Abdominal Closure

Updated: Jul 24, 2023
  • Author: Luis G Fernández, MD, KHS, KCOEG, FACS, FASAS, FCCP, FCCM, FICS; Chief Editor: Kurt E Roberts, MD  more...
  • Print


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]  Guidelines for the management of the open abdomen in the surgical setting have been published by a number of authorities, including the World Society for Emergency Surgery (WSES), [2, 3] the Eastern Association for the Study of Trauma (EAST), [4] the Western Trauma Association (WTA), [5] and the European Hernia Sociwety (EHS). [6]

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. Guidelines for addressing abdominal compartment syndrome have been published by the World Society of the Abdominal Compartment Syndrome (WSACS) [7] and others. [8]


Technical Considerations


The anterior abdominal wall is clearly defined by anatomic borders. [9] The superior border is marked by the costal margins, whereas the inferior border is the pubic symphysis (see the image below). [10]

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 (from 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). [11]

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 [12, 13, 14] :

  • 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. [11]