Section: Abdominal wall and retroperitoneum Curriculum: Curriculum, page 3
Principles of abdominal wall closure
Materials
- Sutures - suture size should be the smallest caliber enough to reapproximate the tissue and keep the wound intact
- Can be synthetic (nylon, polyester) versus natural (catgut, silk)
- Absorbable vs non-absorbable
Common synthetic absorbable sutures and their half-lives
- Polyglactin 910 (Vicryl) - 2 weeks
- Poliglecaprone (Monocryl) - 2 weeks
- Polydioxanone (PDS) - 4 weeks
- Polyglyconate (Maxon) - 6 weeks
Non-absorbable vs absorbable sutures
- Non-absorbable sutures don’t decrease the risk of dehiscence and hernia but ARE associated with sutures sinuses and prolonged wound pain.
Needles
- Taper - taper point needles are atraumatic - create small holes which tissue spreads around.
- Blunt - good for closing laparotomies and preventing injury.
- Cutting - good for closing skin or scarred tissue.
Wound closure by layer
- Mass closure is associated with a lower rate of incisional hernia.
- A slowly absorbable suture should be used with a suture to wound length ratio of 4:1
- Peritoneum - there is good evidence that peritoneal closure results in more advanced adhesion formation AND that is re-epithelializes after 48 hours
Bite size
- There are a number of trials which have compared small bite technique using 2/0 with large bite technique using 0 or 1.
- Generally small bite technique is associated with a lower risk of wound hernia BUT
- These trials generally have excluded obese patients and emergency patients.
- Thus for a patient with a BMI > 30 having an elective operation you can use it - otherwise use the large bite technique.
Complications of surgical incisions
Haematoma and seroma
- Result from failure of primary hemostasis or bleeding diathesis.
- Can manage expectantly or washout with primary closure (or heal by secondary intention).
Fascial dehiscence
- Occurs due to abdominal wall tension overcoming tissue or suture strength or knot security - can be partial or complete.
- In up to 95% of dehiscence’s, the sutures and knots are intact but the suture has pulled through the fascia.
Risk factors
- Male sex
- COPD
- Ascites
- Anaemia
- Emergency surgery
- Post-operative coughing
- Wound infection
- Malignancy
- Obesity
- Hypoalbuminaemia
- Sepsis
- Steroids
Clinical signs and symptoms
- Profuse seroanguinous drainage
- Popping sensation
- Incisional bulge
- Mostly occur 4 to 14 days after surgery, mean of 8 days post-operatively.
- Associated with a mortality of 10%.
Treatment
- When fascial disruption is suspected - should go to theatre for exploration.
- Place moist dressing over wound at the bedside.
- Internal or external retention sutures are occasionally used although this hasn’t ben shown to reduce the risk of fascial disruption or hernia.
Closure
- Interrupted large monofilament (Nylon, PDS or Prolene)
- Consider mesh reinforcement
- May need bridging mesh - use biological mesh