SECTION 12.00 CLOSING THE ABDOMEN

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12.01 DECIDE ABOUT DEEP TENSION SUTURES

Put in deep tension sutures for:
Expected prolonged abdominal distension.
Sepsis.
Expected excess coughing.
Steroid treatment.
Any other risk factor for poor wound healing.

12.02 REMOVE THE FINOCHIETTO RETRACTOR

12.03 REMOVE SKIN EDGE TOWELS AND CLIPS

12.04 CHECK THE ABDOMEN IS FULLY RELAXED

Bowel pushing out of the wound is a sign of inadequate relaxation.
Wait for the anaesthetist to get full relaxation before continuing.

12.05 PICK UP THE PERITONEUM

Use 4 Moynihan's cholecystectomy forceps:
1 on each side of the wound and 1 on each end.
Get your assistant to lift his side of the wound with the forceps.

12.06 FOR CLOSURE WITHOUT DEEP TENSION SUTURES

GO TO STEP *** (CLOSE THE PERITONEUM)

12.07 FOR CLOSURE WITH DEEP TENSION SUTURES - READ ON

Use 0 nylon on a 50mm hand needle, with a segment of plastic tube and an artery clip on the loose end (Ethicon W***).
Insert the stitches 5cm from the wound edge, through all layers at 5cm intervals.
Lay the sutures across the abdomen, with artery clips dangling on each end to maintain a steady pull.
Cut off the needles.
Make sure you do not damage the structures inside the peritoneum with the needles.
Make sure the stitches stay under tension to prevent bowel or omentum getting caught in a slack loop of nylon.

12.08 CLOSE THE PERITONEUM AND LINEA ALBA (OR POSTERIOR RECTUS SHEATH FOR A PARAMEDIAN INCISION)

Use 1 layer of continuous no.1 nylon (Ethicon W749).
Start at the upper end of the wound.
Tie the ends of the nylon with 5 throws.
Take 1cm bites, 1cm apart.
Cut the ends nylon 10mm long.
Check all the time that you are avoiding needle damage to the structures inside the abdomen.
If the peritoneum will not close or the single stitches are tearing:
Take 4 bites and pull the stitches through en masse.
If you are still unable to close:
Call a more experienced surgeon.

12.09 CLOSE THE ANTERIOR RECTUS SHEATH (FOR A PARAMEDIAN INCISION ONLY)

Use 1 layer of continuous no.1 nylon (Ethicon W749).
Start at the upper end of the wound.
Tie the end with 5 throws.
Hold the loose end in the line of the wound with an artery so that the next stitches will bury the knot.
Take 1cm bites, 1cm apart.
Cut the buried end 3cm long
Bury the ends of the final knot back in the wound.
Cut the ends of the knot where they protrude from the closed rectus sheath.

12.10 CHECK HAEMOSTASIS IN THE FAT

12.11 PUT 1G AMPICILLIN POWDER IN THE SUBCUTANEOUS FAT

Use a 10 second burst of Povidone iodine spray if there is an ampicillin hypersensitivity.

12.12 CLOSE THE SUBCUTANEOUS FAT

Use continuous 2/0 Vicryl (Ethicon W9251).
Cut the ends 3mm long.

12.13 CHECK THE SWAB, NEEDLE, AND INSTRUMENT COUNTS AGAIN

12.14 CHECK THERE IS NO OTHER PROCEDURE TO DO

12.15 CLOSE THE SKIN

Use continuous 3/0 Vicryl (Ethicon W9890).
Make a 5 throw knot at the end of the Vicryl to act as an anchor when burying the first stitch.
Take six 5mm bites before pulling on the Vicryl to close the skin edges.
Bury the final end with a loop stitch.

12.16 TIE THE DEEP TENSION SUTURES

Use 5 throws to tie the sutures.
Cut the ends 10mm long.

12.17 CLOSE ANY ILEOSTOMY WOUND

Close the fat and the wound as for the main wound.

12.18 SPRAY THE WOUND

Use an acrylic spray (Nobecutaine).

12.19 DRESS THE WOUND

Use a compliant dressing (Mepore).

12.20 CONNECT THE DRAIN TUBE

Use a closed system of drainage with a drainage bag.