Incise the linea alba with the scalpel. Remember that the linea alba is narrow close to the xiphoid and wide close to the umbilicus. Incise it first in the immediate supraumbilical area. With incremental cuts of your knife, extend the linea alba incision upward. Do not yet cut through the preperitoneal fat and peritoneum that lies under the linea alba (Fig. 42.2).

Grasp the left side of the fascia with a Kocher clamp mid-way between the xiphoid process and the umbilicus, and with a gauze bluntly dissect the preperitoneal fat away from the overlying fascia moving laterally. You will realize that the thick fatty tissue lying under the midline transitions to a thin and almost transparent peritoneal layer lying under the fascia laterally to the midline. You can usually enter into the peritoneal cavity bluntly by pushing your digit through this thin peritoneal layer (Fig. 42.3).

Under direct vision, incise the peritoneum up and down.

Insert your hand to protect the bowel, and with electrocoagulation, extend the incision below the umbilicus. As opposed to the supraumbilical midline, on which the fascia fuses in the relatively avascular linea alba below the midline, there is no linea alba and electrocoagulation will help in minimizing the bleeding from the muscle (Fig. 42.4).