Br. J. Surg. Vol.

63 (1976) 873-876

The burst abdominal wound : a mechanical approach

The burst abdominal wound has a mechanical cause. It is the result of suture breaking, knot slipping, the intact suture cutting out of the tissues or protrusion of gut or ornentum between stitches. Measurements of abdominal girth and the xiphoidpubis distance before and during abdominal distension show that a wound may lengthen by 30 per cent if distension occurs. An adequate reserve of suture length in the wound is necessary to allow this lengthening to occur and to ensure a minimal resulting rise in tension between the sutures and the tissues. Three variables present in every continuous wound closure-the suture length inserted, the wound fascial length and the number of stitches-determine the stitch interval and the size of the tissue bite, which are the two vital factors in wound strength under the surgeons control. These variables may be expressed by the ratio ojthe length of suture (SL) inserted to the wound length (WL),the ratio SL : WL. Analytical and clinical evidence is presented to show that: I . Deep wound disruption (evisceration and ventral hernia) is associated with the use of an SL : WL ratio of 2 :1 or less-the lower the ratio, the greater is the risk of a burst wound. 2. Wound disruption because of cutting out of sutures can be prevented by the use of non-absorbable continuous sutures at I-cm intervals and an SL : WL ratio of 4 :I or more. SURGEONS seem to have accepted as unavoidable a continuing incidence of deep wound disruption (with or without evisceration) of about 5 per cent in vertical laparotomy wounds, and recent writers have continued to propound the view that neither the suture material (Reitamo and Moller, 1972) nor the technique used (Efron, 1965; Ferrer, 1969) is of importance. No rational explanation of the occurrence of wound bursting has been offered and little attempt has been made either to analyse the mechanical factors potentially involved in disruption or to relate these to the apparent remarkable success of some surgeons using particular methods of avoiding burst abdominal wounds in their own practice (Abel and Hunt, 1948; Spencer et al., 1963). A return to first principles offers a solution to the problem, and in this paper a theoretical analysis of the abdominal wound exposed to distending intra-abdominal forces and the practical application of this analysis to wound closure are presented.

inverse relationship to the distribution of forces at the suture-tissue interface. Thus, large bites with thick sutures should have less tendency to cut out than small bites with thin sutures. However, this statement neglects the dynamic state of the wound after laparotomy and the changes in tension which may result from stretching as the abdomen distends. This will now be considered, principally in relation to continuous sutures.
Changes in girth, xiphoid-pubis distance and wound length The wound fascial layers tend to lengthen as the abdomen distends. Table I gives the percentage change in values for abdominal girth and xiphoid-pubis distance for three distending circumstances : voluntary inspiration, Caesarean section and paralytic ileus. In the last two cases the values found (mean and extreme) are such that an increase in wound length of 30 per cent is a reasonable figure to select for use in further calculations.
Table I : INCREASES IN GIRTH AND XIPHOIDPUBIS DISTANCE CAUSED BY ABDOMINAL DISTENSION increase in distension
Abdominal distension associated with : Voluntary inspiration (n= 18) Caesarean section (n = 27) Gut obstruction or paralytic ileus
(n= 5 )

Type of measurement Girth Xiphoid-pubis Girth Xiphoid-pubis Girth Xiphoid-pubis

Mean value 6 12 18 15 27 37

Extreme value

11 18 94 36
53 67

Mathematical approach to a single stitch in a confinuous suture Consider a length of continuous suture (Fig. 1) inserted to resemble a series of identical isosceles triangles, thus maintaining a constant transverse distance across the wound ( T D in Fig. 1). Selection of an isosceles triangle stitch pattern simplifies calculation. By geometric use of one individual stitch, ATB, and by dropping a perpendicular, T D , a rightangled triangle, DTB, is defined in which D B is half the stitch interval and TE is half the stitch length. It is clear that: T D = J[(TE)2-(DB)Z],

Theoretical analysis It has been shown (Dudley, 1970) that the size of the bite and the diameter of the suture material bear an

and that this distance, T D (which is the sum of the tissue bites), can be related to the stitch interval and the stitch length.

* St Lukes Hospital, and Royal Surrey County Hospital, Guildford.

T. P. N. Jenkins
Table 11: COMPARISON OF THE NUMBER OF EVISCERATIONS OCCURRING IN THE PERIODS 1947-56 AKD 1957-73 1947-56 1957-73 Type of incision

No. of No. of eviscerawounds tions

D
B

Upper paramedian Upper midline Lower paramedian Full length paramedian Total
f = 15.81, P<O.Ol.

5 3 0 0
8

No. of No. of eviscerawounds tions I15 0 323 0 369 1 38 0 1505

Fig. 1. Geometric use of an individual stitch, ATS, in a continuous suture closure. AB is the stitch interval and T D comprises the two tissue bites.

- - - - - .
1.94 SL : WL 4:l Suture length(cm) 40 Wound length(cm) 10

TD (cm)

0.87 0.4 2 : i 1.3:I

I
20
10

4
I
i

I
1

I
I
I

1
I

13
10

1.89 4:f 40

0.76 O
2 : l 1.3:I

2o
13.3

13.3

13 13.3

Fig. 2. Diagrams of three 10-cm wounds each closed with a continuous suture at an SL : W L ratio of 4 : 1, 2 : 1 or 1.3 : 1 and a stitch interval of 1 cm. Following 30 per cent wound lengthening, as by abdominal distension, the stitch interval becomes 1.3 cm.

Further, for an individual stitch of given length, lengthening of the base of the triangle, AB, by wound stretching must reduce T D . Reduction of T D implies tissue compression and a rise in tension. The amount of reduction of T D and also the rise in tension between sutures and tissues can be calculated for any percentage of wound stretching and for closure by any ratio of suture length to wound length (SL : WL). The mathematical result of stretching wounds by 30 per cent Fig. 2 shows three 10-cm wounds closed with an overand-over continuous suture adjusted to appose the cut edges but differing in the size of the tissue bites.
874

The stitch interval is 1 cm initially in all three, becoming 1.33 cm when stretched by 30 per cent as by distension. For subsequent practical application instead of determining bite size directly it is easier to choose an S L : WL ratio which expresses the same measurement. In the model (Fig. 2) a 4 : 1 ratio gives a value TD of 1.94 cm, a 2 : 1 ratio 0.87 cm and a 1.3 : 1 ratio 0.4 cm. If the wound is lengthened by 30 per cent and the suture length remains (as it must) constant the new values for TD are 1.89, 0.76 and 0 cm. Small bite continuous suturing such as with an SL : WL ratio of 1.3 : 1 would favour wound disruption by the suture cutting through the tissues. These observations can be generalized by plotting the SL : WL ratio against the percentage decrease in transverse distance T D caused by abdominal distension (Fig. 3). The shorter the suture, the smaller is the bite of tissue and, in response to stretch, the greater is the resulting tissue compression and rise in tension, whatever the surgeon may think about the size of bite at the time of wound closure. From Fig. 3 , SL : WL ratios of 4 : 1 or more seem ideal for maintaining the tension between sutures and tissues at a minimum. Conversely, as the SL : WL ratio decreases from 2.5 : 1 the risk of wound disruption increases and it would appear to be inevitable at an SL : WL ratio of 1 : 1 or less. The analysis of interrupted suture closure follows similar but simpler lines. However, wound elongation still lengthens the stitch interval, thus increasing the risk of protrusion of abdominal contents between stitches. Shortening the length of the interrupted loop in tying the knot inevitably compresses the tissue held, so increasing the tension at the stitch site. If the stitch is tied just to oppose the fascia1 cut edges and the suture length in the knot and the knot tails is ignored, for a tissue bite of 1 cm (moderate size) the stitch length is at least 4 cm and this with a stitch interval of 1 cm requires an SL : WL ratio of 4 : 1.
Clinical studies Ratio of suture length to wound length in evisceration and ventral hernia If when there is an evisceration or ventral hernia a non-absorbable suture can be recovered, its length would provide a practical test of the SL : WL hypothesis outlined above. A less direct comparison can

The burst abdominal wound

also be attempted for absorbable sutures if the operator reinserts a suture to resemble the initial closure, removes it for measurement, measures the wound and then proceeds to a definitive and more appropriate wound closure. Data of both kinds are obviously difficult to collect, but in 7 cases that have been studied (evisceration 3, ventral hernia 4) the SL : WL ratio was less than 2 : 1, the mean was 1.3 : 1 and the lowest ratio was 0.9 : 1.
Abdominal wound absorbable sutures closure with continuous

50

40

T
CI

non-

30

0
E

Between 1947 and 1973, 2012 vertical incisons have been closed with continuous non-absorbable sutures using a stitch interval of about 1 cm by the author and his associates (Table ZZ). The material was nylon (metric 3) looped on a needle (Everett, 1970). In the period 1947-56 the tendency was to suture rather tightly, probably at an SL : WL ratio of about 2 : 1 , and there were 8 eviscerations as a consequence of the intact suture cutting out. From 1956 a large bite, slack suture technique was developed based on an SL : WL ratio of around 4 : 1. In this second series, 1957-73, only one evisceration occurred from cutting out. That this value 4 : 1 was in fact realistic was checked in 1971 by analysing a series of 127 consecutive wound closures for stitch interval, suture length and wound length, and thus the ratio of S L : WL (Table ZZZ). These data hide a biphasic distribution (Fig. 4) of the tighter wounds closed by registrars and the looser closure of the more experienced surgeon. Nevertheless, the usual ratio for the latter is in the zone 3 : 1 to 6 : 1 which conforms with the theoretical value. Although to apply statistical analysis to a consecutive series is not entirely appropriate, the difference between the evisceration rates in the two periods 1947-56 and 1957-73 is statistically significant
(Table Zl).

c
0 .! 4

I-

s 20

10

I .o

2.0

3:O

4 : O

5 1 0

SL : W L Fig. 3. Graph showing the relationship between the rise in tension between sutures and tissues caused by a 30 per cent wound stretch and the SL : WL ratio.

25

Discussion Adequate strength of suture material will prevent suture breakage, efficient knots will prevent knot slippage and a sufficiently small stitch interval will prevent protrusion of abdominal contents into the intact wound. Prevention of sutures cutting out will not be possible until the cause is recognized. As yet there is little scientific basis on which a surgeon can make his choice of closure technique; it is made largely on a basis of custom, teaching or recommendation. The expressions tight and loose suturing and small and large tissue bites have no accurate meaning unless they refer to measured

.. *... ..

SL : W L Wounds closed by consultant Wounds closed by registrars

Fig. 4. Frequency histogram of the distribution of the SL : WL ratio in 127 measured abdominal closures.

quantities, and few surgeons have applied measurements to wound closure. Abel and Hunt (1948) used a I-cm tissue bite, but did not measure the stitch interval; Spencer et al. (1963) used a 1-cm stitch
a75

T. P. N. Jenkins interval and a 3-cm tissue bite but did not measure the suture length actually inserted (calculation of SL : W L for their data suggests a value of 12 : 1). The simple calculations described in this paper provide a basis for rational wound closure: a low incidence of dehiscence (0.007 per cent) was obtained when sutures were inserted so that the length of the suture material was greater than four times that of the wound. Conversely, lower ratios are associated with high incidences of disruption. Future studies of abdominal wound dehiscence should incorporate quantitative observation of the amount of suture material used in relation to the length of wound and must also use as the standard of comparison the low incidence that can be achieved by the technique used here. Such a monofilament closure not only gives almost complete protection from dehiscence but also acts as an inert buried tissue splint whose strength is unaffected by sepsis. Though persistent wound sinuses occurred in 3 per cent of the series between 1947 and 1956, the looser sutures now inserted and attention to cutting the tails of the knots flush have subsequently reduced this to 0.07 per cent. Acknowledgements 1 would like to acknowledge that nylon as a loop on the needle was introduced by Ted Moloney and Gordon Gill in 1945 and that I was taught the technique by the latter. I am grateful to Sister FieIdus who collected the measurements at Caesarean section, to Colin Binks for guidance in the mathematical analysis of wound measurements and to Professor H. A. F. Dudley for his kind help in the final drafting of this paper. References and HUNT A. H. (1948) Stainless wire for closing abdominal incisions and for repair of herniae. Br. Med. J . 2, 379-382. DUDLEY H . A . F. (1970) Layered and mass closure of the abdominal wall. A theoretical and experimental analysis. Br. J. Surg. 57, 664-667. EFRON G. (1965) Abdominal wound disruption. Lancet 1, 1287. EVERETT w. G. (1970) Suture materials in general surgery. Prog. Surg. 8, 15-37. FERRER R . 0.(1969) Wound disruption after abdominal laparotomies. Md State Med. J . 18, 57-60. REITAMO J. and MOLLER c. (1972) Abdominal wound dehiscence. Acta Chir. Scand. 138, 170-1 75. SPENCER F. R., SHARP E. H . and JUDE J. R . (1963) Experiences with wire closure of abdominal incisions in 293 selected patients. Surg. Gynecol. Obstet. 117, 235-238.
ABEL A. L.

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