and laparoscopic techniques, many of the traditional complications associated with surgical incisions is likely to be minimized in future\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Until then, the choice of an open surgical approach should be carefully tailored based on the surgeon\u0026rsquo;s preference and individual patient factors to achieve the best possible outcomes. In conclusion, bilateral subcostal incisions lead to consistent regions of sensory impairment in long-term survivors of Whipple surgery. This anticipated outcome should be communicated to patients during preoperative counseling. Placing the subcostal incision further away from the rib cage may help mitigate the extent of sensory impairment. The choice of the optimal surgical approach should be individualized, considering the surgeon's preferences and patient-specific factors.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Ethical review committee, Faculty of Medicine, University of Kelaniya, Sri Lanka (Ref No: P/14/02/2024). Informed written consent was obtained from all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to unit policy but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAN – Formal analysis and Investigation\u003c/p\u003e\n\u003cp\u003eST – Data Curation\u003c/p\u003e\n\u003cp\u003eMG - Supervision\u003c/p\u003e\n\u003cp\u003eNR – Project administration\u003c/p\u003e\n\u003cp\u003eSN – Writing – original draft\u003c/p\u003e\n\u003cp\u003eSG - Formal analysis and Investigation\u003c/p\u003e\n\u003cp\u003eRC – Conceptualization, Writing – review and editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors acknowledge professor L P Samaranayake (Professor Emeritus University of Hong Kong, Hong Kong, Editor-in-Chief International Dental Journal) for the assistance given in language editing and reviewing the article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe thank Miss Esheli Ranawaka for the assistance given in coordinating the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eStrasberg SM, Drebin JA, Soper NJ. Evolution and current status of the Whipple procedure: an update for gastroenterologists. Gastroenterology. 1997; 113: 983-94.\u003c/li\u003e\n\u003cli\u003eBai L, Han YN, Zhang WT, Huang W, Zhang HL. Natural history of sensory nerve recovery after cutaneous nerve injury following foot and ankle surgery. Neural Regen Res. 2015; 10: 99-103.\u003c/li\u003e\n\u003cli\u003eLincoln NB, Jackson JM, Adams S. Reliability of the Revised NSA. Physiotherapy. 1998; 84: 358-65.\u003c/li\u003e\n\u003cli\u003eBalogh B, Zauner-Dung A, Nicolakis P, Armbruster C, Kriwanek S, Piza-Katzer H. Functional impairment of the abdominal wall following laparoscopic and open cholecystectomy. Surg Endosc. 2002; 16: 481-6.\u003c/li\u003e\n\u003cli\u003eHuang H, Yao D, Saba R, et al. A contemporary medicolegal claims analysis of injuries related to neuraxial anesthesia between 2007 and 2016. J Clin Anesth. 2019; 57: 66-71.\u003c/li\u003e\n\u003cli\u003eKent CD, Stephens LS, Posner KL, Domino KB. What Adverse Events and Injuries Are Cited in Anesthesia Malpractice Claims for Nonspine Orthopaedic Surgery? Clin Orthop Relat Res. 2017; 475: 2941-51.\u003c/li\u003e\n\u003cli\u003eAnderson OA, Wearne IM. Informed consent for elective surgery--what is best practice? J R Soc Med. 2007; 100: 97-100.\u003c/li\u003e\n\u003cli\u003eQian LM, Huang JM. Impact of bilateral subcostal rooftop incision combined double lifting retractor on recent surgical outcomes of obese patients with advanced gastric cancer. Eur Rev Med Pharmacol Sci. 2016; 20: 2792-8.\u003c/li\u003e\n\u003cli\u003eSeiler CM, Deckert A, Diener MK, et al. Midline versus transverse incision in major abdominal surgery: a randomized, double-blind equivalence trial (POVATI: ISRCTN60734227). Ann Surg. 2009; 249: 913-20.\u003c/li\u003e\n\u003cli\u003eBrown SR, Goodfellow PJ, Adam IJ, Shorthouse AJ. A randomised controlled trial of transverse skin crease vs. vertical midline incision for right hemicolectomy. Tech Coloproctol. 2004; 8: 15-8.\u003c/li\u003e\n\u003cli\u003eLohsiriwat V, Lohsiriwat D, Boonnuch W, et al. Comparison between midline and right transverse incision in right hemicolectomy for right-sided colon cancer: a retrospective study. J Med Assoc Thai. 2009; 92: 1003-8.\u003c/li\u003e\n\u003cli\u003eJunker S, Jacobsen A, Merkel S, et al. Transverse Incision for Pancreatoduodenectomy Reduces Wound Complications: A Single-Center Analysis of 399 Patients. J Clin Med. 2023; 12: 2800.\u003c/li\u003e\n\u003cli\u003eShyr YM, Wang SE, Chen SC, Shyr BU, Shyr BS. Robotic pancreaticoduodenectomy for pancreatic head cancer and periampullary lesions. Ann Gastroenterol Surg. 2021; 5: 589-96.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Outcomes, Pancreatectomy/methods, Pancreas, Treatment","lastPublishedDoi":"10.21203/rs.3.rs-7362975/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7362975/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhipple surgery needs adequate surgical exposure. The bilateral subcostal incision (BSI) is one of the traditional preferred approaches. However, the long-term sensory impairment following BSI in survivors has not been thoroughly investigated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOut of 196 patients who underwent Whipple surgery with bilateral subcostal incision, 39 patients who completed 6 months follow up (median 43 months) were included in the study. The area of sensory impairment (SI) was measured using pin prick method and the Nottingham Sensory Assessment (NSA) scale and factors affecting the sensory impairment were evaluated. Factors influencing sensory impairment were analyzed, and correlations were determined\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe median age was of the cohort was 51 yrs (range 16-78 yrs) with 61% (n =23) being male. The median area of sensory loss was 109.27 cm\u003csup\u003e2\u003c/sup\u003e and 97.3 % (n=36) had grade NSA 1/0 SI. In univariate analysis incision angle (p=0.050), length of the right limb (p = 0.019), Body mass index (p = 0.021) and distance from subcostal margin (p=0.029) had a significant association with SI. In multivariate analysis, the distance from the subcostal margin had a significant association (p=0.037) with SI and it showed a significant negative correlation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is a consistent area of sensory impairment in long-term survivors after Whipple surgery. This can potentially be minimized when an incision is placed furthest away from the subcostal margin.\u003c/p\u003e","manuscriptTitle":"Sensory Impact of Bilateral Subcostal Incision in Long Term Survivors After Whipple Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-30 07:34:38","doi":"10.21203/rs.3.rs-7362975/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"261715d2-f4d3-45ff-8110-fdb9d163dac5","owner":[],"postedDate":"September 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-16T15:23:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-30 07:34:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7362975","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7362975","identity":"rs-7362975","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}