Advertisement

Fundamentals of Laparotomy Closure

  • William W. Hope
  • Michael J. Rosen
Chapter

Abstract

Despite the increased adoption of minimally invasive techniques in all fields of surgery, the use of a laparotomy incision is still common. Knowledge of closure techniques is essential for all surgeons who perform laparotomies, because adherence to evidence-based principles can significantly decrease the incidence of incisional hernias.

This chapter reviews basic anatomy and closure techniques that all surgeons should know and highlights recent advances and controversies related to laparotomy closure. Specifically, this chapter explains the importance of the suture to wound length ratio, reviews the recent literature supporting the short stitch technique for laparotomy closure, and reviews guidelines on type of suture and techniques that should be employed. Although laparotomy closure can be a neglected portion of an abdominal operation, the importance of closure technique should be stressed to surgeons and trainees, because minor changes in technique can have a major impact on outcomes such as incisional hernia formation.

Keywords

Laparotomy Closure Incisional Hernia Short stitch Abdominal Celiotomy 

Suggested Readings

  1. Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J, Cuccurullo D, de Beaux AC, Deerenberg EB, East B, Fortelny RH, Gillion JF, Henriksen NA, Israelsson L, Jairam A, Janes A, Jeekel J, Lopez-Cano M, Miserez M, Morales-Conde S, Sanders DL, Simons MP, Smietanski M, Venclauskas L, Berrevoet F, European Hernia S. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia. 2015;19:1–24.  https://doi.org/10.1007/s10029-014-1342-5.CrossRefPubMedGoogle Scholar
  2. Israelsson LA, Millbourn D. Prevention of incisional hernias: how to close a midline incision. Surg Clin North Am. 2013;93:1027–40.  https://doi.org/10.1016/j.suc.2013.06.009.CrossRefPubMedGoogle Scholar
  3. Hope W. Prevention of incisional hernia development. Minerva Chir. 2011;66:145–52.PubMedGoogle Scholar
  4. Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, Wijnhoven BP, Schouten WR, Cense HA, Stockmann HB, Berends FJ, Dijkhuizen FP, Dwarkasing RS, Jairam AP, van Ramshorst GH, Kleinrensink GJ, Jeekel J, Lange JF. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet. 2015;386:1254–60.  https://doi.org/10.1016/S0140-6736(15)60459-7.CrossRefPubMedGoogle Scholar

References

  1. 1.
    Cobb WS, Kercher KW, Heniford BT. Laparoscopic repair of incisional hernias. Surg Clin North Am. 2005;85(1):91–103.; ix.  https://doi.org/10.1016/j.suc.2004.09.006.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg. 1985;72(1):70–1.CrossRefPubMedGoogle Scholar
  3. 3.
    Alnassar S, Bawahab M, Abdoh A, Guzman R, Al Tuwaijiri T, Louridas G. Incisional hernia post repair of abdominal aortic occlusive and aneurysmal disease: five-year incidence. Vascular. 2012;20(5):273–7.  https://doi.org/10.1258/vasc.2011.oa0332.CrossRefPubMedGoogle Scholar
  4. 4.
    Bower C, Roth JS. Economics of abdominal wall reconstruction. Surg Clin North Am. 2013;93(5):1241–53.  https://doi.org/10.1016/j.suc.2013.06.007.CrossRefPubMedGoogle Scholar
  5. 5.
    Reynolds D, Davenport DL, Korosec RL, Roth JS. Financial implications of ventral hernia repair: a hospital cost analysis. J Gastrointest Surg. 2013;17(1):159–66.; Discussion p. 66–7.  https://doi.org/10.1007/s11605-012-1999-y.CrossRefPubMedGoogle Scholar
  6. 6.
    Hoer J, Lawong G, Klinge U, Schumpelick V. Factors influencing the development of incisional hernia. A retrospective study of 2,983 laparotomy patients over a period of 10 years. Chirurg. 2002;73(5):474–80.  https://doi.org/10.1007/s00104-002-0425-5.CrossRefPubMedGoogle Scholar
  7. 7.
    Sorensen LT, Hemmingsen UB, Kirkeby LT, Kallehave F, Jorgensen LN. Smoking is a risk factor for incisional hernia. Arch Surg. 2005;140(2):119–23.  https://doi.org/10.1001/archsurg.140.2.119.CrossRefPubMedGoogle Scholar
  8. 8.
    Llaguna OH, Avgerinos DV, Lugo JZ, Matatov T, Abbadessa B, Martz JE, et al. Incidence and risk factors for the development of incisional hernia following elective laparoscopic versus open colon resections. Am J Surg. 2010;200(2):265–9.  https://doi.org/10.1016/j.amjsurg.2009.08.044.CrossRefPubMedGoogle Scholar
  9. 9.
    Santora TA, Roslyn JJ. Incisional hernia. Surg Clin North Am. 1993;73(3):557–70.CrossRefPubMedGoogle Scholar
  10. 10.
    Veljkovic R, Protic M, Gluhovic A, Potic Z, Milosevic Z, Stojadinovic A. Prospective clinical trial of factors predicting the early development of incisional hernia after midline laparotomy. J Am Coll Surg. 2010;210(2):210–9.  https://doi.org/10.1016/j.jamcollsurg.2009.10.013.CrossRefPubMedGoogle Scholar
  11. 11.
    Franchi M, Ghezzi F, Buttarelli M, Tateo S, Balestreri D, Bolis P. Incisional hernia in gynecologic oncology patients: a 10-year study. Obstet Gynecol. 2001;97(5 Pt 1):696–700.PubMedGoogle Scholar
  12. 12.
    Sugerman HJ, Kellum JM Jr, Reines HD, DeMaria EJ, Newsome HH, Lowry JW. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg. 1996;171(1):80–4.  https://doi.org/10.1016/S0002-9610(99)80078-6.CrossRefPubMedGoogle Scholar
  13. 13.
    Takagi H, Sugimoto M, Kato T, Matsuno Y, Umemoto T. Postoperative incision hernia in patients with abdominal aortic aneurysm and aortoiliac occlusive disease: a systematic review. Eur J Vasc Endovasc Surg. 2007;33(2):177–81.  https://doi.org/10.1016/j.ejvs.2006.07.009.CrossRefPubMedGoogle Scholar
  14. 14.
    Hope W. Prevention of incisional hernia development. Minerva Chir. 2011;66(2):145–52.PubMedGoogle Scholar
  15. 15.
    Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J, Cuccurullo D, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia. 2015;19(1):1–24.  https://doi.org/10.1007/s10029-014-1342-5.CrossRefPubMedGoogle Scholar
  16. 16.
    Israelsson LA, Millbourn D. Prevention of incisional hernias: how to close a midline incision. Surg Clin North Am. 2013;93(5):1027–40.  https://doi.org/10.1016/j.suc.2013.06.009.CrossRefPubMedGoogle Scholar
  17. 17.
    Rappaport WD, Hunter GC, Allen R, Lick S, Halldorsson A, Chvapil T, et al. Effect of electrocautery on wound healing in midline laparotomy incisions. Am J Surg. 1990;160(6):618–20.CrossRefPubMedGoogle Scholar
  18. 18.
    Kim H, Brunner E, Ritter E, Thompson D, Devereux D. Relevance of methods of skin incision technique on development of wound infection. Am Surg. 1991;57(2):129–30.PubMedGoogle Scholar
  19. 19.
    Ozgun H, Tuncyurek P, Boylu S, Erpek H, Yenisey C, Kose H, et al. The right method for midline laparotomy: what is the best choice for wound healing? Acta Chir Belg. 2007;107(6):682–6.CrossRefPubMedGoogle Scholar
  20. 20.
    Allan SN, Spitz L, van Noort R, Black MM. A comparative study of scalpel and electrosurgical incision on subsequent wound healing. J Pediatr Surg. 1982;17(1):52–4.CrossRefPubMedGoogle Scholar
  21. 21.
    Franchi M, Ghezzi F, Benedetti-Panici PL, Melpignano M, Fallo L, Tateo S, et al. A multicentre collaborative study on the use of cold scalpel and electrocautery for midline abdominal incision. Am J Surg. 2001;181(2):128–32.CrossRefPubMedGoogle Scholar
  22. 22.
    Kearns SR, Connolly EM, McNally S, McNamara DA, Deasy J. Randomized clinical trial of diathermy versus scalpel incision in elective midline laparotomy. Br J Surg. 2001;88(1):41–4.  https://doi.org/10.1046/j.1365-2168.2001.01625.x.CrossRefPubMedGoogle Scholar
  23. 23.
    Shamim M. Diathermy vs. scalpel skin incisions in general surgery: double-blind, randomized, clinical trial. World J Surg. 2009;33(8):1594–9.  https://doi.org/10.1007/s00268-009-0064-9.CrossRefPubMedGoogle Scholar
  24. 24.
    Ziv Y, Brosh T, Lushkov G, Halevy A. Effect of electrocautery vs. scalpel on fascial mechanical properties after midline laparotomy incision in rats. Isr Med Assoc J. 2001;3(8):566–8.PubMedGoogle Scholar
  25. 25.
    Garcia A, Nascimento JE, Darold EM, Pimentel RE, Curvo EA, Daud FO. Healing of abdominal wall aponeurosis of rats after incision with either cold scalpel or electrocautery. Acta Cir Bras. 2007;22(Suppl 1):12–5.CrossRefPubMedGoogle Scholar
  26. 26.
    Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet. 2015;386(10000):1254–60.  https://doi.org/10.1016/S0140-6736(15)60459-7.CrossRefPubMedGoogle Scholar
  27. 27.
    Jenkins TP. The burst abdominal wound: a mechanical approach. Br J Surg. 1976;63(11):873–6.CrossRefPubMedGoogle Scholar
  28. 28.
    Israelsson LA, Jonsson T, Knutsson A. Suture technique and wound healing in midline laparotomy incisions. Eur J Surg. 1996;162(8):605–9.PubMedGoogle Scholar
  29. 29.
    Leaper DJ, Pollock AV, Evans M. Abdominal wound closure: a trial of nylon, polyglycolic acid and steel sutures. Br J Surg. 1977;64(8):603–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Hogstrom H, Haglund U, Zederfeldt B. Suture technique and early breaking strength of intestinal anastomoses and laparotomy wounds. Acta Chir Scand. 1985;151(5):441–3.PubMedGoogle Scholar
  31. 31.
    Sanders RJ, DiClementi D, Ireland K. Principles of abdominal wound closure. I. Animal studies. Arch Surg. 1977;112(10):1184–7.CrossRefPubMedGoogle Scholar
  32. 32.
    Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg. 2009;144(11):1056–9.  https://doi.org/10.1001/archsurg.2009.189.CrossRefPubMedGoogle Scholar
  33. 33.
    Gurusamy KS, Cassar Delia E, Davidson BR. Peritoneal closure versus no peritoneal closure for patients undergoing non-obstetric abdominal operations. Cochrane Database Syst Rev. 2013;7:CD010424.  https://doi.org/10.1002/14651858.CD010424.pub2.CrossRefGoogle Scholar
  34. 34.
    Muysoms FE, Detry O, Vierendeels T, Huyghe M, Miserez M, Ruppert M, et al. Prevention of incisional hernias by prophylactic mesh-augmented reinforcement of midline laparotomies for abdominal aortic aneurysm treatment: a randomized controlled trial. Ann Surg. 2016;263(4):638–45.  https://doi.org/10.1097/SLA.0000000000001369.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.New Hanover Regional Medical CenterUniversity of North Carolina at Chapel HillWilmingtonUSA
  2. 2.Cleveland ClinicClevelandUSA

Personalised recommendations