Four modified techniques to close the fascia after paramedian laparotomy were compared in a prospective randomized 
trial. The four techniques were lateral paramedian incision (group A); vertical muscle – splitting incision (group B); 
laparotomy done via medial incision of the anterior rectus sheath and lateral incision of the posterior rectus sheath (group 
C) or vice versa (group D). In order to determine the necessity for incising both layers of the rectus sheath laterally to provide 
the shutter mechanism which is held responsible for the wound integrity. More medial incision of the anterior sheath 
significantly reduced the time required to perform the incision (P< 0.02) and tended to reduce wound sepsis rate (9.3%, 
5%, 2.6% and 12.5% in groups A, B, C and D respectively). However, this was achieved at the cost of a higher incisional 
hernia rate (0%, 2.5%, 5.3% and 7.5% in groups A, B, C and D respectively, P < 0.02). The criteria used to assess the results
were the occurrence of wound infection and wound dehiscence in the early post-operative period, and the occurrence of
incisional hernia one year after operation. 
We conclude that lateral incision of both the anterior and the posterior layers of rectus sheath is necessary to obviate the risk of wound hernia later on.