Finding the best abdominal closure: An evidence-based review of the literature

Background

Despite advances in surgical technique and materials, abdominal fascial closure has remained a procedure that often reflects a surgeon’s personal preference with a reliance on tradition and anecdotal experience. The value of a particular abdominal fascial closure technique may be measured by the incidence of early and late wound complications, and the best abdominal closure technique should be fast, easy, and cost-effective, while preventing both early and late complications. This study addresses the closure of the vertical midline laparotomy incision.

Data sources

A MEDLINE (National Library of Medicine, Bethesda, Maryland) search was performed. All articles related to abdominal fascia closure published from 1966 to 2003 were included in the review.

Conclusions

Careful analysis of the current surgical literature, including 4 recently published meta-analyses, indicates that a consistent conclusion can be made regarding an optimal technique. That technique involves mass closure, incorporating all of the layers of the abdominal wall (except skin) as 1 structure, in a simple running technique, using #1 or #2 absorbable monofilament suture material with a suture length to wound length ratio of 4 to 1.

Introduction

Despite advances in surgical technique and materials, abdominal fascial closure has remained a procedure that often reflects a surgeon’s personal preference with a reliance on tradition and anecdotal experience. Several theoretical and practical facts have been described about operative site healing and include the physiology of fascial healing, the physical properties of specific closure methods, the properties of the available suture materials, and patient-related risk factors.1, 2 Yet the ideal techniques and materials, although suggested by the surgical literature, have not been uniformly accepted.

The value of a particular abdominal fascial closure technique may be measured by the incidence of early and late wound complications. Early complications include wound dehiscence (sometimes associated with evisceration) and infection, whereas late complications are hernia, suture sinus, and incisional pain.

The best abdominal closure technique should be fast, easy, and cost-effective, while preventing both early and late complications. Traditionally, individual authors have advocated 1 technique over another for theoretical or practical reasons, but until recently, evidence-based principles have not been applied to the subject as a whole. Relevant factors for review include (1) layered closure, mass closure, and retention sutures; (2) continuous closure and interrupted closure; (3) suture material, and (4) suture thickness and the suture length-to-wound length ratio. Careful analysis of the current surgical literature, with the identification of evidence-based conclusions, indicates that a relative consensus exists regarding the most effective method of midline abdominal fascial closure.