[Full text] Abdominal wound closure: current perspectives | OAS
the various abdominal incisions, sutures and closure methods used in muscles at their insertion on the pubic symphysis and retraction There is no difference in wound infection, . Relationship between the rise in tension between sutures. In abdominal surgery, the routinely used incisions include the Lanz incision, they are removed may vary depending on the site and indication of the closure. Due to its continuation with Langer's lines, the Lanz incision produces much . and does not create any doctor-patient relationship, and should not be used as a . Incision and closure of the abdominal wall is one of the most frequently The fibers of the internal oblique fan out from their origin on the anterior two thirds of the Richardson AC, Lyon JB, Grahm EE: Abdominal hysterectomy: Relationship.
The next task is isolation of the fascial edges and freshening of them if the size of the defect will allow primary closure. Several satisfactory approaches may be used, including Smead-Jones closure, mass closure, and overlapping of fascia pants-and-vest closure.
Theoretical considerations would point to the selection of a permanent monofilament suture. Appropriate selections would include 0 or 1 Prolene, nylon, or other permanent sutures. Wire, although important historically, has no advantages over the newer, nonreactive, monofilament sutures. Large defects may need to be closed with the use of prosthetic mesh e. Other indications for the use of a graft would include repair of a recurrent hernia, grossly attenuated tissues, and fascia that is too weak for adequate repair.
Most commonly, the graft is placed anterior to the peritoneum and transversalis fascia, and posterior to the rectus muscles. The anterior rectus sheath is approximated as closely as possible. In some instances, dissection between the hernial sac and the fascia may prove exceedingly difficult or impossible, in which case the Marlex mesh may be anchored to the anterior aspect of the rectus muscles and, again, the anterior rectus sheath would be approximated as closely as possible.
This location of the dissection is not as satisfactory, however, in that the already increased risk of wound infection due to the presertce of the graft is further increased by its proximity to subcutaneous tissue and skin. Postoperatively, predisposing conditions for wound failure should be addressed fastidiously, including control of nausea and vomiting, aggressive and early treatment of ileus and pulmonary complications, and attention to adequate nutrition.
Clean incisions are defined as those initiated on prepared skin without entering a contaminated viscus or encountering infection. Clean contaminated wounds are the same as clean incisions, but a contaminated viscus, such as the vagina that has been prepared, is entered without gross spillage.
A wound is classified as contaminated if an infected genitourinary tract is entered or gross gastrointestinal spillage occurs.
A dirty wound is one that occurs when pus from an abscess is spilled intraoperatively, or previously ruptured bowel is present. The rate of infection varies not only according to increasing severity, but also according to patient socioeconomic status, surgical technique, operating time, obesity, age, and sex.
Infection is often initiated by direct inoculum of bacteria into the wound from the patient's or surgeon's skin and is potentiated by the presence of necrotic tissue.
Proper preparation of both is necessary to ensure the lowest possible rate of infection.
Abdominal Incisions in General Surgery
If hair removal is required, clipping immediately before surgery is preferable to shaving, and either is preferable to shaving the evening before, which has been associated with higher rates of wound infection. After adequate skin antisepsis, multiple intraoperative factors come to bear. Since devitalized tissue offers increased opportunity for poor wound healing and infection, every effort should be made to minimize infection's presence, including meticulous incisional technique with a stainless steel scalpel and precise hemostasis with cautery or fine, nonreactive suture.
These same considerations hold true while operating i. Mass closure of the abdominal wall with continuous mortoff-lament suture would seem preferable in theory, although clinical studies have not yet supported this view other considerations, such as decreased risk of dehiscence, may suggest this combination. Even in clean wounds, however, irrigation removes fragments of free tissue and fat globules from separated adipose cells that will prolong inflammation and delay repair. Drains may be placed in the subcutaneous tissue when diffuse oozing resistant to hemostatic efforts is present.
Soft drains, such as the Penrose, have been replaced by closed suction drains brought out through a separate stab wound with improved results i. A trial of closed, subcutaneous drains alternately placed in suction and irrigated every 8 hours for 3 days with an antibiotic solution showed possible benefit in grossly infected wounds, but probably are not justified in clean contaminated wounds. With delayed primary closure, Verrier and colleagues showed a decrease in infection rates in contaminated wounds from A delayed primary closure is one in which the subcutaneous tissue and skin are not closed at the time of initial surgery, but covered by a: Sutures can be placed during the original operation and left to be tied later, or the wound can be sutured under local anesthesia in the patient's room.
During this time, the body's immune response has had a chance to clean the wound, and microscopic capillary formation has begun, creating excellent oxygenation of the wound edge. Closure of the wound on the fourth day greatly decreases the chance of infection, allowing patients to avoid the potentially serious problem of sepsis associated with wound infection.
Abdominal incisions and their closure.
This approach is most helpful during treatment of pelvic infection, especially in patients with poor healing characteristics. In these patients, delayed primary closure has resulted in an extremely low complication rate. Wound infections may present in several ways, depending on the extent of the infection, host resistance, and the etiologic microorganisms. Early, mild infections may be associated with only scant exudate from the incision and, upon exploration of the wound, poor healing.
Hemolytic streptococcal organisms may cause erysipelas, an infection marked by a rapidly extending erythematous cutaneous border. Deeper infections may be found during the process of evaluation for postoperative fever and may additionally be associated with erythema, induration of skin and subcutaneous tissues or, possibly, fluctuation.
One must be alert for the rare but devastating signs of necrotizing infections, including brawny edema, cutaneous sensory loss, and obvious necrosis. Patients with necrotizing fasciitis need prompt and aggressive debridement under general anesthesia to avoid death. In cases of contaminated and infected wounds, consideration should be given to delayed primary or secondary closure.
In these situations characteristics of each case should be taken into account, such as the amount of infected tissue left behind, nutritional status of the patient, presence of diabetes, malignancy, or obesity--factors associated with poor wound-healing. When the decision is made to proceed with delayed closure, retention sutures may be placed.
Permanent, monofilament suture would be the best choice. Cultures, of course, should be obtained.
Postoperatively, the incision can be left covered until the fourth day, at which time the attending physician assesses whether the wound is clean enough to close. If there is any infected or necrotic tissue, then regular dressing changes and debridement can be commenced postoperatively until the wound is ready to close. Delayed primary closure may be done using one of several techniques: In the high-risk patient, when coaptation of the wound is difficult, or if the wound does not appear clean in a reasonable period of time, the wound may be allowed to heal by secondary intention.
Perhaps surprisingly, the cosmetic result in such a case is equal to that of delayed primary closure. Careful instruction prior to discharge and follow-up by a visiting nurse will be very helpful to the patient and her family.
Treatment for superficial and minor infections may consist only of application of moist heat. Erysipelas usually responds rapidly to such local treatment with the addition of penicillin. When discharge from the wound is prominent, or fluctuation is thought to be present, the wound should be explored and all areas presenting little resistance to separation opened fully.
Cultures should be obtained, appropriate antibiotics should be started and the wound should be debrided and packed. Secondary closure may be desirable and possible if the wound reveals healthy granulation tissue 3 to 5 days after opening. Again, the patient may be sent home with follow-up by a visiting nurse.
Nerve Injury Nerve injury associated with abdominal incision can pose a distressing, and often unexpected ending to an otherwise successful operation.
Abdominal Incisions - Lanz - Kocher - Midline - TeachMeSurgery
Two types of injury occur. First, the incision and closure may transect or damage the nerves of the abdominal wall. Second, a retractor used during the operation can cause injury to nerves on the posterior body wall. The most serious nerve damage is that to the fiemoral nerve, because of the loss of innervation to the quadriceps muscle in the leg and loss of the ability to extent the leg at the knee joint.
This damage is usually caused by the blades of a self-retaining retractor. The lateral blades of these instruments can press upon the nerve as it emerges from the lateral border of the psoas muscle before passing under the inguinal ligament Fig.
Damage to the nerve should be suspected with loss of sensation in the anteromedial thigh, diminished knee jerk, and weakness of extension of the knee, which creates a specific problem climbing stairs. Retractor inductor nerve injury. Fernoral nerve impairment subsequent to hysterectomy. Am J Obstet Gynecol Although this situation creates no motor abnormality, the loss of sensation in the upper medial thigh and labium majus can be quite distressing. The risk of these complications is higher in thin individuals and when retractors with deep blades have been used.
Simply placing a laparotomy pack over the retractor blades will not diminish the amount of force that impinges on the nerve, and a space between the blade and nerve should always be confirmed, remembering that some downward pressure will unavoidably be placed on the retractor during surgery. Although the nerve itself can not readily be palpated in the operating room, the psoas muscle can be.
It lies lateral to the external iliac artery, and identification of the vessel by its pulse will lead the examining finger laterally to the muscle.
An additional type of injury that can occur is entrapment of the iliohypogastric or ilioinguinal nerves in the lateral closure of a transverse incision Fig. These nerves lie medial to the anterior superior iliac spine, first, between the layers of the transversus abdominus and internal oblique muscles, and then, more medially, come to lie between the internal oblique and external oblique.
Although most surgeons fail to notice them during the lateral extension of a transverse incision, they are sometimes visible in the lateral aspects of the wound and should be looked for and avoided when seen. Several randomized studies have compared midline incisions with transverse incisions. Greenall et al 12 randomized patients to either the midline or transverse incision groups and reported no differences in postoperative hernias between the two groups.
Seiler et al 13 randomized patients to midline or transverse incisions in major elective abdominal surgery and also reported no difference in mortality, pulmonary complications, length of hospital stay, and incisional hernia formation at 1 year. Conversely, Halm et al 14 reported that midline incisions resulted in significantly more incisional hernias. A Cochrane review concluded that there was no difference in incisional hernia rates or other complications among patients undergoing midline compared with transverse incisions.
Nonabsorbable, slowly absorbable, and rapidly absorbable sutures can be used for fascial closure. These sutures can be either monofilament or multifilament. Multifilament sutures have greater tensile strength for a given size; 16 however, they cause greater tissue reactivity and are more prone to infection and sinus formation.
Several randomized trials and meta-analyses have examined continuous versus interrupted closures. Continuous closure is typically recommended over interrupted closure, since it is faster and less costly. Dehiscence, wound complication rates, and incisional hernia rates are similar between interrupted and continuous closures. There is a theoretical benefit of even distribution of tension across the entire incision with continuous sutures.
Self-locking knots are smaller and less likely to slip than conventional knots. The analysis also showed that polydioxanone PDSunlike other more rapidly absorbable sutures, did not significantly increase the risk of hernia.
Similar outcomes were observed with continuous and interrupted sutures, but continuous sutures took less time to insert.
There is little literature regarding the optimal closure technique of emergent laparotomies with significant contamination. A randomized trial of patients undergoing laparotomy for peritonitis by Agrawal et al 27 showed no significant difference in incisional hernia formation between the absorbable and nonabsorbable suture.
However, the study showed significantly more sinus formation with the use of nonabsorbable sutures. The presumed strength benefits of passing the suture through the skin and the entire abdominal wall have not borne out. They are associated with increased postoperative pain and do not decrease the incidence of fascial dehiscence.
One factor that affects the suture-to-wound-length ratio is the size and distance between the fascial bites.
Abdominal incisions and their closure.
Some have questioned the traditional teaching that fascial bites should be 1 cm from the fascial edges and have 1 cm advances. Several studies from Israelsson et al have reported that a 4: Two recent randomized trials by Millbourn et al 36 and Deerenberg et al 38 comparing fascial closure using smaller bites 5—8 mm to larger bites 10 mm demonstrated decreased incisional hernias when smaller fascial bites were used.
Other closure techniques that affect the suture-to-wound ratio are mass closure versus closure of the aponeurosis only and the appropriate amount of tension to apply to the closing suture. A systematic review by Ceydeli et al concluded that mass closure should be used; 41 however, an animal study in pigs showed more wound edge separation with mass closure compared with aponeurosis only.
One study by Mayer et al revealed that greater tension on the suture line increased the rate of wound infection compared with a lower suture line tension. One study found no change in hernia formation when a sized suture was used. There has been little research comparing fascial closure with double-loop suture compared with nonlooped suture.
One study demonstrated an increased rate of pulmonary complications and death with double-loop suture. Another prospective study found decreased rate of wound infection and dehiscence with the use of looped suture compared to nonlooped suture.
A single-layer mass closure technique includes all layers of the abdominal wall except the skin. These risks include obesity, advanced age, male sex, smoking, diabetes mellitus, malnutrition, malignancy, and steroid use. Studies reporting the effect of weight loss and smoking cessation on the reduction of incisional hernia formation are lacking and likely reflect the difficulty of behavior modification. Compared with patients undergoing laparotomy for aortoiliac occlusive disease, patients undergoing AAA repair have more than a threefold increase in the rate of incisional hernia formation.
Distention increases tension along the suture line, causing higher risk of suture breaking, knot slipping, and suture cutting through the fascia and soft tissue. Loosening of the suture and separation of the fascial edges can lead to incisional hernia formation.