abdominal wall closure
TRANSCRIPT
Features of good technique
• Fast• Easy• Cost effective• Minimal early and late complications
Jenkin’s Rule
• Length of the incision increases to variable length(30%) in post operative period
• If length of suture is not able to accommodate this stretch it will cut through the fascia
• Use of 4:1 suture length to wound length ratio will take adequate bite and avoid cutting through the fascial sheath
• Sutures could be placed at 1cm away from the fascial edge and 1cm away from each other to maintain jenkins rule
Outcome of laparotomy closure
• Out come assessed by early and late complications– Early complications
• Wound dehiscence • Infections
– late complications • Hernia• Suture sinuses• Incisional pain
• Analysed factors – Technique – mass closure vs layered closure– Continuous vs interrupted – Suture material– Suture length
• Techniques related to complications– SSI– Wound dehiscence– Incisional hernia
Mass closure and layered closure
• Layered closure – closure of layer by layer from peritoneum to skin
• Mass closure(Smead Jones technique)
• Layered closure– Problems with peritoneal closure• Increase adhesions• Time• Compromise closure of other layers
Evidence
• Layered closure associated with dehiscence rate of 11% compare to 1% of mass closure
• Layered closure consumes more time• Statistically significant reduction in hernia and
dehiscence in mass closure
Continuous vs interrupted
• Continuous suturing – Evenly distributed tension– Cost effective– Less time – Less suture materials– Bursting strength is higher
• Same rate of incision hernia with interrupted sutures
• Theoretical disadvantage is loosening of the knot will compromise strength of the wound, but it is a rare cause of wound dehiscence.
Suture material
• Healing of abdominal wall– 52 – 59 % of original strength in 42 days– 70 – 80% in 120 days– 73 – 93% by 140 days– Maximum strength is 93% of original strength
Non absorbable monofilamant
• Polypropylene – prolene• Nylon• Polyethylene – Ethibond• Polyamide – ethilone
Advantages of non absorbable monofilament sutures
• Less tissue reaction than absorbable sutures• More resistance to infections than absorbable
• Disadvantages– Increased button hole hernia– Sinus formation– Wound pain
Absorbable sutures
• Polydioxanone and polyglyconate• Slowly absorbable materials• Absorption will take 180 days• Incidence of chronic wound pain and sinus
formation is significantly low• No statistically significant difference in
incidence of incisional hernia, wound dehiscence and infections compare to non absorbable sutures.
Recommendations
• Use monofilament suture material• 2/0 slowly absorbable or non absorbable
mounted on small needle• Use self locking anchor knots• Use continuous suture in one layer avoiding
high tension on suture and not compressing wound edges
• Place the stitches – In the aponeurosis only– 5 to 8 mm from wound edge– 4 to 5 mm apart
• Do not accept closure with suture length less than 4 times of wound length
Surgical site infections
• Will lead to both wound dehiscence and incisional hernia
• Monofilament fibres are superior to multifilament fibres
• Too much tension will increase SSI, wound edge should not be compressed
• Stitch size - smaller stitches reduce amount of compressed tissue and necrosis. 5 to 8 mm from the wound edge compared to stitches more than 10 mm will reduce SSI (5.2% vs 10.2%)
Wound dehiscence
• Mainly due to cut through of fascia • Crucial factor is suture length to wound length• SL to WL ratio 4: 1 or more is recommended• Provided the correct SL to WL ratio 2/0 size
suture has achieved a zero dehiscence rate in 356 patients
• Continuous suturing is recommended• Single layer suturing of rectus sheath
Incisional hernia
• If aponeurotic edge detach more than 12mm with in 1st month risk is higher for incisional hernia
• Correct technique and suture material should hold the edges at least 6 weeks
• Higher the SL to WL outcome is good
Recommendation
• Many small stiches placed at short intervals improves outcome
• Use slowly absorbable suture• 2/O suture with small needle• Catch aponeurosis only• 5 to 8 mm from the wound edge• 4 to 5 mm apart• This will reduce rate of incisional hernia by 3
times
References
• Prevention of incisional hernias, how to close a midline incision – Leif A. Israelsson, MD, PhD, Daniel millbourn, MD, PhD
• Finding the best abdominal closure: An evidence based review of the litreature – Adil Ceydeli, MD, James Rukinski MD
How to repair wound dehiscence
• Distance from wound edge – 3 cm• Include all layers of abdominal wall except skin• Stitch interval should be 4mm to 5mm• SL to WL – 10 to 15 times