Abdominal Wound Closure

Principles

1. Mass closure
2. Strong absorbable suture
3. Cosmetically sensitive skin closure.

The Procedure

1. Prepare

-
replace viscera
- +/- drains
- ensure adequate muscle relaxation: needs to be tension-free. insist on it.
- place a sponge or fish under the fascia to protect the viscera if tight.
- get a 1 loop PDS or 1 Maxon.

2. Start superiorly
- start a few mm above the defect to take tension off suture / prevent hernia.
- loop through or knot with six square-knots.

3. Continuous run
1-2cm apart, 1-2cm from fascial edges.
- pull after each suture
- ensure uniform tension and closure.
- after every few stitches, put fingers in under-surface of wound to ensure absence of gaps in fascia / verify no viscera are caught.

4. Second suture from inferior wound margin
- bring sutures up to middle of wound and tie together
- six square knots.
- bury it.

5. Palpate length for fascial defects
Anything that allows a pinkie finger through should be securely closed.

6. Close.


Questions

Mass closure or just fascia
Prefer mass closure.
Don't be shy to include muscle if its sitting there; strength is in mass layering.

Which suture?
Early experience with chromic gut sutures and dehiscence / herniation led to the mistaken supposition that only permanent sutures are appropriate.
But permanents are associated with higher incidence (10%) of suture fistulas and scar pain.
A large number of clinical trials tell us that delayed-degredation absorbable sutures are best.
- PDS and maxon
- no increase in hernia or dehiscence.
- lower incidence of suture fistulas, granulomas and scar pain.
Total suture length should theoretically be 4 times wound length.

Continuous or interrupted?
Continuous is faster by 15 minutes on average.
Incidence of dehiscence and incisional hernia is similar.
Uneven distribution of individual sutures can lead to focal areas of ischaemia.

Why not close peritoneum?
It is a waste of time.
It will recompose within 48hrs.
May promote adhesions.

Do I close Scarpa's? Do a fat stitch?
No. No role in strength or cosmesis.
Biologically irrelevant to do so.

The patient has ascites.
I use a running locked 3-0 nylon skin suture to prevent leakage.

Suture breakage occurred, what did I do wrong?
Use a suture with adequate strength and absorption time.
Do not touch the suture with metal instruments.

The knot unraveled or slipped, what did I do wrong?
Leave long tails and do six square knots.
- this allows maximal holding capacity.

Dehiscence occurred, what did I do wrong?
Sutures tearing through tissue is commonest reason.
Sutures may have been pulled too tight leading to ischaemia.
Typically patients have risk factors eg age, steroids, smoking.
Too small bites (<1-2cm) can contribute.
- remember when the anaesthetic wears off / abdo swells, the tension will increase.
- just use enough force to bring fascial edges together.

The abdomen is too tight, what if they get compartment syndrome?
See managing the open abdomen.

Deitch.