Closure of midline abdominal wounds: should we all do it the same?

Slawik S and Kiff ES

Keywords: laparotomy, wound closure, sutures

Abstract

Introduction

The seemingly routine closure of a midline abdominal wound still appears to involve many different methods and materials.

Materials and Methods

A questionnaire was sent to one hundred and twenty five surgeons in one region. They were asked to describe their methods and materials used to close a single midline abdominal incision. Seventy-one replied. Their replies were checked with their theatre sister.

Results

Four of seventy-one surgeons closed the peritoneum separately.

The linea alba was closed by all surgeons but using twenty-nine different sutures: six different lengths and six different types, and twenty-four different needles : nine different sizes and twelve different types.

Two surgeons closed the subcutaneous layer.

The 71 surgeons closed the skin using twenty-four different sutures: four different length and nine different types, with eleven different needles: ten different sizes and five different types. Six different types of staples were used.

Discussion

This surprising variety does have cost and storage space implications. There is enough evidence in the literature to agree on one method to close a midline abdominal wound. Suture material should not be needed in such variety. The closure of a midline abdominal wound could be standardised so that all surgeons close the same wound the same way with the same materials.

Introduction

The midline incision has been the most common incision used for laparotomy for many years. One might expect that its routine closure would be standardised. However, a series of registrars were observed closing a midline abdominal wound satisfactorily but using a variety of different materials. Furthermore a visit to any theatre storeroom will illustrate the enormous range of suture materials stocked in order to cater for this variety.

We wished to examine the range of materials used to close identical wounds by a larger group of surgeons.

Materials and Methods

A questionnaire was sent to one hundred and twenty five Consultant Surgeons within the North West Region. They were asked to describe the materials and methods they used to close a single midline abdominal incision as used for a laparotomy.

Replies were received from 71 surgeons. These included General Surgeons, GI Surgeons, Urologists, Gynaecologists, Vascular Surgeons, Breast Surgeons and anyone else who was on the on call rota and might be called upon to perform a laparotomy. Their replies were confirmed by checking with the theatre sister most closely involved with each surgeon.

This enabled us to accurately identify the particular materials used.

Results

There are four layers that one might close in a midline abdominal wound. The results are presented for each of these layers.

Peritoneum : Four of the seventy-one surgeons routinely closed the peritoneum using an absorbable suture.

Linea alba : All Seventy-one surgeons used twenty-nine different sutures: six different lengths and six different types, and twenty-four different needles: nine different sizes and twelve different types, to close this layer.

Subcutaneous layer : Two surgeons routinely closed this layer with interrupted absorbable sutures.

Skin: Seventy-one surgeons used twenty-four different sutures: four different lengths and nine different types, with eleven different needles: ten different sizes and five different types. Staples were used of six different types.

The cost of closing the abdominal wound ranged between £3.64 and £20.40.

Discussion

These results were surprising. The closure of a midline laparotomy wound would seem to be a straightforward procedure. The aim is to bring the wound edges together with the least tissue damage so that healing can occur. The materials used should cause the minimum of disturbance to the tissue but allow the wound to gain sufficient strengths to avoid late herniation. Perhaps the bestl known method to achieve this is mass closure using wide bites with the sutures sufficiently close together so as to comply with 'Jenkin's rule'. This rule declares the need for four times the length of material as the length of the wound (1). To comply with this rule necessarily means that the suture is kept away from the wound edge and thus ensures optimum blood supply to the healing tissue.

As we see in this study there are still different opinions as to how many layers need to be closed. There is no evidence of benefits to be gained from closing the peritoneum (2) and some studies show that its closure increases adhesion formation (3).

Subcutaneous tissue sutures may increase infection rates and inflammation in contaminated wounds (4).

The strength of the abdominal closure lies in the linea alba. Evidence recommends mass closure observing 'Jenkin's rule' (5, 6, 7, 8).

There is less evidence as to which type of material to use to close this layer.

Comparisons have been made between absorbable and non- absorbable sutures.

As supported by evidence we see that the closure of choice is a mass closure conforming with 'Jenkin's rule'.

Morbidities encountered from failure in this layer are incisional hernia, wound dehiscence, infection, pain and suture sinus formation. To prevent incisional herniae non-absorbable material seems to be advantageous (9). There is evidence that a monofilament non-absorbable suture is associated with less infection and less stitch sinus formation than similar braided material (10). The cheapest monofilament, non-absorbable suture is Ethilon 100cm (code 747).

In one study (9) however, absorbable sutures are associated with less pain and less risk of suture sinus. Absorbable material is therefore still used (11). A long lasting absorbable monofilament suture can also fulfil the criteria of reliable abdominal wall closure (12). PDS has a good tensile strength. Looped PDS 150cm (PDSL W9262) allows a wound up to 30 cm to be closed with only one knot. Cutting the loop doubles the length of suture available but does need two knots.

Interrupted non-absorbable sutures or staples can be used for skin closure in contaminated wounds (13). Continuous absorbable or non-absorbable sutures used in subcuticular suturing are reserved for clean wounds (14).

There is no evidence about the type of needle that is used. In practice the needle needs to be large enough to allow wide enough tissue bites to comply with 'Jenkin's rule'. Safety is obtained by the use of a blunted round bodied atraumatic needles. These are available in a 50mm size (code W9262). For skin closure a cutting needle is required and a 6cm hand held straight needle is the commonest choice in our survey. However, with safety in mind one might suggest using a curved cutting needle with the needle holder or alternatively use skin clips.

The variety of material and needles used to close a midline abdominal wound is surprising. If we assume that all surgeons in the survey were satisfied with the cosmetic and long term results of their routine abdominal wound closure then their choice of closure and the material used may be justified. Equally, this would mean that any one of these many methods was satisfactory so we could all use the same method.

There would be advantages if we standardised the closure of this common wound.

It would lead to savings in theatre costs. The introduction of new materials or methods in the future could be assessed against the results of a large set of data.

The principle of standardisation could be extended to other common wound closures.

On the current evidence we would select from the materials shown in table 2.

Reference list

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