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

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.