Abdominal Closure Technique

Updated: Jul 21, 2017
  • Author: Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS, KHS; Chief Editor: Kurt E Roberts, MD  more...
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Technique

Closure of Abdomen

Midline laparotomy closure

A midline incision (see the image below) is the most commonly used route of access to the abdominal cavity [1] ; for this reason, the ensuing discussion of abdominal closure focuses on this incision. The general technique can be applied to other abdominal incisions (some of which are discussed more briefly below); however, it must be kept in mind that the actual layers composing the abdominal wall vary, depending on the location of the incision.

Midline incision. Midline incision.

Peritoneal closure

A number of randomized, controlled trials have showed no benefit to peritoneal closure; thus, refraining from closing the peritoneum is a commonly accepted practice. [10] Some surgeons believe that closure of the peritoneum reduces adhesions between the abdominal contents and the suture line; however, at this time, there is only limited scientific evidence for this belief.

Fascial closure

The technique of fascial closure is highly variable among surgeons; however, the various approaches may be grouped into two primary methods as follows [1] :

  • Layered closure
  • Mass closure

Layered closure is sequential closure of each fascial layer individually. The primary advantage of this method is that multiple suture strands exist, so that if a suture breaks, the incision is held intact by the remaining sutures.

Mass closure is continuous fascial closure with a single suture. This method allows even distribution of tension across the entire length of the suture, resulting in minimization of tissue strangulation. The goal is approximation of tissue edges to allow scar formation. Excessive tension leads to tissue necrosis and eventual failure of the closure. [5]

The theoretical disadvantage of mass closure is that a single suture is responsible for maintaining the integrity of the closure. The benefits of mass closure include decreased cost and decreased operating time. There is no evidence that mass closure is associated with an increased incidence of hernia formation or wound dehiscence. [11]

Numerous trials and meta-analyses found continuous mass closure to be the superior closure method. [1, 12, 13, 14] In the INSECT trial, which compared three methods of abdominal wall closure in 625 patients, Seiler et al found no significant benefit related to any specific closure method. [15] The results of this study underscore the necessity of carrying out further randomized, controlled trials to facilitate the development of a consensus on the best method of abdominal closure.

In continuous fascial closure, two Kocher clamps are clamped to the fascial layer midway through the incision and then retracted by the assistant. Often, having the assistant cross the Kochers allows for better visualization for the surgeon. Suture material is chosen. For most closures, the authors prefer to use looped 0 polydioxanone (PDS) suture.

Starting at the superior or inferior aspect of the incision, the looped PDS is passed through the vertex of the fascia (see the image below). The needle is then passed through the loop locking the stitch in order to anchor the knot or tied if it is not a looped suture. The suture is subsequently run in a continuous fashion, with each bite including tissue from the linea alba, the rectus sheath, and muscle itself if necessary to get an adequate bite.

(A) Fascial closure. (B) Looping of 0 polydioxanon (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.

When rectus muscle is incorporated, using absorbable suture and a loose closure in order to decrease postoperative pain and tissue necrosis is important. The assistant following the continuous closure should apply sufficient tension to approximate the tissue without strangulating it. Suture is run in 1-cm intervals (maximally), with at least a 1-cm bite of fascia in each throw.

A malleable retractor can be placed under the suture line to ensure that the underlying structures are not incorporated into the closure. When the center of the incision has been reached, the same method is used on the opposite end of the incision. When the two ends are within 1 cm of each other, they are tied with six to 10 knots. [7, 16, 4, 3]

Subcutaneous closure

The vascular supply to the subcutaneous tissue of the abdominal wall is limited, increasing susceptibility to soft-tissue infection. [4] The purpose of subcutaneous closure is to close any potential space, reducing the area for seroma accumulation.

Although in theory this may stand, a paucity of data exists regarding the significance of closing the subcutaneous fat. Only one prospective randomized controlled trial has been conducted to determine the value of this practice, and the authors found no significant differences in complications between closure and nonclosure. [17] Subcutaneous closure may be accomplished with absorbable suture in an interrupted or continuous fashion.

Skin closure

The skin can be closed using various methods [1] ; however, a few consensus techniques are generally used. The two primary methods of skin closure are with suture or staples. Suture closure is generally performed with 3-0 or 4-0 absorbable suture in a running subcuticular fashion or with nylon running or interrupted transdermal suture. Staple closure is a viable alternative to suturing the skin. In a study comparing scar cosmesis at 6 months, no difference in appearance existed in patients with suture versus staple skin closure. [18, 19]

Finally, class III (contaminated) and IV (dirty) wounds should not be closed and should be left open to heal by secondary intention, [5, 20] with the possibility of delayed primary closure, depending on the state of the wound bed as it progresses. Adhesive tapes and synthetic glues can be used in addition to sutures and staples to reinforce closure.

Other closures

Paramedian incision

Paramedian closure is similar in technique to midline closure; however, it is necessary to ensure reapproximation of the anterior and posterior rectus sheath when above the arcuate line (see the image below).

Paramedian incision. Paramedian incision.

Transverse incision

A transverse incision traverses the anterior and posterior rectus sheath when above the arcuate line; thus, it is necessary to repair both, together or separately. Transverse incisions are felt to have more intrinsic strength than their vertical counterparts because the abdominal fascia fibers are transversely oriented, causing sutures to be placed perpendicular to the fiber direction (see the image below). [21, 22, 4] Incisional hernia is two to five times more common in vertical incisions than in transverse incisions. [23, 24]

Transverse incision. Transverse incision.

Kocher subcostal incision

Closure of a Kocher subcostal incision requires closure of the anterior and posterior rectus sheaths. This can be accomplished as either a layered or a mass closure (see the image below).

Kocher subcostal incision. Kocher subcostal incision.

Rockey-Davis muscle-splitting incision

With a Rockey-Davis incision, some benefit to closing the peritoneum has been shown. [4] Continuous absorbable suture may be used. The internal oblique and transversalis muscles should be subsequently closed in a single layer with interrupted or running suture. The external oblique aponeurosis is then closed with an interrupted or continuous absorbable suture (see the image below).

Rockey-Davis muscle-splitting incision. Rockey-Davis muscle-splitting incision.

Pfannenstiel incision

The Pfannenstiel incision is a transverse suprapubic incision, placed approximately 5 cm superior to the pubic symphysis (see the image below).

Pfannenstiel incision. Pfannenstiel incision.

Additional considerations

Retention closure

Guidelines for the prophylactic use of retention sutures are imprecise at best. The only controlled study that was performed showed no positive effect in the use of prophylactic retention sutures; in fact, patients receiving retention sutures had a greater amount of postoperative pain. [25, 26] Nevertheless, these sutures may be useful and are often used in the following patients [16, 25] :

  • Those with increased tension on the incision
  • Those who are severely malnourished
  • Those who are immunocompromised
  • Those with previous fascial defect
  • Those with massive contamination

Retention sutures are placed outside of the primary suture line through all layers of the abdominal wall, including the skin; a large-bore suture material, usually nonabsorbable, is employed. The effect is to alleviate the tension on the primary suture line. Various bridges, bumps, and bolsters are available to alleviate some of the tension the retention suture places on the skin surface. These sutures should be removed as soon as the danger of increased abdominal pressure has passed.

Temporary abdominal closure

Occasionally, circumstances may dictate that permanent closure of the abdomen is contraindicated. Examples of such circumstances include the following:

  • Early planned reexploration of the peritoneal cavity
  • Unacceptable abdominal wall tension with conventional closure
  • Increased intra-abdominal pressure
  • Intraoperative instability necessitating a rapid temporary closure

Various methods and materials are used to accomplish temporary closure (eg, sterile intravenous bag, fish-shaped viscera retainer, or abdominal vacuum pack). Evidence-based recommendations have been developed for the use of negative-pressure wound therapy in the setting of the open abdomen. [27] Some have reported good results with the use of expanded polytetrafluoroethylene mesh for temporary abdominal closure in critically ill nontrauma patients. [28]

Regardless of the method used for temporary abdominal closure, the primary aims must be to protect the abdominal viscera and to maintain sterility. (For more information, see Temporary Abdominal Closure Techniques.)

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Postoperative Care

Staple or suture removal should occur at approximately 7-14 days. Sterile dressings applied during surgery are generally removed on the second to seventh postoperative day per surgeon preference. Saturated dressings should be changed when noted.

Patients should be cautioned to avoid lifting, pushing, or pulling anything heavier than 10 lb and generally to avoid any type of straining (increased abdominal pressure) as much as possible for 4-6 weeks after surgery. They should be educated on signs and symptoms of incisional hernia and should be encouraged to contact the surgeon postoperatively in the presence of any of the following (any of which may portend postoperative complications):

  • Purulent drainage
  • Protracted serosanguineous drainage
  • Erythema
  • Uncontrolled pain
  • Bulging at the incision
  • Protracted nausea or vomiting
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Complications

Short-term complications include wound infection and dehiscence. The most commonly documented postoperative complication is incisional hernia, which occurs in approximately 9-20% of patients after an abdominal closure. [1, 15, 29] Long-term monitoring after the postoperative period is not considered necessary.

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