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Abdominal Closure

  • Author: Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS, KHS; Chief Editor: Kurt E Roberts, MD  more...
 
Updated: Dec 14, 2015
 

Background

Surgical access to the abdomen is required for many operative procedures, with approximately 4 million open abdominal surgeries occurring annually in the United States.[1] The measures used to close the abdomen may vary from physician to physician, depending on training, circumstance, and comfort level. However, basic principles govern all abdominal closures. This article outlines these principles.

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Indications and Contraindications

Indications for abdominal closure include the following:

  • Surgery on the abdominal cavity
  • Trauma

The main contraindication is abdominal compartment syndrome.

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Technical Considerations

Anatomy

The anterior abdominal wall is clearly defined by anatomic borders.[2] The superior border is marked by the costal margins, whereas the inferior border is the pubic symphysis (see the image below).[3]

Abdominal anatomic landmarks. Abdominal anatomic landmarks.

The abdominal wall is composed of distinct tissue types that must be taken into consideration in closing the surgical abdomen. Generally, the anatomic layers of the abdominal wall (superficial to deep) are as follows.

The most superficial component of the abdominal wall, the skin (the largest human organ), is composed of the following three layers:

  • The epidermis, which provides waterproofing and serves as a barrier to the environment
  • The dermis, from which the appendages of the skin originate (e.g. mammary glands)
  • The hypodermis, which contains the subcutaneous adipose layer.
Epidermis, dermis, and subcutis, showing hair foll Epidermis, dermis, and subcutis, showing hair follicle, sweat gland, and sebaceous gland. Image courtesy of Wikimedia Commons.

For a fuller description, see Skin Anatomy.

Next is the superficial fascia, in which the fasciae and ligaments of the anterior abdominal wall are organized into the following two layers:

  • A thin, fatty superficial layer (tela subcutanea), referred to as the Camper fascia
  • A membranous or fibrous deep layer, referred to as the Scarpa fascia

The superficial layer of the superficial fascia (ie, Camper fascia) continues over the inguinal ligament to merge with the superficial fascia of the thigh and continues over the pubis and perineum as the superficial layer of the superficial perineal fascia.

The deep layer of the superficial fascia (ie, Scarpa fascia) is attached to the fascia lata just below the inguinal ligament. It continues over the pubis and perineum as the membranous layer (Colles fascia) of the superficial perineal fascia and continues over the penis as the superficial fascia of the penis and over the scrotum as the dartos fascia (tunica dartos), which contains smooth muscle.

The innermost component of the anterior abdominal wall comprises muscle and deep fascia, including the following:

  • External oblique muscle
  • Internal oblique muscle
  • Rectus abdominis
  • Transversus abdominis
  • Pyramidalis
  • Fascia transversalis
  • Peritoneum

However, the presence or absence of various layers is location-dependent (see the image below).[4]

Layers of abdomen, from interior to exterior: peri Layers of abdomen, from interior to exterior: peritoneum, extraperitoneal fascia, muscle, deep fascia, superficial fascia, subcutaneous tissue, and skin.

The anatomic planes of the abdominal wall are made up of multiple muscular and fascial layers that interdigitate and unite to form a sturdy, protective musculofascial layer that protects the visceral organs and provides strength and stability to the body's trunk. This anatomy varies with respect to the different topographic regions of the abdomen; thus, a firm understanding of these layers, their blood supply, and their innervation is essential to surgical management of the abdomen. (See Regions and Planes of the Abdomen.)

Complication prevention

Correct patient preparation, adherence to sterile technique, and the general principles of closure are outlined below. Known risk factors for abdominal wall dehiscence and hernia formation include the following[5, 6, 7] :

  • Wound infection
  • Obesity
  • Advanced age
  • Jaundice
  • Postoperative pulmonary complications
  • Emergency surgery
  • Immune suppression
  • Reoperation through previous incision
  • Ascites
  • Abdominal distention
  • Malnutrition
  • Cancer
  • Multiple comorbidities
  • Irradiated wound bed
  • Chemotherapy

Drains and ostomies should not be brought out through the main abdominal incision, because they tend to weaken it and may predispose the wound to infection and sepsis.[4]

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Contributor Information and Disclosures
Author

Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS, KHS Assistant Clinical Professor of Surgery and Family Practice, University of Texas Health Science Center; Adjunct Clinical Professor of Medicine and Nursing, University of Texas, Arlington; Chairman, Division of Trauma Surgery and Surgical Critical Care, Chief of Trauma Surgical Critical Care Unit, Trinity Mother Francis Health System; Brigadier General, Texas Medical Rangers, TXSG/MB

Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS, KHS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Legal Medicine, American College of Surgeons, American Society of Abdominal Surgeons, American Society of General Surgeons, American Society of Law, Medicine & Ethics, American Trauma Society, Association for Surgical Education, Association of Military Surgeons of the US, Chicago Medical Society, Illinois State Medical Society, International College of Surgeons, New York Academy of Sciences, Pan American Trauma Society, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Southeastern Surgical Congress, Texas Medical Association, Undersea and Hyperbaric Medical Society

Disclosure: Received honoraria from KCI for speaking and teaching; Partner received honoraria from PACIRA for speaking and teaching. for: Received honoraria from PACIRA for speaking and teaching.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Laura A Harmon, MD Resident Physician, Department of General Surgery, Scott and White Hospital

Laura A Harmon, MD is a member of the following medical societies: American College of Physicians, American College of Surgeons, American Medical Association, Texas Medical Association, Association of Women Surgeons

Disclosure: Nothing to disclose.

Russell Van Husen, MD, FACS Professor, Department of Surgery, Surgical Clerkship Director, Texas Tech University Health Sciences Center-Permian Basin

Russell Van Husen, MD, FACS is a member of the following medical societies: American College of Surgeons, Texas Surgical Society

Disclosure: Nothing to disclose.

References
  1. Rahbari NN, Knebel P, Diener MK, Seidlmayer C, Ridwelski K, Stöltzing H, et al. Current practice of abdominal wall closure in elective surgery - Is there any consensus?. BMC Surg. 2009 May 15. 9:8. [Medline]. [Full Text].

  2. Standring S, ed. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 41st ed. Philadelphia: Elsevier; 2015.

  3. Seymour NE, Bell RL. Abdominal Wall, Omentum, Mesentery, and Retroperitoneum. Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. Schwartz's Principles of Surgery. 9. United States: The McGraw-Hill Companies, Inc; 2010. 35. [Full Text].

  4. Burt Bryan M, Tavakkolizadeh Ali, Ferzoco Stephen J. Incisions, Closures, and Management of the Abdominal Wound. Zinner MJ, Ashley SW. Maingot's Abdominal Operations. 11. United States: McGraw-Hill Companies, Inc; 2007. 4. [Full Text].

  5. Franz MG. Wound Healing. Doherty GM. Current Diagnosis & Treatment: Surgery. 13. United States: McGraw-Hill Companies, Inc.; 2010. 6. [Full Text].

  6. Mäkelä JT, Kiviniemi H, Juvonen T, Laitinen S. Factors influencing wound dehiscence after midline laparotomy. Am J Surg. 1995 Oct. 170(4):387-90. [Medline].

  7. Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg. 2009 Nov. 144(11):1056-9. [Medline].

  8. Wissing J, van Vroonhoven TJ, Schattenkerk ME, Veen HF, Ponsen RJ, Jeekel J. Fascia closure after midline laparotomy: results of a randomized trial. Br J Surg. 1987 Aug. 74(8):738-41. [Medline].

  9. Corman ML, Veidenheimer MC, Coller JA. Controlled clinical trial of three suture materials for abdominal wall closure after bowl operations. Am J Surg. 1981 Apr. 141(4):510-13. [Medline].

  10. Ellis H, Heddle R. Does the peritoneum need to be closed at laparotomy?. Br J Surg. 1977 Oct. 64(10):733-6. [Medline].

  11. Goligher JC, Irvin TT, Johnston D, De Dombal FT, Hill GL, Horrocks JC. A controlled clinical trial of three methods of closure of laparotomy wounds. Br J Surg. 1975 Oct. 62(10):823-9. [Medline].

  12. van 't Riet M, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel J. Meta-analysis of techniques for closure of midline abdominal incisions. Br J Surg. 2002 Nov. 89(11):1350-6. [Medline].

  13. Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg. 2000 Mar. 231(3):436-42. [Medline]. [Full Text].

  14. Weiland DE, Bay RC, Del Sordi S. Choosing the best abdominal closure by meta-analysis. Am J Surg. 1998 Dec. 176(6):666-70. [Medline].

  15. Seiler CM, Bruckner T, Diener MK, Papyan A, Golcher H, Seidlmayer C. Interrupted or continuous slowly absorbable sutures for closure of primary elective midline abdominal incisions: a multicenter randomized trial (INSECT: ISRCTN24023541). Ann Surg. 2009 Apr. 249(4):576-82. [Medline].

  16. Zollinger RM, Ellison EC. Plate 8. Laparotomy, the Closure. Zollinger RM, Ellison EC. Zollinger's Atlas of Surgical Operations. 9. United States: McGraw-Hill Companies; 2011. [Full Text].

  17. Hussain SA. Closure of subcutaneous fat: a prospective randomized trial. Br J Surg. 1990 Jan. 77(1):107. [Medline].

  18. Zwart HJ, de Ruiter P. Subcuticular, continuous and mechanical skin closure: cosmetic results of a prospective randomized trial. Neth J Surg. 1989 Jun. 41(3):57-60. [Medline].

  19. Ranaboldo CJ, Rowe-Jones DC. Closure of laparotomy wounds: skin staples versus sutures. Br J Surg. 1992 Nov. 79(11):1172-3. [Medline].

  20. Duttaroy DD, Jitendra J, Duttaroy B, Bansal U, Dhameja P, Patel G. Management strategy for dirty abdominal incisions: primary or delayed primary closure? A randomized trial. Surg Infect (Larchmt). 2009 Apr. 10(2):129-36. [Medline].

  21. Rucinski J, Margolis M, Panagopoulos G, Wise L. Closure of the abdominal midline fascia: meta-analysis delineates the optimal technique. Am Surg. 2001 May. 67(5):421-6. [Medline].

  22. Grantcharov TP, Rosenberg J. Vertical compared with transverse incisions in abdominal surgery. Eur J Surg. 2001 Apr. 167(4):260-7. [Medline].

  23. Fassiadis N, Roidl M, Hennig M, South LM, Andrews SM. Randomized clinical trial of vertical or transverse laparotomy for abdominal aortic aneurysm repair. Br J Surg. 2005 Oct. 92(10):1208-11. [Medline].

  24. Brown SR, Goodfellow PB. Transverse verses midline incisions for abdominal surgery. Cochrane Database Syst Rev. 2005 Oct 19. CD005199. [Medline].

  25. Irvin TT, Stoddard CJ, Greaney MG, Duthie HL. Abdominal wound healing: a prospective clinical study. Br Med J. 1977 Aug 6. 2(6083):351-2. [Medline].

  26. Rink AD, Goldschmidt D, Dietrich J, Nagelschmidt M, Vestweber KH. Negative side-effects of retention sutures for abdominal wound closure. A prospective randomised study. Eur J Surg. 2000 Dec. 166(12):932-7. [Medline].

  27. Bruhin A, Ferreira F, Chariker M, Smith J, Runkel N. Systematic review and evidence based recommendations for the use of Negative Pressure Wound Therapy in the open abdomen. Int J Surg. 2014 Oct. 12(10):1105-14. [Medline].

  28. Robin-Lersundi A, Vega Ruiz V, López-Monclús J, Cruz Cidoncha A, Abella Alvarez A, Melero Montes D, et al. Temporary abdominal closure with polytetrafluoroethylene prosthetic mesh in critically ill non-trauma patients. Hernia. 2014 Jun 12. [Medline].

  29. Israelsson LA, Jonsson T. Incisional hernia after midline laparotomy: a prospective study. Eur J Surg. 1996 Feb. 162(2):125-9. [Medline].

 
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Abdominal anatomic landmarks.
Layers of abdomen, from interior to exterior: peritoneum, extraperitoneal fascia, muscle, deep fascia, superficial fascia, subcutaneous tissue, and skin.
Midline incision.
(A) Fascial closure. (B) Looping of 0 polydioxanone (PDS) at vertex. (C) Continuous suture. (D) Two PDS ends meeting in middle of incision, tied together, and cut.
Paramedian incision.
Transverse incision.
Kocher subcostal incision.
Rockey-Davis muscle-splitting incision.
Pfannenstiel incision.
Epidermis, dermis, and subcutis, showing hair follicle, sweat gland, and sebaceous gland. Image courtesy of Wikimedia Commons.
 
 
 
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