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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


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.


Indications and Contraindications

Indications for abdominal closure include the following:

  • Surgery on the abdominal cavity
  • Trauma

The main contraindication is abdominal compartment syndrome.


Technical Considerations


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]

Contributor Information and Disclosures

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.

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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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