A prospective study of single layer abdominal wall closure in the tertiary care hospital
Keywords:Abdominal wall closure, Mass closure, Wound infection, Wound dehiscence, Sinus formation, Continuous closure, Incisional hernia
Background: Despite advances in surgical techniques and material, abdominal wound closure remains challenging. Most abdominal wall incisions are either midline or paramedian. The value of a particular method of closing is determined by the incidence of early and late wound complications. The best abdominal wound closure technique should be, fast, easy, safe and cost effective. It should also prevent or minimize the early and late complications. This study addresses the midline single-layer closure of the abdominal wound.
Methods: The purpose of this study is to evaluate the single layer midline abdominal wound closure. The early and late complications associated with this method are studied, and relevant literature reviewed. The study period is from May 2016 to May 2018, i.e. 24 months. The study group comprises of 52 patients, admitted in the department of surgery SBRKM Government medical college Jagdalpur. In all of them, the midline incisions closed in a single layer by a non-absorbable continuous suture. The skin closed separately. The mean age of the patient is 46.5 years. The male to female ratio is 3:1. Emergency laparotomy done in 35 cases and 17 (38.4%) underwent elective surgeries.
Results: In this series 20 (38.4%) patients had wound infection. 10 (19.2%) patients had wound gaping. There was no incisional hernia in six months follow-up.
Conclusions: Single layer abdominal wall closure has a definite advantage. It is fast, easy and cost-effective. Continuous running suture with non-absorbable material provides enough strength during healing and is better than interrupted sutures. The incidence of early and late complications is also significantly less. The results are comparable to many meta-analyses and RCT did in this field.
Knaebel HP, Koch M, Sauerland S, Diener MK, Bucher MW, Seiler CM. INSECT Study Centre of the German Surgical Society. Interrupted or continuous slowly absorbable sutures, Multi-centre randomized trial to evaluate abdominal closure technique INSECT-Trial. BMC Surg. 2005;5:3.
Ceydeli A, Rucinski J, Wise L. Finding the best abdominal closure: an evidenced-based review of the literature. Curr Surg. 2005;62:220-5.
Challa V, Dhar A, Anand S, Srivastava A. Abdominal wound dehiscence: the science and art of its occurrence and prevention. In: Gupta RL, eds. Recent advances in surgery-11. 1st ed. New Delhi: Jaypee Brothers; 2009: 225-250.
Weiland DE, Bay RC, Del Sordi S. Choosing the best abdominal closure by meta-analysis. Am J Surg. 1998;176:666-70.
Rucinski J, Margolis M, Panagopoulos G, Wise L. Closure of the abdominal midline fascia: meta-analysis delineates the optimal technique. Am Surg. 2001;67:421-6.
Hodgson N C, Malthaner R A, Ostbye T. The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg. 2000;23:436-42.
Single layer abdominal wall closure. Available at http://www.google.com/ single layer abdominal wall closure/images. Accessed on 17 February 2019.
Justinger C, Slotta JE, Ningel S, Grӧber S, Kollmar O, Schilling MK. Surgical-site infection after abdominal wall closure with triclosan-impregnated polydioxanone sutures: Results of a randomized clinical pathway facilitated trial. Surgery. 2013;154(3):589-95.
Elkheir IS, Idris SA. Evaluation of abdominal wall closure technique in emergency laparotomies at a peripheral hospital. Sch J App Med Sci. 2014;2(5B):1591-5.
Chowdhury SK, Choudhury JD. Mass closure versus layered closure of the abdominal wound. J. Indian Med Assoc. 1994;92(7):229-32.
Togart RE. The suturing of abdominal incisions. Ar J Surg. 1967;54:124-27.
Idris SA, Ali AQ, Shalayel MH, Idris TA, Alegail IMA. Design of a multi-centre study to evaluate frequency and risk factors for wound dehiscence/burst abdomen: a study of 1683 major midline laparotomies. Sudan Med Monitor. 2010;5(4):185-91.
Rajneesh Kumar, Ankur Hastir. Prospective clinical study: Mass closure versus layer closure of the abdominal wall. IJSM. 2017;3(4):228-33.
Ellis H, Heddle R. Does the peritoneum need to be closed at laparotomy? Br J Surg. 1977;64(10):733-6.
Shukla HS, Sandeep Kumar, Mishra MC, Naithan YP. Burst abdomen and suture material: A comparison of abdominal wound closure with monofilament nylon and chromic catgut. Ind J Surg 981;43:487-91.
Singh A, Singh S, Dhaliwal US, Singh S. Technique of abdominal wall closure. Ind J Sur. 1981;11:785-9.
Jones TE, Newell ET Jr, Brubaker RE. The use of alloy steel wire in the closure of abdominal wounds. Surg Gynecol Obstet. 1941;72:1056-9.
Dudley HAF. Layered and mass closure of the abdominal wall—a theoretical and experimental analysis. Br J Surg. 1970;57:664-7.
Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. Br Med J. 1982;284:931-3.
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;89:1350-56.
Diener MK, Voss S, Jensen K, Büchler MW, Seiler CM. Elective midline laparotomy closure: The INLINE systematic review and meta-analysis. Ann Surg. 2010;251:843-56.
Van’t Riet M, de Vos Van Steenwijk PJ, Bonjer HJ. Incisional hernia after repair of wound dehiscence: Incidence and risk factors. Am Surg. 2004;70:281-6.
Mingoli A, Puggioni A, Sgarzini G, Luciani G, Corzani F, Ciccarone F, et al. Incidence of incisional hernia following emergency abdominal surgery. Ital J Gastroenterol Hepatol. 1999;31:449-53.
Gupta H, Srivastava A, Menon G R, Agrawal C S, Chumber S, Kumar S. Comparison of interrupted versus continuous closure in abdominal wound repair : a meta-analysis of 23 trials. Asian J Surg. 2008;31:104-14.
O’Dwyer PJ, Courtney CA. Factors involved in abdominal wall closure and subsequent incisional hernia. Surgeon. 2003;1:17–22.
[Israelsson L, Millbourn D. Prevention of incisional hernias: how to close a midline incision. Surg Clin North Am. 2013;93:1027–40.
Jenkins TPN. The burst abdominal wound: a mechanical approach. Br J Surg. 1976;63:873-6.
Israelsson LA. Abdominal incision closure: small but important bites. Lancet. 2015;15.
Israelsson LA, Jonsson T. Suture length to wound length ratio and healing of midline laparotomy incisions. Br J Surg. 1993;80:1284–6.
Millbourn D. Closure of Midline Abdominal Incisions with Small Stitches. Studies on Wound Complications and Health Economy [Doctoral thesis]. Umea, Sweden: Umea University; 2012.
Millbourn D, Cengiz Y, Israelsson LA. Risk factors for wound complications in midline abdominal incisions related to the size of stitches. Hernia. 2011;15:261–6.
Mayer AD, Ausobsky JR, Evans M. Compression suture of the abdominal wall: a controlled trial in 302 major laparotomies. Br J Surg. 1981;68:632–4.
Varshney S, Manek P, Johnson CD. Six-fold suture: wound length ratio for abdominal closure. Ann R Coll Surg Engl. 1999;81:333-6.
van Ramshorst GH, Nieuwenhuizen J, Hop WC, Arends P, Boom J, Jeekel J, et al. Abdominal wound dehiscence in adults: development and validation of a risk model. World J Surg. 2010;34:20-7.
Israelsson LA, Jonsson T. Incisional hernia after midline laparotomy: a prospective study. Eur J Surg. 1996;162:125-9.
Israelsson L A, Jonsson T. Overweight and healing of midline incisions: the importance of suture technique. Eur J Surg. 1997;163:175-80.