The ideal abdominal wound closure provides strength and a barrier to infection. In addition, the closure should be efficient, performed with no tension or ischemia, comfortable for the patient, and esthetic. Wounds have less than 5 percent of normal tissue strength during the first postoperative week, thus wound security is dependent solely upon the suture closure.
The suture chosen for closure should be absorbable and have a caliber that will provide adequate strength to the wound while minimizing foreign body content. Multifilament sutures provide better knot strength but are more prone to infection and sinus formation.
Most abdominal incisions can be safely closed with one-half or five-eighths circle, taper point, general closure needles.
Secure knots are critical for a strong closure. Most suture failures occur at the knot. Knot security is a function of how the loops and throws are configured, as well as the type and size of the suture. In most situations, a single strand of suture should be tied to a single strand. Tying a single strand of suture to a double strand of suture may reduce knot security. This is especially important if the suture will significantly experience tension, such as with fascia closure. There is no benefit to the use of a surgeon’s knot (a double throw in the first loop) over a square knot. The primary benefit of a square knot is that it becomes tighter when the ends of the suture are pulled.
Current clinical evidence indicates that continuous mass closure is the ideal closure method using a suture length-to-wound length ratio of 4:1 in a simple running technique. The tissue should be reapproximated with low tension to prevent ischemia. A single strand should be tied to another single strand using a square knot or surgeon’s knot.
Closure of the peritoneum is not recommended as it appears to confer no benefit.
To reduce the incidence of incisional hernia following elective midline abdominal closure (first time closure or repeat closure), we recommend a continuous suture technique using slowly absorbable monofilament suture.
Regardless of whether interrupted or continuous closure is chosen, sutures should be placed approximately 10mm from the fascial edge. However, in Europe, a further reduction in suture width from 10mm to 5-8mm is advocated by the 2015 European Hernia Society guidelines on the closure of abdominal wall incisions.
Prophylactic mesh and drains
The incidence of incisional hernia following laparotomy varies widely and depends upon the patient’s risk factors for hernia formation and the surgical procedure.
There are no studies demonstrating a better quality of life or a cost benefit with the use of prophylactic mesh so given the limitations of the available data, the mesh is not recommended prophylactically at the time of closure of the abdominal wall.
The primary indication for the placement of a drain is the prevention of fluid collection and subsequent infection. Intraabdominal procedures frequently associated with large collections of blood and serum may benefit from prophylactic drainage. Drains are placed adjacent the injured tissue or in the vicinity of an anastomosis at risk for leakage. Drains should be placed through a small incision separate from the primary incision. The drain should have a direct path to prevent kinking and subsequent obstruction and an incision larger than 5 mm but smaller than 10 mm is usually advised.
A sterile dressing is generally used to protect the closed surgical wound for 24 to 48 hours postoperatively. There is no persuasive data to suggest that one type of dressing is better than another with respect to surgical site infection. Systematic reviews have found no significant difference in surgical site infection rates for surgical wounds covered with different dressings (basic wound contact dressing, film dressing, hydrocolloid dressing) and those left uncovered for a variety of wound conditions (clean, mixed contamination levels). Although the dry sterile dressing has been a standard for decades, wounds heal better in a moist environment. Thus, modern film dressings that are impermeable to fluid and bacteria but allow passage of moisture vapor may be preferable.