Closure of the abdominal wall after laparotomy
Target-group and scope
To all doctors in the Gastrointestinal Unit, Surgical Section.
Definitions
Wound complications of up to 20% has been described after midline incision.
Wound-dehiscence, infection and herniation is associated with significant morbidity and mortality.
Choice of sutures and suturing techniques are crucial predictors for prevention of rupture, infection
and herniation (1-6).
The optimal distance from the edge of the fascia and between two stitches has not been established
(1). However, it has been shown that the lowest frequency of wound complications after closing the
midline incision (without pre-existing herniation or wound-dehiscence) can be obtained by closing
the fascia with continuous suturing (2), with the use of slowly absorbable monofilament suture (3)
and with use of suture of at least 4 times the length of the incision (4). Experimental studies suggest
that the anchoring of the continuous suture with a slip-knot/ self-locking anchor knots reduces the
risk of rupture of the suture (5-6).
Procedure
Surgical Technique:
• Monofilament suture (150 cm), 2-0 PDS mounted on a small needle is used.
• Initiation is done with a self-locking anchor knot in the fascia, adjacent to the incision in the one
end (Fig. 1).
• Thereafter, closing is done in the upper fascia with continuous suturing with 5-6 mm to the edge
of the fascia and 4-5 mm distance between sutures.
• Closure is terminated with a self-locking knot (Fig. 2).
• It is not recommended to trim fascial edges (increased risk of bleeding, increased size of wound
cavity and devitalization of subcutis), and one should avoid too much tension to avoid ischemia.
• A senior consultant must be present in the operating room during closure of the abdominal wall.
The description of the procedure should indicate wound length (WL) in cm, suture consumption
(SC) in cm and WL / SC ratio.
• WL/SC ratio must be above 4 (Fig. 3).
In practice, the incision is measured, and the length of excess suture left after closure, is subtracted
from the length of the suture opened during surgery.
Fig. 1
Fig. 2
Fig. 3
Suturforbrug (SF) > 4 x SL
Sårlængde (SL)
Link for video of knot tying: http://www.youtube.com/watch?v=5pQ20lknuww
Closing the fascia after dehiscence
The optimal way to close the fascia after complete wound dehiscence is debatable. The problem is
that very often, the fascia is weak, perhaps due to tearing of sutures or accompanying wound
infection. As for primary closure of the abdominal wall, re-suturing with continuous monofilament
suture is recommended. Hereby, the optimum tensile strength is achieved with respect to the
individual sutures. The spiral tension will distribute the tension across largest possible tissue surface
area, in order to avoid further ischemia and necrosis.
The possibility of adapting the fascial edges without creating tension must be assessed.
Is this not possible, due to loss of substance or tightening and consequent risk of abdominal
compartment syndrome, use VAC therapy with mesh-mediated fascial traction with successive
closure within 14 days, alternatively bridging with mesh can be used. Retention sutures must not be
used. (7)
References
1
Harlaar JJ et al. STUDY PROTOCOL Open Access A multicenter randomized controlled trial evaluating
the effect of small stitches on the incidence of incisional hernia in midline incisions. BMC Surgery 2011, 11:20
2
Diener MK et al. Elective midline laparotomy closure: the INLINE systematic review and meta-analysis. Ann
Surg. 2010 May;251(5):843-56
3
Seiler CM et al. Interrupted or continuous slowly absorbable sutures for closure of primary elective midline
abdominal incisions: a multicenter randomized trial (INSECT: ISRCTN24023541). Ann Surg 2009,
249(4):576-582.
4
Israelsson LA et al. Suture length to wound length ratio and healing of midline laparotomy incisions. Br J Surg
1993, 80(10):1284-1286.
5
Aanning HL et al. Running sutures anchored with square knots are unreliable.
Am J Surg 2012;204:384-8
6
Israelsson LA. Prevention of Incisional Hernias How to Close a Midline Incision. Surg Clin N Am 2013;1027–1040
7
Rink AD et al. Negative Side-effects of Retention Sutures for Abdominal Wound Closure. A Prospective Randomized
Study. Eur J Surg 2000; 166:932-937
8
Rasilainen SK et al. Vacuum and mesh-mediated fascial traction for primary closure of the open abdomen in critically ill
surgical patients. Br J Surg 2012; 99:1725-1733
9
Acosta S et al. Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated
fascial traction. Br J Surg 2011;98: 734-743