Closing the Abdomen

Peritoneum

TRANSVERSE INCISIONS

 

1. Peritoneum

a. It is currently controversial whether to close the peritoneum following laparotomy or leave it to heal spontaneously.

b. Several recent studies have shown no benefit in closing the peritoneal membrane; however, surgeons are still concerned that failure to close this layer will result in pelvic and abdominal organs becoming adherent to the anterior abdominal wall.

c. One exception is with the May lard incision; in this case, the peritoneum should be closed to keep the split ends of the rectus muscles outside the peritoneal cavity.

d. To close the peritoneum, the following is done:

(1) The entire length of the defect can be grasped with clamps. This allows definition of the membrane and its elevation to aid in suturing.

(2) Using an absorbable or delayed absorbable suture, this layer can be closed in a running stitch, which generally begins at the cranial apex of the incision and extends to the inferior apex.

(3) When suturing near the caudal aspect of the incision, more superficial stitches should be used to avoid including the bladder.

(4) A malleable ribbon can be used to protect the bowel from inadvertent needle punctures.

e. Manipulation of this layer in patients under regional anesthesia, as at cesarean section, can result in discomfort, nausea, and vomiting.

 

2. Muscle

Closing the muscle defect in the Maylard incision is not useful in providing extra strength for the incision because the rectus will be reapproximated when the rectus fascia is closed and will heal spontaneously.

Reapproximation of the rectus muscles in the Pfannenstiel incision is also of little value.

c. In the Cherney incision, it is necessary to reattach the aponeurosis of the rectus and pyramidalis muscles to their origin on the pubic symphysis using a permanent suture.

d. Should one choose to close the muscle layer in a Pfannenstiel incision, wide bites of a delayed absorbable or absorbable suture should be used and these should be loosely tied, just allowing for gentle reapproximation of the musculature.

 

3. Rectus fascia: This layer should be closed using a delayed absorbable or permanent suture of sufficient strength.

a. The apex of the defect should be identified and the initial suture placed behind the apex, through both leaves of the fascia.

b. Care should be taken not to include the corpus of the oblique or transverse musculature because ligature of these could result in damage to the ilioinguinal and iliohypogastric nerves, causing numbness inferior to the incision and over the upper thigh.

c. The sutures should be placed at 1-cm to 2-cm intervals and at least 1.5 cm away from the cut edge. This avoids strangulation of the fascia and weakening the incision.

d. Again, the fascia should be approximated with gentle pressure and not pulled taut. This too avoids strangulation of the tissues and postoperative pain.

 

4. Superficial fascia

 

a. Recent reports have shown that closure of the superficial fascia in patients with greater than 3 cm of tissue in this plane results in a decreased incidence of wound separation.

b. When dealing with an obese patient, it is often prudent to leave this layer and the skin open to heal by secondary intention or by a delayed primary closure.

c. Other cases in which leaving this layer open is desirable include infected or contaminated cases.

d. Leaving the skin and superficial fascia open with aggressive wound care allows the area to remain clean and for good granulation tissue to accumulate before closure.

 

(1) Closure of this layer can be achieved by using a fine absorbable or delayed absorbable suture that can be run from apex to apex of the incision.

(2) Again, it is only necessary to approximate the edges of the tissue gently.

(3) Apart from allowing fewer wound separations, this stitch serves to support the skin and allows better anatomical reapproximation at skin closure.

 

5. Skin

a. There are multiple methods for closing the skin; these include the following:

(1) Skin clips

(2) A running subcuticular stitch

(3) Mattress stitches

(4) Interrupted through-and-through stitches b. An important consideration when closing the skin is potential compromise of the microvasculature.

c. This can be avoided with any of the above techniques, provided that the tissue is not strangulated at closure.

d. An advantage to the skin clips is their ease of removal to allow opening and drainage of the wound should a hematoma, seroma, or wound infection develop.

e. Another consideration when closing the skin is whether it should be closed at all. As mentioned previously, in certain cases (such as infected cases, contaminated cases, and in obese patients) leaving the skin open has certain advantages.

f. In these cases, permanent mattress sutures can be placed in the skin and subcuticular tissues and not tied. These can be left loose until adequate granulation tissue has developed in the wound and then tied at the bedside, giving a delayed primary wound closure.

 

VERTICAL INCISIONS

1. A running mass closure is an excellent means of closing a midline incision.

2. With this technique, a permanent, thick suture is used to grasp the peritoneum, the posterior and anterior rectus sheath, and the superficial fascia.

3. This is carried in a running fashion from apex to apex, avoiding the inclusion of muscle in the suture.

4. Stitches should be taken at 1-cm to 2-cm intervals and at least 1.5 cm from the fascial edge.

5. This allows the microcirculation to remain intact and results in a decreased incidence of wound eviscerations.

 

The skin incision

Paramedian incision. The skin incision is made on either the right or the left side of the abdomen along the path of the dashed line as shown in A, 1 inch lateral to the midline. The anterior rectus sheath is incised over the midportion of the underlying rectus muscle (B) and retracted laterally. The anterior rectus sheath is reflected immediately (C). The posterior rectus sheath, transversalis fascia, and peritoneum are incised in the bed temporarily vacated by the muscle (D).

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