Mass closure technique plus wound edges augmentation with two longitudinal subcutaneous tubes for all ages and all incisions to avoid burst abdomen

Mass closure technique plus wound edges augmentation with two longitudinal subcutaneous tubes for all ages and all incisions to avoid burst abdomen

Yasser Hussein, MD; Abd Elwahhab M Hamed, MD;

Wael Shelfa, MD; Hasan Awad, MD

General Surgery Department, Zagazig University, Sharkiya, Egypt.

Abstract

Background:  Burst  abdomen  and incisional  herniation    are continuing  problems  for the general surgeon. A prospective study was carried out to define the extent of the problem.

Patients  and methods: The present study was carried out over a period of two years from September 2009 to September 2011 in Zagazig University Hospital, Surgery Department  and included  50 patients for various intra-abdominal  conditions  both in  emergency and routine cases. Such cases were included the high risk group for developing  burst abdomen.

Results: Eighty percent of our patients belonged to the high risk group. Postoperatively, none of the patients developed  burst abdomen. One case developed  incisional  herni a. Superficial wound infection was noticed in 5 cases.

Conclusion:  This method of abdominal  closure resulted i n zero percent incidence  of burst abdomen in spite of the presence of predisposing factors for burst abdomen.

Introduction:

Burst abdomen is a serious  postoperative complication that concerns every abdominal surgeon. Efforts have been made to overcome this  complication  with  various  innovations in the technique  of closure of laparotomy incisions and use of different types of suture materials.

Some authers published that there was a high incidence of wound dehiscence (3.88 to

14%)5,9 after multilayer closure of abdominal incisions with catgut sutures. In the other aspect,  recent  experimental  and  clinical studies have reported a significant  reduction in the incidence of burst abdomen by using a single layer closure of laparotomy incisions with a non-absorbable suture material.

The incidence of burst abdomen with this technique  varies  from  0 to  0.9%. 2,4,11,12  In some cases, skin cut through had occurred before the linea alba and rectus sheath healed strongly, especially in patients with increased

intra-abdominal pressure and with high risk factors.  Thus the logical answer is therefore to support the wound edges as a trial to avoid it. We tried to  solve  this problem   through placing two SC plastic tubes.

Thus  the  purpose  of  the  present  study was to assess the efficacy of a mass closure technique of laparotomy incisions with interrupted   monofilament    polyprolyne sutures  after wound edges augmentation with two subcutaneous tubes in the prevention and treatment of burst abdomen.

Patients and methods:

The present study was carried out over a period  of  two  years  from  September  2009 to September  2011 and included 50 patients in Zagazig University Hospital, Surgery Department, operated on by the four authors for various intra abdominal conditions.  Both emergency  and routine  cases were included and there was no patient selection. The patients

were  particularly  assessed  for the  presence of factors responsible for delayed wound healing and burst abdomen, i.e. nutritional status, anaemia, hypoproteinaemia, pre- and postoperative prolonged steroid therapy, peritonitis, malignancy, presence of jaundice, uraemia, prolonged post-operative abdominal distension and persistent cough. Such cases were included in the high risk group for developing burst abdomen.5,9

Post-operatively,  each  patient  was examined for the presence or absence of any wound  infection,  extrusion  of  suture  ends, sinus formation and development of burst abdomen.  The diagnosis  of  burst  abdomen was made when all the abdominal layers gave way.s

Technique:

After completion of intraperitoneal procedure,  First step  was to  make  a small stab  wound  incision  (lcm) about  two  em away from  the  wound  edges  in  both  sides to introduce the plastic tubes through subcutaneous tunneling using a long artery forceps Figure(l).

Second step; a deep seated suture picking up  all layers  including  the  skin  was made. The parietal peritoneum, posterior rectus sheath, and the anterior rectus sheath were all

Table (1): Preoperative patient's characters'.

approximated by a single layer of interrupted sutures of No. '1' monofilament polyprolyne, mounted on a large half circle, cutting needle. Each suture was placed 2 to 2.5 em away from the  wound  edge including  the  plastic tubes on either side,  at an interval of about 3 em from each other. In the case of paramedian incision,   rectus  muscle   was  not   included within the suture bite. To achieve this, while passing  suture  through  the  lateral  cut  edge of the incision, first the peritoneum and the posterior rectus sheath were pierced, then the medial border of the muscle was displaced laterally with the curve of the needle, before finally passing the suture through the anterior rectus sheath.

Interrupted sutures were taken in between the deep tension sutures with Vicryl suture 2/0 picking  also  all layers in one mass  closure. The skin was closed as a separate layer with

3/0 silk sutures.

Age,  weight,  body  build,  site  and  type of incision, preoperative and postoperative complications,   and  the  bacteriological findings   in  the  wound   and  status   of  the surgeon who performed the wound closure were   noted.   The  patients   were  reviewed at one, three,  six, and 12 months,  when the presence of any infection or wound herniation was carefully recorded.

Table (2): Postoperative complications.

Results:

There   were  50  patients,  40  males  and

10  females.  The  age  vruied  fi:om 1  to  62 yeru·s with  an  average   44  yeru·s of  age.

30   patients  were  operated   on  as  elective cases, while 20 undetwent an emergency lapru·otomy. The  majmity  of  cases  were explored through a midline incision Table(l) Eighty  percent  of  the  patients  belonged  to high 1isk group  for the development  of the

burst  abdomen.  Table(l) shows  the list  of predisposing causes present in these patients.

- None of the patients developed  burst abdomen

- One case developed incisional henria.

-  Superficial  wound  infection  was  noticed in 5 cases. However, in all of them the wounds healed in due course of time, without  requiting  removal  of  the  nylon

sutures Table(2).

Figure (1): Diagram showing placing SC tubes at either wound edges.

(a): During operation.                                                                               (b): After operation.

Figure (3): An infant with bust abdomen after exploration and colostomy in a transverse incision closed by our method. (a,b)

(a): During operation.                                        (b): After removal oftubes. Figure (2): An edery patient 65 year after splenectomy due to malignancy in a subcostal

incision closed by our method.(a,b)

Discussion:

The ideal method of abdominal wound closure has not been discovered. The ideal method  should be technically  so simple that the results are as good in the hands of the trainee  as  in  those  of  the  surgical  master. It should  be  free  from  the  complications of burst abdomen, incisional hernia, and persistent sinuses; it should be comfortable to the patient; and it should leave a reasonably aesthetic scar.ll Since 1975 a series oftrials of different techniques  of closure of abdominal incisions were conducted.3,5,10,15 We report here a modification trial for a mass closure technique to improve the results of abdominal closure.  It is  very  much  within  the  means

of a surgeon to prevent the development of burst abdomen from taking place, even in the presence  of predisposing factors responsible for poor wound healing (e.g. poor nutrition, cirrhosis of liver, uraemia, prolonged steroid therapy, infection and malignancy) and cutting through of suture material (post-operative paralytic    ileus,    and    persistent     cough). In  our  series  we  had  various  risk  factors that  threaten  to  burst  abdomen  and  delay wound healing thus we advised to use a monofilament non-absorbable polypropylene sutures    to    overcome    this    risk    factor. Marked reduction in the incidence of burst abdomen   can  be  achieved   by  utilizing   a proper  suture   material  and  by  employing

a  correct  teclmique  of  abdominal  closure. From   the   above   criteria,   chromic   catgut suture  appears  highly  unsatisfactory  for closure  of laparotomy  incisions.  It loses its tensile strength very fast and little is left after

8-9 days. It gets prematurely  absorbed.l,4,14

Jones  et  aLl  first  reported  the  use  of  an interrupted             mass       far                  and-near   suture technique  and  had only one  burst abdomen in  81operations  after  steel  closure.  We had the same satisfactory results  with no patients with   burst   abdomen   after   our  technique. GoligherlO  reported    one   burst             abdomen and    no          hernias          after                 108   paramedian elective       laparotomies    using    interrupted

28-gauge    stainless    steel    wire    sutures. Similar satisfactory results have been reported in our work without the use of stainless steel sutures, with no patients with burst abdomen. Using         monofilament         polypropylene suture, we decreased the incidence of late incisional  herniation,  in  our  series  to  2 %. In other  series  by  Pollock,3-4 Kei116  and Blomstedt7  the   herniation   rate  was   11%, using polyglycolic acid sutures, which is unacceptably high. Most of these wound failures occurred within the first three months and possibly result from the disappearance of the suture material before sufficient collagen has   been   laid   down   to   restore   intrinsic tensile   strength.    Polyglycolic   acid   loses over 90% of its strength within three weeks8 whereas the abdominal wall fascia requires about   120   days   to   regain   its   strength.9

Versus   The   original   technique    of   mass closure under the skin by Dudley (1970)16 showed  that  the  tendency  to  cut  through is  inversely  proportional  to  the  size  of  the tissue bite. Thus smaller tissue bites have a higher  incidence to cut through.  Thus if we put an augmentation tube on either side of wound edges as our technique   and making deep   seated   sutures   picking    all   layers, we can avoid the risk of cut through and postoperative herniation or burst abdomen. Moreover, in our procedure the wound augmentation,   even if a small bite of tissue by  the  suture  still  occurs,  the  distribution of  forces  will  be  distributed  to  the  whole wound   length  not  only  the  suture  site.  It

offers enough support till healing is complete and avoids the process of cut through. Experimentally,   it   has   been   proved   that the    mean    suture    holding    capacity    of the   anterior   rectus   sheath   alone   is  just over half that of full thickness of the peritoneum,  muscle  and  the  aponeurosis.l 6

Agarwal et al,17 reported that closure of midline incision by reinforced tension line (RTL) on 90 patients resulted in no burst abdomen, the same satisfactory results have been reported in our work. The interrupted sutures  were  preferred  over  continuous sutures in the present study, as it was feared that continuous mass suture might produce strangulation   of   the   tissues    included   in the bite. Though Jenkin (1976)5 has used continuous   sutures   with   good  results,   he has recommended that a ratio of about 4:1 between  the  length  of  the  suture  material and the wound length should be maintained to avoid strangulation  of the tissues. Conclusion: There was zero per cent incidence ofburst abdomen in the present series despite the presence of predisposing factors in the majority  of  cases. The type  of surgery, the basic  disease, type  of incision  and age and sex of the patient did not  affect the results.

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6-   Keill  RH,   Kcitzer  WF,  Nichols   WK,