Indian Journal of Surgery (April 2018) 80(2):105–108

https://doi.org/10.1007/s12262-018-1776-6

EDITORIAL

Editorial: Ten Commandments of Safe and Optimum Abdominal

Wall Closure
Chintamani 1

Received: 13 May 2018 / Accepted: 13 May 2018 / Published online: 30 May 2018
# Association of Surgeons of India 2018

of the injured tissue and debris is cleared from the wound

by phagocytosis.
“There are few things more embarrassing to a surgeon & Proliferation: Fibroblasts are activated and produce extra-
than the sight of his recently operated patient, his abdo- cellular matrix components. Angiogenesis occurs, and the
men gaping, and the gut spilling out all around…” resulting granulation tissue appears red.
………Moshe Schein & Remodeling: For up to a year after injury, the extracellular
matrix is remodeled, helping the wound to regain strength.
Closing the abdomen after a laparotomy is an important As the healed tissue matures, fibronectin and hyaluronan
skill that is taught to all surgeons during the initial training are broken down, and collagen bundles increase in diam-
period. The skill however takes a while to be understood op- eter, corresponding with increasing tensile strength of the
timally. There are few facts that are now considered as the wound. However, these collagen fibers never regain the
“scientific truths” like midline laparotomy, although conve- original strength of unwounded fascia, and at best 80%
nient, bloodless, faster, and popular, is associated with slightly strength can be achieved.
higher rates of burst abdomens and incisional hernias as com-
pared to transverse incisions. Also, that the incisional hernias Initial type III collagen is weaker than the definite scar,
would have started happening immediately after the closure of type-I collagen [2, 3]. Initial phase of wound healing has type
abdomen but may take up to 2 years to show up. Although III (weak) collagen (80%) that has low tissue tensile strength
there are many patient-related, surgeon-related, and other mis- and finally definite scar type I (strong) collagen (80%) that has
cellaneous factors that play their role in healing of abdominal high tissue tensile strength. Initial wound is thus totally de-
wall, the understanding of the basic physiology of healing is pendent on suture for strength [1–3].
essential. Alterations in one or more of these phases would result in
wound complications. Although these factors are predomi-
nantly patient related, other factors like suture breaks, though
rare, are also important and poor judgment or technique is also
The Phases of Fascia Healing [1] not rare.
Healing of fascial wounds is a coordinated event of many
processes (triggered by tissue injury) and involves three over-
lapping but well-defined phases: Commandment 1: One Has to Be Thorough
with the Basics in Fascia Healing Including Its
& Inflammation: Lymphocytes, neutrophils, and macro- Anatomy
phages take up residence in the wound over the first week
after injury, drawn by an array of cytokines and Fascia is the firm, strong connective tissue that sheaths mus-
chemokines. The wound becomes edematous, and much cles and is a main supportive structure of the body. Healing of
the abdominal wall fascia by around 2 weeks is 20%; by the
* Chintamani
end of 1 month, it is nearly 50%; at 2 months, 60–80%; and
drchintamani7@gmail.com after 1 year, up to 90% healing would have happened. This
healing depends on successful wound closure, and after 2–
1
VMMC, Safdarjung Hospital, New Delhi, India 4 weeks, healing fascia begins to have the strength to be
106 Indian J Surg (April 2018) 80(2):105–108

self-supporting but is still vulnerable to wound dehiscence. Commandment 4: One Should Use the Right
Thus, the abdominal wall attains 52–59% of its original Technique; Surgical Technique Is Only As
strength in 42 days, 70–80% in 120 days, and 73–93% by Good As the Surgeon
140 days. Maximum strength finally achieved is 93% of the
original strength. One should adhere to basic principles in the technique and
Thus, healing fascia requires at least 14 to 28 days before surgical technique is only as good as the surgeon. One must
becoming self-supportive. During this time, the wound is not cut corners with the length of the suture and it should be
completely dependent on the closure device for its initial hold- optimum (at least four times the length of the wound). Simple
ing strength. This time is also known as the “critical healing sutures without locking would generally suffice on most oc-
period” and the concept is true for all tissues, though they will casions but should not be too tight (strangulation of the tissue).
have different critical healing periods. This has also been observed that the length of abdominal
Disruptions in any of the phases of wound healing can lead incision increases up to 30% in postoperative period.
to wound complications or can result in severely reduced Therefore, 4:1 suture to wound length ratio will allow ade-
strength of healing fascia. quate bites and would also avoid cutting through the fascial
These disruptions can be localized infection or can be attrib- sheath.
uted to delayed healing due to patient factors such as diabetes or
smoking. The wound is at its weakest at post-operative day 3 [4].
“If it looks all right, it’s too tight—if it looks too loose,
it’s all right”
Commandment 2: One Shall Make the Right ……….Matt Oliver
Incision

Making right incision forms the basis of a good wound clo-

sure. While most agree that midline incisions are associated Commandment 5
with increased risk of incisional hernias, these are the most
commonly used incisions for ease and speed of access, less One should deploy a safe technique that is fast, easy, cost
bleeding, and subsequent mass closure. This incision also effective, and associated with minimal early or late complica-
does not involve cutting of any muscle (Fig. 1). tions. The continuous suture is associated with greater tensile
strength when compared to interrupted one. Layered closure
has been shown to have wound dehiscence rates of 11% as
compared to 1% with mass closure technique. Layered closure
Commandment 3: One Should/Need Not also consumes more time. Statistically significant reduction in
Close the Peritoneum hernia and dehiscence rates has been observed with mass clo-
sure technique [4].
The peritoneum is a one-cell layer that usually heals as a sheet
rather than from the edges. Peritoneum heals itself within 48–
72 h and therefore does not need to be sutured. Suturing of Commandment 6
peritoneum has been found to be associated with a higher rate
of postoperative pain and adhesions. Sheath is the most im- One should use mass closure technique based on Jenkins’s
portant layer of the abdominal wall, as it must bear maximum rule (Fig. 2).
stress on the incision (Fig. 1). The “spring coil effect theory” of Jenkins revolutionized
the concept of abdominal wound closure especially following
a midline laparotomy. It is based on the concept of closure of
aponeurosis using continuous bites (without locking) at a
width of more than 1 cm and not more than 1 cm away from
the previous bite (“1x1 cm without locking and tension”), in
the end producing a spring coil that would accommodate the
wound distension in the immediate postoperative period. This
Fig. 1 The sheath bears the maximum stress of the abdominal wall. Linea
alba or the white line is a relatively avascular line for a quick and blood
spring coil also promotes healing with type I collagen that is
less entry in to the abdomen. Midline laparotomy is therefore the present around 1 cm away from the edge of the rectus sheath.
preferred approach There is however no consensus on the surgical technique [5].
Indian J Surg (April 2018) 80(2):105–108 107

Fig. 2 Mass closure technique involves continuous suturing with a

minimum width of 1 cm and not more than 1 cm away from the
previous bite

Fig. 3 The self-locking knot

Commandment 7: One Would Use the Right
Suture Commandment 8: Shall Use Good Knotting
Techniques [6]
An ideal suture as defined by Sir Moynihan should be
“absorbable, non reactive, easily available, cheap and Self-locking knots or an Aberdeen knot is a very effective and
easy to handle for knotting purposes etc.”. Needless to frequently used knot in view of high knot security, efficiency,
say, such a suture does not exist. There are however and minimal volume. This knot is also known for not slipping
monofilament “synthetic” absorbable as well as non- and has minimal effect on suture strength unlike the conven-
absorbable sutures that are close to being ideal. The suture tional reef or square knot in this scenario (Fig. 3).
should be tailored to the tissue, its tensile strength and the
support that it needs to heal optimally. It is generally
accepted that non-absorbable sutures cause less tissue re- Commandment 9: One Should Not “always”
action and are more resistant to infection than the absorb- Close the Abdomen—Shall not stuff a living
able sutures. However, these sutures are associated with Turkey [7]
higher incidence of buttonhole hernias and sinus forma-
tion leading to increased wound pain. A study comprising All abdomens should not be closed, especially if there is as-
of 12 centers reporting about the closure tactics following sociated tension. Also, if there is intraperitoneal contamina-
elective laparotomies showed no consensus on the type of tion or more importantly if the patient has poor APACHE-II
suture material to be used [4]. scores, one needs to understand that the physiological changes
produced as a result of intra-abdominal hypertension (even if
transient) are often irreversible. One has to rely on objective
scoring rather than gut feeling and subjective assessment to
Commandment 7: One Should Follow make a decision regarding closing or leaving the abdomen
Recommendations Regarding the Suturing open. The author likes to rely on APACHE-II scoring system
and Knotting Techniques to triage the patients in to high-, moderate-, and low-risk
groups. As a protocol, the abdomens of patients with poor
Monofilament suture material, 2/0 slowly absorbable or APACHE-II scores are not closed and these should be
non-absorbable mounted on small needle, should be de- managed as laparostomies [7–9].
ployed as continuous sutures without any locking. The
suture would terminate with self-locking anchor knots
(Figs. 2 and 3). Continuous suture when used in one Commandment 10: One Should Not Use
layer avoids high tension on suture and does not com- “tension band sutures” to Close the Abdomen
press the wound edges. This prevents devascularization
of the sheath and formation of a good quality collagen, The age old practice of using tension sutures when dehiscence
i.e., type I. is anticipated should not be encouraged and in fact should not
108 Indian J Surg (April 2018) 80(2):105–108

be used. There is a risk of producing “bow string” damage to 2. Höer J, Junge K, Schachtrupp A, Klinge U, Schumpelick V.
Influence of laparotomy closure technique on collagen synthesis in
the bowel coming in contact with these tight sutures and also
the incisional region.Hernia. 2002 Sep;6(3):93-8. Epub 2002 Jul 20
the fact that associated tension may actually hurt the cause. 3. Hawley PR, Hunt TK, Dumphy JE. Etiology of colonic anastomotic
Every abdomen can/should not be closed. In the event of leaks Proc R Soc Med. 1970;63 Suppl 1:28-30.
peritoneal sepsis, poor sepsis scores/APACHE scores, it is 4. Rath AM, Chevrel JP (Am J Surg 1992, 1987) The healing of lapa-
rotomies: a review of the literature. Part 1. Physiologic and patho-
not wise to close the abdomen as it would open up on its
logic aspects. 1:727
own but not before setting up a sequence of events leading 5. Chintamani et al (2012) Technique related issues—Indian scenario.
to an irreversible physiological damage. Such abdomens are Indian J Surg 74(3):213–216. https://doi.org/10.1007/s12262-012-
better managed as open abdomens or laparostomies with or 0585-6 Current debates in surgery—a cross sectional study
amongst Indian surgeons
without any zippers [7–9].
6. Israelsson LA, Jonnson T (1994) Physical properties of self locking
and conventional surgical knots. Eur J Surg 160:323–327
7. Chintamani, Bhatnagar D (2001) The role of APACHE-II triaging in
optimum management of small bowel perforations & wound closure.
Trop Dr 31(4):198–201
8. Chintamani, Singhal V (2003) Urobag zipper laparostomy in intra-
References peritoneal sepsis. Trop Doct 33(2):123–124
9. Chintamani, Singhal V (2003) Temporary closure of open abdominal
1. Poole GV Jr, 1985 Jun; 97(6):631-40.Ramshorst V et al (2010) wounds by the modified sandwich-vacuum pack technique—letter.
Abdominal wound dehiscence in adults. World J Surg 34(1):20–27 Br J Surg 90:718–722