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.
Indications and Contraindications
Indications for abdominal closure include the following:
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Surgery on the abdominal cavity
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Trauma
The main contraindication is abdominal compartment syndrome.
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]
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:
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The epidermis, which provides waterproofing and serves as a barrier to the environment
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The dermis, from which the appendages of the skin originate (e.g. mammary glands)
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The hypodermis, which contains the subcutaneous adipose layer.
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:
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A thin, fatty superficial layer (tela subcutanea), referred to as the Camper fascia
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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:
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External oblique muscle
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Internal oblique muscle
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Rectus abdominis
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Transversus abdominis
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Pyramidalis
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Fascia transversalis
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Peritoneum
However, the presence or absence of various layers is location-dependent (see the image below). [4]
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] :
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Wound infection
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Obesity
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Advanced age
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Jaundice
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Postoperative pulmonary complications
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Emergency surgery
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Immune suppression
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Reoperation through previous incision
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Ascites
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Abdominal distention
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Malnutrition
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Cancer
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Multiple comorbidities
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Irradiated wound bed
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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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Abdominal anatomic landmarks.
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Layers of abdomen, from interior to exterior: peritoneum, extraperitoneal fascia, muscle, deep fascia, superficial fascia, subcutaneous tissue, and skin.
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Midline incision.
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(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.
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Paramedian incision.
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Transverse incision.
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Kocher subcostal incision.
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Rockey-Davis muscle-splitting incision.
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Pfannenstiel incision.
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Epidermis, dermis, and subcutis, showing hair follicle, sweat gland, and sebaceous gland. Image courtesy of Wikimedia Commons.
