Abdominal wall closure – techniques: Loop suture and small tissue bites

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  • MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Surgical anatomy of the anterior abdominal wall

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    1. Muscles of the anterior abdominal wall

    Rectus abdominis muscle: straight abdominal muscle invested by the rectus sheath with its three to four tendinous intersections (intersectiones tendineae) conjoined with the anterior lamina of the rectus sheath.

    Pyramidalis muscle: originates at the superior pubic ramus, inserts in the linea alba, is situated anterior to the rectus abdominis and invested by its own sheath in the anterior lamina of the rectus sheath.

    2. Layered anatomy of the anterior abdominal wall

    Rectus sheath: Invests the rectus abdominis muscle; craniad to the midpoint between the umbilicus and pubic symphysis, the sheath divides into an anterior and posterior lamina. The posterior lamina ends there in the shape of the arcuate line; craniad to this line, the abdominal external oblique inserts in the anterior lamina of the rectus sheath, the abdominal internal oblique in both the anterior and posterior laminae, and the transverse abdominal muscle in the posterior lamina.

    Semilunar (Spigelian) line: Transition zone between the aponeuroses of the lateral abdominal muscles and the lateral edge of the rectus sheath.

    Linea alba: About 1 cm wide firm band of connective tissue between the right and left rectus sheaths, extending from the sternum to the pubic symphysis.

    Transversalis fascia: Craniad to the arcuate line, it covers the posterior lamina of the rectus sheath, while caudad it is in intimate contact with the rectus abdominis.

    3. Internal relief of the abdominal wall

    Median umbilical fold: Median fold of peritoneum extending from the umbilicus to the urinary bladder; the fold invests the median umbilical ligament (strand of connective tissue = remnant of the urachus).

    Medial umbilical fold: Paired folds of peritoneum; each side investing the medial umbilical ligament = obliterated remnant of the paired umbilical artery.

    Lateral umbilical fold: Paired folds of peritoneum; on each side craniad to the inferior epigastric artery, with its two accompanying veins each.

    4. Vessels and nerves

    a) Arteries

    Superior epigastric artery: Extension of the internal thoracic artery, anastomoses with the inferior epigastric artery at the level of the umbilicus.

    Inferior epigastric artery: Arises from the external iliac artery and courses, just like its superior counterpart, within the rectus sheath on the posterior surface of the rectus abdominis.

    Superficial epigastric artery: Arises from the femoral artery and, after passing over the inguinal ligament, radiates into the subcutaneous tissue of the anterior abdominal wall.

    Posterior intercostal arteries VI-XI and subcostal artery: Arise from the thoracic aorta; their terminal segments course obliquely caudad between the abdominal internal oblique and transverse abdominal muscles, and coming from the lateral aspect they extend into the rectus sheath, where they join with the superior and inferior epigastric arteries.

    b) Veins

    Superior epigastric veins: Parallel the eponymous artery; anastomose with branches of the inferior epigastric vein and empty into the internal thoracic veins.

    Inferior epigastric vein: Branches into veins accompanying the inferior epigastric artery and empties into the external iliac vein.

    Superficial epigastric vein: Parallels the eponymous artery (see above)

    c) Lymphatics

    Superficial lymphatics Craniad to the umbilicus, they course to the axillary lymph nodes and caudad to the inguinal lymph nodes.

    Deep lymphatics Usually parallel the blood vessels, pass into the parasternal, lumbar, and external iliac lymph nodes.

    d) Nerves

    Intercostal nerves VI – XII: As ventral rami of the thoracic nerves VI - XII; they course posterior to the rib cartilages into the abdominal wall between the internal abdominal oblique and transverse abdominal muscles; motor branches supply the anterior and lateral abdominal muscles, and sensory branches the abdominal skin.

    Iliohypogastric nerve, ilioinguinal nerve, and genitofemoral nerve: Involved in motor and sensory innervation of the inferior  abdominal region and genitals.

  • Physiology of the abdominal wall

    Function and tension systems of the abdominal wall

    Due to their distance from the spine, the straight muscles of the abdominal wall can exert considerable leverage on the spine. When bending forward, the four oblique abdominal muscles act in unison and synergistically, thereby supporting the rectus abdominis muscles.

    The Valsalva maneuver or abdominal press involves the synchronous contraction of the abdominal muscles, diaphragm, and pelvic diaphragm. Since the diaphragm is much weaker than the abdominal muscles, effective Valsalva maneuver necessitates closing the glottis and retaining air in the lungs which, when filled with air, buttress the diaphragm.

    When upright, the abdominal muscles in the human body bear the load of the abdominal cavity contents. The weight of the intestines increases from craniad to caudad and thus so does the load on the abdominal wall, which explains why the latter protrudes more strongly inferior the umbilicus. The tension of the abdominal wall in midline laparotomy is double that laterally, with a simultaneous increase in the craniocaudal direction. Interlacing of the aponeuroses of the abdominal muscles along the linea alba results in the formation of functional muscle loops.

    Thus, the integrity of the abdominal wall plays a key role in physical strength.

    Mechanics

    The mechanical demands placed on fascial closure depend primarily on the intraabdominal pressure. While the resting pressure is about 0.2 kPa, the maximum pressure is just under 20 kPa (= 150 mmHg). However, the suture retention force required for secure fascial closure also depends on the diameter of the abdominal cavity. For example, with an abdominal circumference of 100 cm and an intraabdominal pressure of 20 kPa, the required mean suture retention strength is 16 N/cm.

  • Pathophysiology of wound healing and incisional hernia formation

    50% of incisional hernias develop within the first 5 months, 75% within the first 2 years, and 97% within the first 5 years. Studies in patients who developed incisional hernia within 3 years revealed that beginning postoperative scar failure already developed during the first 4 weeks. Where technical errors can be ruled out, Incisional hernia formation therefore is nothing more than a failed attempt to induce strong enough scar tissue at the site of the abdominal wall incision.

    Wound healing resembles inflammatory processes. Produced and deposited in the wound, particularly in the first two months after surgery, collagen is of fundamental importance for mechanically strong healing. This is followed by so-called “cross-linking”, equivalent to collagen maturation, which may persist up to 12 months. Collagen metabolism disorders, among other factors, are blamed for the frequent occurrence of inguinal hernias.

    The most serious wound healing disorder is manifest wound infection. Other factors interfering with formation of a stable scar include:

    • Suture materials
    • Suture technique
    • Bacterial contamination
    • Local perfusion (hypoxia decreases collagen synthesis)
    • Zinc deficiency
    • High calcium level
    • Dehydration

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  • Special anatomical and functional aspects of the anterior abdominal wall

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  • Aspects of surgical wound closure in laparotomy

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  • Suture material

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  • “Small bites” technique

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  • Subcutaneous wound closure and skin sutures

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  • Abdominal wound dehiscence

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  • Continuous fascial closure with looped sutures; superior suture

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    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.

  • Continuous fascial closure with looped sutures; inferior suture

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    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.

  • Continuous fascial closure with looped sutures; knotting technique

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    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.

  • Subcutaneous sutures and skin closure

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    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.

  • Running fascial closure ("small-bites" technique) with sublay mesh; posterior rectal sheath lamina

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    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.

  • Running fascial closure ("small-bites" technique) with sublay mesh; anterior rectal sheath lamina

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    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.

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  • Postoperative complications and their prevention

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  • Klinikum München Schwabing

    Dr. med. Anne Heiss

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  • Literature summary

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  • Current trials

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  • References on this topic

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  • Reviews

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  • literature search

    Literature search under: http://www.pubmed.com