Abdominal wall closure – techniques: Loop suture and small tissue bites - general and visceral surgery

Hold the fascia with the surgical forceps and with a twisting motion place a stitch through the fascia 1 cm from the edge Grasp the anterior and posterior fascial laminae together.

Place the first stitch about 1 cm craniad of the end of the wound to anchor the loop in the region of the fascia not incised. Start the V-shaped stitch from healthy tissue into the incision and from the incision back into healthy tissue on the contralateral side (outside in, inside out). Pull the needle through the loop and then continue in standard running technique. Suture the loop from the edge of the wound toward its middle. Space the sutures about 1 cm apart, resulting in a suture-to-wound length ratio of at least 4:1. Continue the superior row of sutures toward the midpoint of the incision. 

Note: For fascial sutures, grasp only the aponeurosis, since muscle caught by the suture would become necrotic, resulting in loosening of the fascial closure. While the peritoneum does not have to be closed separately, it may be included in the suture. Avoid peritoneal bulging in the suture line.

Owing to the length of the wound, start a second loop from the other end of the wound in the same manner. To avoid tissue strangulation, do not tighten the suture too much, nor appose the fascial edges too loosely, as this may lead to suture leakage with delayed wound healing, which also increases the risk of fascial dehiscence.

Note: Due to its elasticity, do not tighten the suture to its maximum tensile strength. This, in turn, reduces the tendency of the stitch to cut through the tissue toward the edges of the fascia and thus protects the tissue. Overstretching must be avoided at all costs, as this could cause both limbs of the loop to assume unequal lengths. Such sutures must be discarded.

To avoid any weak points, continue the inferior suture such that both looped sutures overlap in the middle by one or two stitches. Next, cut off both needles and tie the ends of both loops diagonally together with 6-8 locking knots. Optionally, tie each loop to itself. During the last stitch, do not pull the loop completely through, cut off the needle and cross one end of the suture under the remaining loop. Follow this by tying 6.8 locking knots.

Note: In emergent surgery, the abdominal wall is often closed using interrupted sutures. If the fascia can only be closed under tension, primary sutures are not recommended, but rather a temporary absorbable mesh should be implanted.

After a rapidly absorbable running suture 2/0, staple the skin closed.

A sterile wound dressing concludes the abdominal wall closure. To maintain sterile wound conditions for as long as possible, it is best to change it after 36 hours at the earliest.

Note: Subcutaneous sutures and drains are not mandatory. In significantly obese patients, short-term postoperative subcutaneous drainage with a Redon drain for 24-48 hours is an option.

As exemplified by open incisional hernia closure using the sublay technique, we want to demonstrate here the “small bites” technique favored by Israelsson, first at the posterior rectus sheath lamina and then, in the next step, after placement of the mesh exemplifying closure of the anterior rectus sheath lamina.

It is important to note that this sutures solely apposes the edges, i.e., the suture must not disappear in the tissue, but remain visible. Equally important is suture guidance by the assistant, who should only apply moderate tension in the stitch direction; this helps to avoid initial tissue trauma.

Special care must be taken with the intestines, which must never be caught by the suture and for this reason should be retracted with a spatula.

Note: Depending on the length of the wound, 1 to 2 sutures are used, the ends of which in the middle of the wound may be tied with each other, as illustrated in the example, or tied down with themselves.

As illustrated in the example, the anterior rectus sheath is closed continuously in caudocranial  direction with a 150 cm delayed-absorbable monofilament MonoMax® suture USP 2/0, keeping a distance of 5‑8 mm to the wound edges and 4 5 mm between stitches, and a suture-wound-length ratio of 5:1 or 6:1.

Note: It is important to objectively determine the length of the suture anchored in the tissue by measuring the remaining suture length.