ORIGINAL ARTICLE

Modified Midline Abdominal Wound Closure Technique in

Complicated/High Risk Laparotomies
Badar Murtaza1, Naser Ali Khan1, Muhammad Ashraf Sharif2, Imran Bashir Malik3 and Asad Mahmood4

ABSTRACT
Objective: To assess the local wound complications in complicated/ high risk laparotomies in terms of wound dehiscence
and incisional hernia formation with a modified technique of midline abdominal wound closure.
Study Design: Quasi-experimental study.
Place and Duration of Study: Department of General Surgery, Combined Military Hospital, Bahawal Nagar Cantonment,
May 2006 to June 2008.
Methodology: Cases of complicated/high risk abdominal conditions, which required laparotomy, were included in the
study. A modified midline abdominal wound closure technique was used. Interrupted Smead-Jones sutures with prolene,
a non-absorbable suture material for closure of linea alba was combined with mass closure involving all the layers (also
with prolene) and drains were placed. Patients were followed-up for 3-23 months. The postoperative wound dehiscence
and incisional hernia formation were noted. Other local wound complications were also recorded.
Results: Out of the 36 patients undergoing this surgical technique, 20 (55.55%) had inflammatory/intra-abdominal sepsis,
8 (22.22%) had trauma, 7 (19.44%) had neoplasia and 1 (2.77%) had vascular aetiology. Only 1 (2.77%) had partial wound
dehiscence and 1 (2.77%) developed incisional hernia. Wound infection was noted in 12 (33.33%) cases; 4 (11.11%)
experienced pain over the subcutaneous palpable knots and 3 (8.33%) developed sinus due to the knots. The average
follow-up period was 12.47+7.17 months.
Conclusion: Patients with extensive widespread generalized peritonitis and metastatic abdominal tumours need special
attention regarding wound closure. This modified technique of midline abdominal wound closure is associated with low
incidence of wound dehiscence and incisional hernia formation.

Key words: Complications. Midline wound closure. Wound dehiscence. Infection. High risk. Laparotomy. Smead-Jones sutures.

INTRODUCTION over the world, but the cost of closing the abdominal
Laparotomies whether elective or emergency, always wound ranges from 3.64 pounds to 20.40 pounds.1 The
remain commonly encountered surgical procedures in main problem arises in dealing with complicated
every surgical department. Pre-operative assessment is laparotomies like cases of extensive peritonitis or even
very essential in knowing the general condition of the in patients with metastatic tumours. In such cases, a
patient but may prove inadequate in making a definitive modified technique for the closure of midline abdominal
diagnosis. Various incisions have been introduced but wounds is used employing Smead-Jones interrupted
the most commonly performed by many surgeons, sutures to the linea alba alongwith mass (all-layer)
remains the midline one. It gives rapid access into the closure with polypropylene. These cases are high risk
peritoneal cavity and the upper midline incision is almost ones and any re-do surgery for burst abdomen or
bloodless. The success of any kind of surgery is not only incisional hernia, can prove not only difficult but also
dependent upon the procedure adopted but also on the increases their morbidity and mortality. The incidence of
method adopted for wound closure and its sequel. wound disruption after 2030 median laparotomies was
noted as 1.3%.2 Postoperative complete wound
The closure of the midline laparotomy wound aims at dehiscence, being an unfortunate and also a very
bringing the wound edges together with the least tissue serious complication, is associated with high morbidity
damage so that adequate healing can occur. The and mortality,3 despite the most sophisticated intensive
material should cause minimum disturbance of the care these patients receive today. The aim of this study
tissue but allow the wound to gain sufficient strength to was to analyze the local wound complications in terms
avoid late herniation. A variety of midline abdominal of wound dehiscence and incisional hernia formation
wound repairs have been introduced and practiced all using this modified midline abdominal wound closure
technique in complicated/high risk laparotomies.
Department of General Surgery1/Pathology2/Anaesthesia3/
Medicine4, Combined Military Hospital, Bahawal Nagar Cantt. METHODOLOGY
Correspondence: Dr. Badar Murtaza, 675-A. Mazhar Qayyum This study was conducted at the Combined Military
Road, Old Lalazar Colony, Rawalpindi. Hospital, Bahawal Nagar Cantonment, from May 2006 to
E-mail: [email protected] June 2008. Cases of complicated/high risk laparotomies,
Received June 16, 2008; accepted June 15, 2009. were included in the study. Only those cases were

Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (1): 37-41 37
Badar Murtaza, Naser Ali Khan, Muhammad Ashraf Sharif, Imran Bashir Malik and Asad Mahmood

included which either had extensive generalized all the cases. Interrupted Smead-Jones sutures were
peritonitis (with extensive peritoneal contamination and applied to the linea alba using No. I prolene suture. In
soiling) or metastatic abdominal tumour. Cases with between two/ three interrupted sutures, mass (all layer)
minimal peritoneal contamination, planned laparotomies suture was applied with No. 1 prolene (polylpropylene).
for benign abdominal lesions/tumours and simple and The Smead-Jones sutures were double far-near, near-
straight forward laparotomies were excluded from this study. far sutures applied to the linea alba. However, the mass
All the cases were initially received in the general out sutures were passed through all the layers from the skin
doors/emergency and later referred for surgical to the peritoneum about 3-4 cm from one margin, then
consultation. A detailed history and clinical examination brought out from the edge of the linea alba on the
was conducted by two general surgeons. The data was ipsilateral side, followed by pushing it inwards from the
noted on a proforma. Baseline investigations like margin of the linea alba on the contralateral side. Lastly,
complete blood count, urinalysis, serum urea/ the suture was brought out from the peritoneum passing
creatinine, serum electrolytes, chest radiograph, through all the layers to the skin on the contralateral side
electrocardiograph and blood sugar (random) were about 3-4 cm from the margin (Figure 1). The skin was
noted in all the cases. Abdominal radiographs and not closed primarily and was left open in a majority of
ultrasonography was also done in a few cases. Blood cases. All the patients were started on injectable
cefoperazone/salbactum 2 grams 12 hourly, combined
was also sent for grouping and cross matching. All the
with injectable metronidazole 500 mg 8 hourly. The
patients had an acute presentation and required
wound was managed by daily antiseptic dressings. The
immediate intervention. Initially intravenous fluid
injectable antibiotics were continued for 5 days and this
resuscitation was carried out with Ringer’s lactate
was later followed by oral sparfloxacillin 200 mg 12
solution alongwith Foley catheterization and nasogastric
hourly for another 5 days. The patients who developed
intubation. All the patients were assessed by one
wound infection were also given injectable amoxicillin/
anaesthetist, written and informed consent was taken
clavulanate 1.2 gram 8 hourly intravenously alongwith
after counseling regarding the condition of the patient
twice daily change in dressings. The patients were
and the possible outcomes.
discharged from the 5th to 9th postoperative day, except
Under general anaesthesia, the operative field was in 3 cases who were discharged from the 17th to 25th
prepared with povidone iodine and all the patients were postoperative day. All layer sutures were removed after
opened through a midline abdominal incision with a size 2 weeks of surgery. All the patients made a satisfactory
20 blade and the surgical procedure was conducted recovery except one case which had a fatal outcome.
according to the requirement of the underlying disease. Postoperatively the patients were followed-up regularly,
After dealing with the primary pathology, a thorough initially weekly for one month and later three monthly.
peritoneal lavage was performed in all the cases with 12 The total follow-up period was variable and had been
litres of normal saline. Two drains were placed in the continued for 3-23 months (mean 12.47+7.17).
peritoneal cavity using a 28Fr Foley catheter and were Data was entered in SPSS version 16.0 and statistical
brought out through separate stab incisions. The drains analysis was done. Mean was calculated for descriptive
were placed in both the paracolic gutters extending into variables like age, sex, follow-up period while frequency
the pelvis, except in the cases of perforated duodenal was determined for different diagnoses (complicated/
ulcers where one drain was placed in the Rutherford high risk) of cases undergoing emergency laparotomies
Morrison’s Pouch and the other in the pelvis. A modified along with wound dehiscence and incisional hernia
repair of the midline abdominal wound was performed in formation.

Figure 1: Modified midline abdominal wound closure technique.

38 Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (1): 37-41
Modified midline abdominal wound closure technique in complicated/high risk laparotomies

RESULTS to total parenteral nutrition. Three had disseminated

intravascular coagulation, out of which one expired and
Out of the 36 cases studied, 25 (69.4%) were males and
the rest improved. Hypoproteinaemia was noted in 5
11 (30.6%) were females. Their age ranged between
cases as well. We had 1 (2.77%) mortality. She was a
17-70 years (mean 42.28+14.80). This study included
case of sigmoid perforation with faecal peritonitis, who
20 (55.55%) inflammatory (intra-abdominal sepsis),
not only developed wound dehiscence but also went into
8 (22.22%) traumatic, 7 (19.44%) neoplastic and
multi-organ failure and could not recover.
1 (2.77%) case of vascular aetiology. The different
diagnoses of the abdominal conditions requiring
emergency laparotomy are mentioned in (Table I).
DISCUSSION
A variety of abdominal wound closure techniques have
Table I: Diagnosis of exploratory laparotomies.
evolved over many years. However, wound dehiscence
remains a serious complication. Penninckx et al.3
Aetiology Diagnosis No. Percentage
Inflammatory Acute perforated appendicitis 7 19.44%
(n 20) Perforated duodenal ulcer 6 16.66% documented a 2.58% wound dehiscence in 4538
Tuberculous peritonitis 3 8.33%
patients treated with gastrointestinal operations. An
Enteric perforation 1 2.77%
Primary peritonitis 1 2.77%
interesting observation was that the group of patients
Perforated acute acalculous cholecystitis 1 2.77% with diseases pre-disposing to wound dehiscence had a
Post c section peritonitis/ wound infection 1 2.77% significantly higher incidence of wound dehiscence
Traumatic Sigmoid perforation/ faecal peritonitis 3 8.33% (4.45%) in contrast to a group of patients presenting with
(n 8) Traumatic ileal perforation 2 5.55%
so-called non-predisposing diseases (0.43%). They also
Traumatic jejunal perforation 1 2.77%
Gun shot wound abdomen/ rectal injury 1 2.77% noted that complicated neoplasms and complicated
Uterine rupture/ induced abortion 1 2.77% inflammatory diseases had an extremely high frequency
Neoplastic Metastatic carcinoma colon 4 11.11% of wound dehiscence; 15.07% and 22.73% respectively,
(n 7) Metastatic granulosa cell tumour ovary 1 2.77% with routine continuous suture closure technique. The
Ruptured mucinous adenoma ovary 1 2.77%
Ruptured benign cystic teratoma ovary 1 2.77%
frequency of wound dehiscence after emergency
Vascular Mesenteric vascular occlusion with acute 1 2.77% laparotomy was 6.7% as compared to 1.5% in elective
(n 1) peritonitis cases. Rahman recorded abdominal wound dehiscence
in 7 (23.23%) cases, among the 33 patients of
The main complications encountered in these patients
spontaneous ileal perforation with acute peritonitis and
was wound infection. It was seen in 12 (33.33%) cases.
an incidence of wound infection in 30.3%.4 This study
Out of these, 01 (2.77%) patient developed partial
also had a small number of patients, but all were
wound dehiscence. This was a case of sigmoid
perforation with faecal peritonitis. Apart from the wound emergency laparotomies with complicated and high risk
infection she also developed prolonged paralytic ileus, cases (neoplasms and intra-abdominal sepsis). There
which had a fatal outcome. One (2.77%) patient had an was only a single case of partial wound dehiscence with
incisional hernia formation. He was a case of gun shot the modified midline abdominal wound closure
wound in the abdomen with rectal injury. He had an technique. Wound dehiscence is associated with a
extensive deep wound infection which took about 3 mortality of above 25%.5,6
weeks to recover. In 4 (11.11%) cases, the patients had van t Riet et al.7 noted that out of 168 patients with wound
pain over the palpable knots and out of these, 3 (8.33%) dehiscence, 42 (25%) died within 60 days of surgery
developed sinus due to the knots (Table II). The pain and 55 of the remaining 126 developed an incisional
subsided with analgesics. However, 2 cases of sinus hernia.7 The rate of incisional hernia is higher after
formation required removal of the underlying stitch.
emergency midline laparotomies. It has been noted to
Table II: Local (wound) complications. be upto 18.1% as well.8 In this study, there was only
Complications Number Percentage
patient who developed an incisional hernia later. Apart
Wound sepsis 12 33.33%
Wound dehiscence 1 2.77%
from the surgical technique, better preparation of the
Incisional hernia 1 2.77% operative field and scrupulous sterility throughout the
Painful knots 4 11.11% procedure can decrease the incidence of postoperative
Knot sinus formation 3 8.33% wound infection and subsequent dehiscence and
The general complications which were not the scope of incisional hernia formation. However, patient variables
this study, however, showed some interesting findings. like age, obesity, co-morbid conditions like diabetes
Most of the patients had deranged renal functions but mellitus, hypoproteinemia, immunocompromised states
two had established acute renal failure (serum and personal cleanliness can also affect the outcome
creatinine > 500 umol/L), which recovered after surgery as well.
and did not require haemodialysis. One patient A majority of the studies recommend the use of
developed a duodenal fistula due to which he was continuous suture closure of the linea alba over the
transfered to a tertiary care hospital and he responded interrupted suture closure technique. This is firstly

Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (1): 37-41 39
Badar Murtaza, Naser Ali Khan, Muhammad Ashraf Sharif, Imran Bashir Malik and Asad Mahmood

because of the fact that the former can be accomplished peritonitis, Among these, ten showed satisfactory wound
more rapidly and secondly, the latter usually has tight healing but one developed partial wound dehiscence
tying and this can result in the lower wound strength,9-12 and one had a late sequel of incisional hernia. The
while continuous suturing usually distributes tension former was a patient with sigmoid perforation with faecal
equally over a continuous line.13 Whipple and Elliott9 peritonitis and had a fatal outcome, while the latter was
indicated that tying sutures too tightly caused a case of gun shot wound in the abdomen with rectal
strangulation of the tissue with ischemic necrosis and injury with extensive deep wound infection. The
was the most common error in abdominal wound antibiotics used in this study may appear to be
closure. Investigators reported that tight tying of unnecessary, but working at a peripheral station and
interrupted sutures resulted in a lower wound strength managing such critically ill patients with no culture
than sutures tied when the wound edges were facilities and lack of intensive care units, such as an
approximated.10-12 antibiotics regimen may prove essential.
In an intact animal model, Poole and co-workers Another interesting problem encountered in this
demonstrated that the continuous suture technique was technique was due to the multiple knots (Smead-Jones
associated with greater wound bursting pressure than sutures) of the non-absorbable suture material, specially
the simple interrupted suture or figure of eight mattress in those that are thin and lean. It was not seen in the
suture.14 Richard and colleagues found no difference in cases that had adequate subcutaneous fat over the
the wound dehiscence rate or incidence of incisional linea alba. These knots caused pain and suture sinus
hernia between continuous and interrupted (Smead- formation. The interrupted sutures were combined with
Jones) suturing.15 In addition, Stone and associates mass (all layers) closure. The technique of the mass
showed that continuous suturing resulted in a closure was also modified as it helped in avoiding any
comparable incidence of dehiscence to interrupted
chance of the gut getting trapped in the inner portion of
suture and had the average saving of 26 minutes
the suture.
anaesthesia time.16 Apart from continuous suturing, the
use of absorbable suture materials is also being In cases of wound dehiscence between the 6th and 8th
promoted over the non-absorbable ones. Absorbable day after operation, the abdominal wound bursts open
monofilament suture material (polydioxanone PDS) is and the viscera are extruded.23,24 The disruption of the
considered superior to both absorbable braided and wound tends to occur a few days beforeh and when the
non-absorbable suture for abdominal fascial closure as sutures apposing the deep layers (peritoneum, posterior
it is associated with lesser incision pain and suture sinus rectus sheath) tear through or even become untied. At
formation.17-20 But the main issue associated with PDS the completion of the operation, any violent coughing set
is the cost constraints. This is much more expensive off by the removal of the endotracheal tube and suction
than the routinely used non-absorbable suture of the laryngopharynx strains the sutures. Likewise
materials. Lastly, the selection of a wound closure cough, vomiting and distension (e.g. due to the ileus) in
technique must also take into account the dynamic the early postoperative period can contribute to wound
changes in wound length during distention. 21 The dehiscence. Incisional hernias after abdominal surgery
continuous suture usually distributes its tension are common but with a varied reported incidence
throughout the wound, while with an interrupted closure, (2-20%), depending upon the type of case.23,24 There
the tension remains isolated to each suture loop.
are several factors that contribute to the etiology of
Despite of all these strong recommendations for a incisional hernias, the most important being adequacy
continuous suture technique, we decided to combine the of abdominal wound closure in the first instance and the
interrupted suture technique with mass (all-layer) occurrence of wound infection and subclinical wound
sutures as a primary surgical method for the closure of dehiscence in the postoperative period. Smith and
midline abdominal wounds using non-absorbable suture Enquist found that a standardized staphylococcal wound
material, polypropylene. Those patients were considered infection produced a significantly weaker fascial wound
who had extensive generalized peritonitis or metastatic/ than the controls.25 Other factors like obesity, chronic
widespread abdominal tumour.
obstructive airway disease, steroid dependence,
Weiland and co-workers conducted in a meta-analysis jaundice, hypoproteinaemia, malnutrition, drainage
that continuous closure with non-absorbable should be through the wound and formation of stoma also
used to close most abdominal wounds. However, if contribute to its etiology. An incisional hernia usually
infection or distension is anticipated, interrupted starts as a symptomless partial disruption of the deeper
(absorbable) sutures are preferred and mass closures layers during the immediate or early postoperative
are superior to layered closures. 22 period, the event passing un-noticed if the skin wound
In this study, 12 (33.33%) cases developed wound remains intact after the skin sutures have been
infection and this was noted in patients with generalized removed.

40 Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (1): 37-41
Modified midline abdominal wound closure technique in complicated/high risk laparotomies

CONCLUSION 12. Wissing J, van Vroonhoven TJ, Schattenkerk ME, Veen HF,
Ponsen RJ, Jeekel J. Fascia closure after midline laparotomy:
The modified technique used in managing the patients results of a randomized trial. Br J Surg 1987; 74:738-41.
with generalized peritonitis and metastatic abdominal
13. Gallup DG, Talledo OE, King LA. Primary mass closure of
tumours (complicated/high risk laparotomies) is midline incisions with a continuous running monofilament suture
associated with a low incidence of serious complications in gynecologic patients. Obstet Gynecol 1989; 73:675-7.
like wound dehiscence and incisional hernia formation
14. Poole GV Jr, Meredith JW, Kon ND, Martin MB, Kawamoto EH,
comparable to internationally recommended techniques.
Myers RT. Suture technique and wound-bursting strength.
Am Surg 1984; 50:569-72.
However, the local problems of the knots are the main
reservation and should not be considered as the only
15. Richards PC, Balch CM, Aldrete JS. Abdominal wound closure.
reason for not adopting this technique in moribund
A randomized prospective study of 571 patients comparing
continuous vs. interrupted suture techniques. Ann Surg 1983;
patients.
197:238-43.
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