Finding the Best Abdominal Closure – An Evidence-Based Overview of the Literature 33 Gislason H, Gronbech JE, Soreide O Burst abdomen and incisional hernia after major gastrointestinal operations – comparison of three closure techniques Eur J Surg 1995; 161:349–354 34 Trimbos JB, van Rooji J Amount of suture material needed for continuous or interrupted wound closure: An experimental study Eur J Surg 1993; 159: 141–143 35 Colombo M, Maggioni A, Parma G, Scalambrino S, Milani R A randomized comparison of continuous versus interrupted mass closure of midline incisions in patients with gynecologic cancer Obstet Gynecol 1997; 89: 684–689 36 Brolin RE Prospective, randomized evaluation of midline fascial closure in gastric bariatric operations Am Surg 1996; 172: 328–332 37 Trimbos JB, Smith IB, Holm JP, Hermans J A randomized clinical trial comparing two methods of fascia closure following midline laparotomy Arch Surg 1992; 127: 1232–1234 38 Sahlin S, Ahlberg J, Grantstrom L, Ljungstrom KG Monofilament versus multifilament absorbable sutures for abdominal closure Br J Surg 1993; 80: 322–324 39 Rodeheaver GT, Powell TA, Thacker JG, Edlich RF Mechanical performance of monofilament synthetic absorbable sutures Am J Surg 1987; 154: 544–547 40 Poole GV, Meredith JW, Kon ND, Martin MB, Kawamoto EH, Myers RT Suture technique and wound-bursting strength Am Surg 1984; 50:569–572 41 Hodgson NC, Malthaner RA, Ostbye T The search for an ideal method of abdominal fascial closure: a meta-analysis Ann Surg 2000; 231: 436–442 42 Alexander HC, Prudden JF The causes of abdominal wound disruption Surg Gynecol Obstet 1966; 122: 1223–1229 43 Wadstrom J, Gerdin B Closure of the abdominal wall: how and why? Acta Chir Scand 1990; 156: 75–82 44 Rath AM, Chevrel JP The healing of laparotomies: a review of the literature Part Physiologic and pathologic aspects Hernia 1998; 2: 145–149 45 Douglas DM The healing of aponeurotic incisions Br J Surg 1952; 40: 79–84 46 Luijendijk RW Incisional hernia; risk factors, prevention, and repair Thesis Erasmus University, Rotterdam Scheveningen: Drukkerji Edauw and Johannissen, 2000 47 Wissing J, van Vroonhoven TJMV, Eeftinck Schattenkerk M, et al Fascia closure after laparotomy: Results of a randomized trial Br J Surg 1987; 74: 738–741 48 Bucknall TE, Teare L, Ellis H The choice of suture to close abdominal incisions Eur Surg Res 1983; 15: 59–66 49 Bucknall TE Factors influencing wound complication: A clinical and experimental study Ann R Coll Surg Engl 1983; 65: 71–77 50 Sharp WV, Belden TA, King PH, Teague PC Suture resistance to infection Surgery 1982; 91: 61–63 51 Krukowski ZH, Matheson NA “Button-hole” incisional hernia: A late complication of abdominal wound closure with continuous non-absorbable sutures Br J Surg 1987; 74: 824–825 52 Larsen PN, Nielsen K, Schultz A, Mejdahl S, Larsen T, Moesgaard F Closure of the abdominal fascia after clean and clean-contaminated laparotomy Acta Chir Scand 1989; 155: 461–464 121 V 53 Corman ML, Veidenheimer MC, Coller JA Controlled clinical trial of three suture materials for abdominal wall closure after bowel operations Am J Surg 1981; 141: 510–513 54 Knight CD, Griffen FD Abdominal wound closure with a continuous monofilament polypropylene suture Arch Surg 1983; 118: 1305–1308 55 Bucknall TE, Ellis H Abdominal wound closure: a comparison of monofilament nylon and polyglycolic acid Surgery 1981; 89: 672–677 56 Schoetz DJ, Coller JA, Veidenheimer MC Closure of abdominal wounds with polydioxanone Arch Surg 1988; 123:72– 74 57 Ray JA, Doddi N, Regula D, Williams JA, Melveger A Polydioxanone (PDS), a novel monofilament synthetic absorbable suture Surg Gynecol Obstet 1981; 153:497–507 58 Gys T, Hubens A A prospective comparative clinical study between monofilament absorbable and non-absorbable sutures for abdominal wall closure Acta Chir Belg 1989; 89:265–270 59 Israelsson LA, Jonsson T Closure of midline laparotomy incisions with polydioxanone and nylon: the importance of suture technique Br J Surg 1994; 81: 1606–1608 60 Carlson MA, Condon RE Polyglyconate (Maxon) versus nylon suture in midline abdominal incision closure: a prospective randomized trial Am J Surg 1995; 61: 980–983 61 Krukowski ZH, Cusick EL, Engeset J, Matheson NA Polydioxanone or polypropylene for closure of midline abdominal incisions: a prospective comparative clinical trial Br J Surg 1987; 74: 828–830 62 Wallace D, Hernandez W, Schlaerth JB, Nalick RN, Morrow CP Prevention of abdominal wound disruption utilizing the Smead-Jones closure technique Obstet Gynecol 1980; 56:226–230 63 Gallup DG, Talledo OE, King LA Primary mass closure of midline incisions with a continuous running monofilament suture in gynecologic patients Obstet Gynecol 1989; 73:675–677 64 Niggebrugge AH, Trimbos JB, Hermans J, Steup WH, Van de Velde CJ Influence of abdominal wound closure technique on complications after surgery: a randomized study Lancet 1999; 353: 1563–1567 65 Jenkins TPN The burst abdominal wound: a mechanical approach Br J Surg 1976; 63: 873–876 66 Israelsson LA, Jinsson T Suture length to wound length ratio and healing of midline laparotomy incisions Br J Surg 1993; 80: 1284–1286 67 Varshney S, Manek P, Johnson CD Six-fold suture: wound length ratio for abdominal closure Ann R Coll Surg Engl 1999; 81: 333–336 Discussion Deysine: In the 1970s Dr Goligher introduced a continu- ous suture with nylon for the closure of laparotomies At that time the number of laparotomies exploded in the world because of vascular surgery and they used be closed by a running suture This technique by Dr Golligher is very well depicted and those who practice it, like me, are 122 Abdominal Wall Closure very happy with it It is a continuous suture with a thick no.1 nylon and it accommodates to the changes in the abdominal wall and, to my surprise, it does not include the skin but all the other layers; the patients have very little pain with this kind of closure Ceydeli: Yes, in the NY State survey also the nonabsorbable, monofilament nylon suture was the most common suture but in the review the most common one was PDS, late absorbable Jeekel: But nylon causes more pain Amid: We really need a correct terminology The most common mistake that is made is the issue of fascia vs aponeurosis When we close midline the abdominal wall we don’t close fascia, we close the linea alba or rec- 14 tus sheath; the fascia is a very thin investing layer of the muscle that has absolutely no role in hernia surgery Jeekel: The suture-length-wound-length ratio, please one remark to small or large bites Israelsson: I was a bit concerned about the recommendation of taking 2-cm-large bites There are several clinical studies that show that by taking that big size of the bite you will end up with a high rate of incisional hernia and wound infection There is also strong evidence by experimental studies that a suture-length-wound-length ratio of 4:1 should be achieved by small tissue bites at short intervals Jeekel: But this is only experimental evidence V 15 Closure of Transverse Incisions J.A Halm, J Jeekel Incisions Any incision chosen for access to the abdominal cavity needs to provide access to the viscera or the lesion to be treated Furthermore, an incision needs to provide extensibility and permit subsequent secure closure A further demand may be the postoperative preservation of function [1] such as containment of abdominal organs and respiration Additional considerations in choosing the incision are the speed of entry, presence of scars, possibility of hemostasis and a cosmetically pleasing outcome Secure closure must be possible and various suture materials are used in this day and age Suture materials should ideally: be sufficient to hold parts together; disappear as soon as its work is accomplished; be free of infection; and be non-irritant To appreciate the different incisions and problems with closure, thorough knowledge of the anatomy of the abdominal wall is mandatory Anatomy Ventral Abdominal Wall The ventral abdominal wall consists of the rectus abdominis muscle on contralateral sides of the line alba The origo of the rectus muscle are the 5th, 6th and 7th rib, the insertion is the pubic bone The rectus muscles are each contained in a fascial layer, the anterior and posterior rectus sheath, which is made up of the aponeurosis (insertion) of the internal, external and transverse muscle The rectus muscle is horizontally incised by the three inscriptiones tendinea Lateral to the rectus abdominis the abdominal wall is made up of the afore-mentioned external oblique, the internal oblique and the transverse muscle, which extend over the ventral and lateral part of the abdomen (the part not covered by the rectus muscle) The origo of the external oblique muscle runs from the 5th to the 12th rib The internal oblique originates from the iliac crest The transverse muscle, with its horizontal fibre direction, originates from the previously mentioned iliac crest, the lumbodorsal fascia and the lower six ribs superiorly The lateral border of the rectus muscle forms the linea semilunaris At the symphysis pubis the posterior sheath ends in the thin curved margin, the linea semicircularis (Douglasi) Below this level the aponeuroses of all three muscles passes in front of the rectus abdominis and the fascia transversalis is responsible for the separation of the rectus from the peritoneum The pyramidalis muscle (if present) lies anterior to the lower part of the rectus abdominis muscle It arises from the superior surface of the pubic ramus and inserts at the linea alba The vasculature of the muscles of the abdominal wall consists of the superior and inferior deep epigastric vessels as well as transverse segmental branches of the aorta The superior and inferior deep epigastrics are located in front of the posterior rectus sheath and the rectus muscle and form its blood supply through perforating vessels The inferior deep epigastric ar- 124 Abdominal Wall Closure tery branches from the external iliac artery whereas the superior deep epigastric is a branch of the internal thoracic artery The deep epigastric arteries are anastomosed and thus form the deep epigastric arcade The transverse segmental arteries supply the transverse muscle, the internal and external oblique and are situated between the transverse and internal oblique Blood supply to the relatively avascular linea alba originates from the perforating vessels of the superior and inferior deep epigastrics Innervation of the abdominal wall is achieved through intercostals nerves, the ilioinguinal and the iliohypogastric nerve The intercostals nerves are ventral branches of thoracic nerves originating from levels Th through Th 12 of the spinal cord to 2.1% in 243 patients after a follow-up between 1.6 and 7.8 years [6] The upper right quadrant transverse incision requires transsection of the oblique and transverse musculature as well as the rectus muscle The linea alba is incised most commonly when extending the transverse incision across the midline Dividing the rectus muscle requires ligating the epigastric arcade yet poses minor damage to the intercostals nerves and superficial arteries supplying the transverse and oblique musculature [7] The transverse incision is thus accompanied by more blood loss than the midline incision and takes longer to achieve [4, 8] Exposure of the lesion is generally good, although unilateral incisions may provide a somewhat limited view Midline Incisions Closure of Incisions The midline incision is possibly the most popular incision amongst surgeons today When investigating alternatives to it, the baseline characteristics need to be described Midline incisions incise the skin, subcutaneous tissue, linea alba and the peritoneum vertically Midline incisions are easy, relatively little blood is lost and the incision takes an average of to perform [2–4] The exposure achieved through a midline incision encompassing the umbilicus is excellent, and includes access to the retroperitoneum The upper or lower abdominal midline incisions may be utilized in case the expected pathology is situated in the upper or lower quadrants of the abdomen respectively Extensions may be made in cranial or caudal direction when deemed necessary The qualities mentioned above make the midline incision the most ideal for emergency and exploratory surgery Transverse Incision 15 Transverse incisions are possible at all levels of the abdomen Common examples are the Pfannenstiel incision just above the pubic bone and the upper right quadrant transverse incision just below the costal margin The Pfannenstiel incision is approximately 8–12 cm in length (distance between the superfiscial epigastric arteries) and transsects the superficial fascia and the fibrous rectus sheath Further access is achieved by a slightly more cranial, vertical incision of the fascia transversalis, the preperitoneal fat and the peritoneum [5] Luijendijk has described incisional hernia formation in Pfannestiel incisions most recently and came Midline Closure Studies describing closure of incisions have been performed focusing on continuous, interrupted, layered closure and various suture materials (absorbable and non-absorbable) A recent meta-analysis reviewed 13 [9–21] clinically homogeneous randomized controlled trials comparing absorbable, non-absorbable, continuous and interrupted closure of abdominal incisions [22] Non-absorbable sutures were found to reduce incisional herniae when compared with absorbable sutures The odds ratio (OR) favouring non-absorbable sutures was 0.68 (95% CI 0.52–0.87) combining data from nine trials [9–12, 15–18, 21] Neither wound infection nor wound dehiscence was statistically more likely in absorbable sutures In contrast, suture sinuses and wound pain were significantly more frequent in the non-absorbable suture group with respective odds ratios of 2.18 (95% CI 1.48–3.22) and 2.05 (95% CI 1.52–2.77) Six trials were identified in the afore-mentioned meta-analysis comparing interrupted and continuous suture technique disregarding suture type [9, 12, 14, 17, 20, 21] Continuous sutures compared favourably to interrupted sutures (OR 0.73; 95% CI 0.55–0.99) No statistical differences were found for wound dehiscence and wound infection When taking into account the differences in technique (nine trials), continuous non-absorbable suturing outperformed the continuous absorbable suture in incisional hernia prevention (OR 0.61; 95% CI 0.46–0.8) [9–11, 14, 16–18, 21] No significant differences were found when comparing interrupted absorbable and interrupted non-absorbable closure V 125 Closure of Transverse Incisions A subgroup analysis revealed that use of slowly absorbable polydioxanone (PDS) and polyglycolic acid (Dexon) did not significantly increase the risk for incisional hernia formation compared to polypropylene Polyglactin (Vicryl) compared unfavourably with non-absorbable sutures Previously Wissing et al have found that nylon has the lowest incidence of incisional hernia yet is unfavourably associated with more wound pain and suture sinuses than polydioxanone sutures [21] Transverse Closure Randomized studies, not mentioned earlier, specifically describing incisional hernia formation with respect to midline, transverse and oblique incisions are summarized in ⊡ Table 15.1 Transverse incisions were found to be prone to incisional hernia formation in 3.6 – 40% of patients Fassiadis et al used continuous single-layered closure with nylon in the trial reported The hernia incidence in high-risk patients undergo- ⊡ Table 15.1 Randomized studies on incisional hernia Author Year Patients [N] Incision(s) Follow-up [months] Rate of incisional hernia [%] Technique, suture type, layers [L] p value Blomstedt [24] 1972 130 Transverse 8–24 19.5 Various suturesa, 2L ns 6 16.4 Variousa, L, cont RCT 234 Midline >6 18.1 Variousa, L, cont 1984 150 Transverse 5 years) studies (or experience), confirmed by several medical centers, remain absent Clinical Studies Porcine Submucosal Acellular Extracellular Matrix (Surgisis) This bioprosthesis is a resorbable biomaterial derived from the submucosal extracellular matrix of the pig small intestine After removing the muscularis externa and the mucosa, the 80-μm submucosa is treated with 0.1% peracetic acid, which removes all cells, is rinsed, and sterilized with ethylene oxide; a construct of eight separate, stacked sheets of this three-dimensional extracellular matrix oriented at 45° angles to adjacent sheets are then subjected to vacuum compression The resultant eight-sheet complex is perforated with 0.9-mm holes spaced about mm apart [7] In a dog model replacing a partial thickness, abdominal wall defect with an inlay of Surgisis at months postimplantation, a well-organized, smooth, dense connective tissue of collagenous material appeared to be well-incorporated into adjacent fascia and muscle, closely resembling the native fascia [8,9] The non-cross-linked preparation composed primarily of fibrillar collagens (types I, III, and IV) and various glycosamine glycans, proteoglycans, and glycoproteins, the relative lack of cellular antigens, and the minimal immune response allegedly supports a site-specific tissue remodeling [10,11] Clinical studies specifically of ventral hernia repair using Surgisis, however, are limited to preliminary, short duration studies; there are no long-term (>5-year) studies available When reviewing the reported studies [12– 15], one must be cognizant of several considerations: first, follow-up is short and poorly defined in terms of definitions of recurrence and actual repeat physical examination/imaging; and second, many patients were recruited because of contaminated or grossly infected surgical fields [13–15] Small, uncontrolled studies suggest good initial strength in preventing evisceration and minimizing dehiscence, and early studies suggested a minimal recurrent rate in clean wounds of 0% [12], 0% [14] and 15% [15], but allegedly with short