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Abdominal incisions

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  • 1. Abdominal incisions and sutures in obstetrics and gynaecology Radhae Raghavan MRCOG,a, * Pallavi Arya,b Prathibha Arya FRCOG,c Susnata China MRCOG d a Specialty Trainee, Worcestershire Royal Hospital, Charles Hastings Way, Worcester WR5 1DD, UK b Medical Student, University of Nottingham, University Park, Nottingham NG7 2RD, UK c Consultant in Obstetrics and Gynaecology, Alexandra Hospital, Woodrow Drive, Redditch B98 7UB, UK d Consultant Gynaecologist, Worcestershire Royal Hospital, Charles Hastings Way, Worcester WR5 1DD, UK *Correspondence: Radhae Raghavan. Email: drradhae@gmail.com Accepted on 23 April 2013 Key content Selection of any incision must be highly individualised. Numerous options of skin closure have become available and it is paramount to choose the method tailored to each patient and surgical procedure. The ideal wound closure device should be easy to use, painless, provide good cosmesis and be cost-effective. This article reviews the traditional closure materials as well as some materials that have recently become available, such as staples and glue. Use of electrosurgery on the skin. Learning objectives To review the medical literature on this subject. To outline the anatomical and technical aspects that influence the choice of incisions and sutures. To assess the safety aspects, risks and the appropriate use of various closure techniques. Ethical issues Is it ethical to allow the selection of an incision dictated by patient choice to preserve cosmesis if it may compromise the surgical approach? Is it ethical to subject high-risk women to laparotomy for diagnostic or therapeutic purposes when laparoscopic management has demonstrated benefits? Keywords: closure / electrosurgery / incision / laparoscopy / suture Please cite this paper as: Raghavan R, Arya P, Arya P, China S. Abdominal incisions and sutures in obstetrics and gynaecology. The Obstetrician Gynaecologist 2014;16:13–18. Introduction One of the lasting marks of any abdominal surgery and most noticeable to the patient is the scar at the site of incision. In selecting an incision, the surgeon must take into account the underlying pathology prompting the surgery, the possibility of adhesions or malignancy, and comorbidities. In this review we aim to present the various abdominal incisions, sutures and closure methods used in obstetrics, benign gynaecology and oncology practice. Skin preparation The incidence of significant wound infections is ≤5% for all abdominal operations and is related to patient and surgical factors.1 Preoperative showering with antiseptics reduces the infection rate in clean wounds (1.3% versus 2.3%).2 Wound infection rates for depilatory preparations versus no hair removal are equal (0.6%).3 The reason for hair removal is to prevent interference with wound approximation in certain incisions.1 Abdominal incisions Incisions of the skin should not be made with a monopolar electrosurgical device. The same scalpel can safely be used for superficial and deep incisions.4 Abdominal incisions used for most gynaecological procedures can be divided into transverse or vertical incisions. Most of the transverse incisions are identified by the name of the surgeon who first described them, whereas the vertical incisions have no such eponyms. Transverse incisions (Box 1) Pfannenstiel incision Introduced by Pfannenstiel in 1900, this curved incision is approximately 10–15 cm long and 2 cm above the pubic symphysis. The skin and rectus sheath are opened ª 2014 Royal College of Obstetricians and Gynaecologists 13 DOI: 10.1111/tog.12063 The Obstetrician Gynaecologist http://onlinetog.org 2014;16:13–18 Review
  • 2. transversely using sharp dissection. The rectus muscles are not cut and the fascia is dissected along the rectus muscles. K€ustner incision The K€ustner incision, sometimes incorrectly referred to as modified Pfannenstiel incision, involves a slightly curved skin incision beginning below the level of the anterior superior iliac spine and extending just below the pubic hairline. The superficial branches of the inferior epigastric artery or vein may be encountered in the fat. This incision is more time-consuming and extensibility is limited. Cherney incision The Cherney incision involves transection of the rectus muscles at their insertion on the pubic symphysis and retraction cephalad to improve exposure. This can be used for urinary incontinence procedures to access the space of Retzius and to gain exposure to the pelvic side-wall for hypogastric artery ligation. Maylard incision The Maylard incision is a muscle-cutting incision, in which all layers of the lower abdominal wall are incised transversely approximately 3–8 cm above the symphysis, depending on the patient habitus and indication for surgery. The fascia is not dissected free of the rectus muscles. The peritoneum is usually entered in a transverse fashion. In a patient with clinical evidence of impaired circulation in the lower extremity, a midline incision should be preferred to the Maylard incision, in view of the risk of lower extremity ischaemia secondary to inferior epigastric artery ligation. Mouchel incision The Mouchel incision runs at the upper limit of the pubic hair and is thus lower than the Maylard incision. The muscles are divided above the openings of the inguinal canals. Joel-Cohen incision Professor Joel-Cohen introduced this incision for abdominal hysterectomy in 1954 and obstetricians have since used this widely to perform caesarean sections.6 This is a straight transverse incision through the skin, 3 cm below the level of the anterior superior iliac spines (higher than the Pfannenstiel incision; Figure 1). The subcutaneous tissues and fascia are opened in the midline and extended laterally with blunt finger dissection. Blunt dissection is used to separate the rectus muscles vertically and then open the peritoneum. Vertical incisions (Box 2) Midline (median) incision The midline incision is the most versatile incision as it can be easily extended. The pyramidalis muscle can be a useful landmark to identify the midline. Box 2. Advantages and disadvantages of vertical incisions Advantages: excellent exposure easily extendable median incision is least haemorrhagic minimum nerve damage rapid entry into abdomen and pelvis with median incision Disadvantages: wound dehiscence and hernia may be more frequent5 poorer cosmetic results higher infection rates, haemorrhage and operative time with paramedian incision7 Figure 1. Joel-Cohen versus Pfannenstiel incisions. Box 1. Advantages and disadvantages of transverse incisions Advantages: best cosmetic results less painful less interference with postoperative respirations greater strengtha Disadvantages: more time-consuming more haemorrhagic compromised ability to explore upper abdominal cavity division of multiple layers of fascia and muscle and nerves, may result in potential spaces with haematoma or seroma a Earlier studies reported that increased incidence of eviscerations with vertical incisions might be associated with inappropriate closures. Recent studies have shown no difference in fascial dehiscence between transverse and vertical incisions.5 14 ª 2014 Royal College of Obstetricians and Gynaecologists Abdominal incisions and sutures
  • 3. Paramedian incision The paramedian incision offers the advantage of extensibility, especially on the side of the pelvis where the incision has been made. There is no difference in wound infection, dehiscence or respiratory problems with midline and paramedian incisions.7 Oblique incisions Oblique incisions can be used for a transperitoneal or extraperitoneal approach to abdominal surgery, and include the Gridiron (muscle-splitting) incision of McBurney and the Rockey–Davis (or Elliot) incisions. The Gridiron incision is a downward and inward incision from the McBurney point. The incision is carried through the skin and subcutaneous fat to the abdominal wall muscles, which is split along the direction of the fibres. The peritoneum may then be reflected away from the abdominal wall inferiorly. This allows extraperitoneal drainage of abscess, avoiding peritoneal contamination. The Gridiron incision can be performed on the left lower quadrant to drain abscess on the left side of the pelvis and can be varied for appendicectomy in pregnant women. Rockey–Davis incision is a transverse incision made at the junction of the middle and lower thirds of the line joining the anterior superior iliac spine to the umbilicus. Incisions for caesarean section Caesarean section is the most frequent major operation performed on women worldwide. Operative techniques used for caesarean section vary and some of these techniques have been evaluated through randomised trials. Traditionally, vertical incisions were used for caesarean delivery.8 Many studies have compared the Joel-Cohen with Pfannenstiel incision and found the former to be superior for reasons such as less postoperative febrile morbidity, less analgesia requirements, shorter operating time, less intraoperative blood loss and adhesion formation, reduction in hospital stay and in wound infection.9 For very obese women, a transverse incision above the umbilicus has been suggested, but not shown, to decrease morbidity.10 Closure techniques In closure of abdominal incisions, it must be remembered that tissues need approximation, not strangulation. Primary suture line The primary suture is the line of sutures that holds the wound edges in approximation during healing by first intention. It can either be continuous or interrupted. Other sutures include buried, purse string and subcuticular sutures. A continuous suture leaves less foreign body mass in the wound. It derives its strength from tension distributed evenly along the full length of suture strand. Interrupted sutures may be used in the presence of infection: if one suture breaks, the remaining sutures will hold the wound edges in approximation. Evidence shows no difference in continuous versus interrupted closure, with a similar incidence of wound breakdown and hernia formation.12 Buried sutures are placed so that the knot protrudes to the inside, under the layer to be closed. Subcuticular sutures are continuous or interrupted sutures placed in the dermis, beneath the epithelial layer. Secondary suture line The secondary suture line, called retention sutures, is done to reinforce the primary suture line, eliminate dead space and prevent fluid accumulation in abdominal wound during healing by first intention. Retention sutures are placed about 2 inches from each edge of the wound. It is the authors’ opinion that if secondary sutures are used in cases of non-healing, they should be placed in the opposite fashion from the primary sutures (i.e. interrupted if the primary sutures were continuous, continuous if primary sutures were interrupted). Fascial closure If transverse incision is extended laterally beyond the edge of the rectus muscles and into the substance of the external and internal oblique muscles, injury to the iliohypogastric and ilioinguinal nerves can occur, with resulting neuroma. Hence, with laterally extended transverse incisions, the extensions should have sutures placed only in the external oblique fascia. Layered versus mass closure Evidence is in favour of mass closure technique using looped delayed–absorbable suture, with a wound:suture length ratio of at least 1:4 (Figures 2 and 3).13 In general, subcutaneous sutures should be avoided because the subcutaneous tissue does not provide support. A D B T Figure 2. Jenkins diagram showing geometric use of an individual stitch, ATB, in a continuous suture closure. AB is the stitch interval and TD comprises the two tissue bites. ª 2014 Royal College of Obstetricians and Gynaecologists 15 Raghavan et al.
  • 4. Principles of suturing skin incisions (Box 3) Smead–Jones The Smead–Jones closure is a mass closure technique of the anterior abdominal wall using a far–far, near–near approach. The closure is done using a delayed absorbable suture, to include all of the abdominal wall structures on the far–far portion (at least 1.5–2 cm from the fascial edges) and only the anterior fascia on the near–near portion. This allows good healing without intervening fat or muscle. This closure technique can be performed in an interrupted fashion or as a running suture.14 The fascial dehiscence rate with running mass closure of the abdomen is 0.4%.3 Gallup closure The Gallup closure technique is the closure of midline incisions using No. 2 polypropylene suture, placing bites 1.5–2 cm from the fascial edge and including all layers of the anterior abdominal wall (peritoneum, fascial layers and the intervening muscle). One suture is started from each end and tied in the middle with three square knots.15 Box 3. Principles of suturing skin incisions The primary function of suture is to maintain tissue approximation during healing Debridement of skin edges should be done if necessary Avoidance of direct tissue trauma helps ensure best outcomes Clean passage of the needle following the arc is imperative Skin sutures that blanch the underlying skin are too tight Skin edges must just touch each other Delayed primary closure and secondary closure Delayed closure should be used for contaminated or dirty wounds. Staples or monofilament delayed sutures or non-absorbable sutures can be placed. If the abdomen is opened for abscess drainage and delayed closure is not used, copious saline irrigation of all layers should be done. Incisions and closure for obese patients Morbid obesity poses problems with incision placement and closure. Morbid obesity carries a seven-fold increased risk of woundinfection.16 Ifanytransverseincisionischosenforobese patients, it should be far removed from the anaerobic moist environment of the subpannicular fold. The midline vertical incision is made by first retracting the panniculus inferiorly to avoid the most anaerobic moist area. Closure is done by Smead–Jones or running mass closure. An intrafascial drain should be left in situ until drain is 50 ml/24 hours. The skin is closed using staples in preference to subcuticular sutures.16 Laparoscopic incisions and closure It has been suggested that primary incision for laparoscopy should be vertical from the base, not below the umbilicus.17 Any non-midline port 7 mm and any midline port 10 mm requires formal deep sheath closure to avoid the occurrence of port site hernia.17 A laparoscopic wound closure device named V-Loc consists of a barbed absorbable thread that is self-anchoring and eliminates the need to tie a knot. This is feasible and appears to be a promising alternative to frequently used peritoneal closuretechniquesbutisyettobeevaluatedinclinicalstudies.18 Electrosurgery Incisions of the skin must not be made with a monopolar electrosurgical device as the desiccation effect may cause skin to blister and heal poorly.19 High electrical current delivered with a fine electrode of a small surface area generates the most efficient cutting effects and the least thermal damage. Therefore, to incise tissue, cut current should be used with a small or thin electrode that isactivated just beforemaking contact with the target tissue. Abdominal fat, which has high intrinsic impedance, can be readily cut using a blade electrode with a coagulation waveform because of the high current density at the edge of the electrode. There are no data indicating that using electrosurgery in pregnancy causes untoward effect on the fetus. Wound closure materials Sutures, staples and adhesive tapes are the traditional methods of wound closure; tissue adhesives have entered clinical practice more recently. Figure 3. Relationship between the rise in tension between sutures and tissues caused by a 30% wound stretch and suture length (SL):wound length (WL) ratio. 16 ª 2014 Royal College of Obstetricians and Gynaecologists Abdominal incisions and sutures
  • 5. Sutures In selecting the ideal suture, many factors must be considered including age of the patient, location of the wound, presence/ absence of infection, and surgeon’s experience in handling a suture material. Three main types of suture include the non-absorbable, slowly absorbable, and the rapidly absorbable. These can be further divided into monofilament or braided sutures. The incidence of wound infection is low with monofilament sutures.20 Characteristics of various sutures (Table 1) The incidence of wound dehiscence and hernia is similar for non-absorbable and slowly absorbable sutures. The incidence of prolonged wound pain and suture sinus is significantly higher with a non-absorbable suture.21 Staples There are two types of staple: non-absorbable and absorbable. The non-absorbable staple (Proximateâ ; Ethicon Endo- Surgery, Inc., Blue Ash, OH, USA) is made of stainless steel and has the highest tensile strength of any wound closure material. Staples have a low tissue reactivity.22 Prior to stapling, it is useful to grasp the wound edges with forceps to evert the tissue so as to prevent inverted skin edges. Additionally, contaminated wounds closed with staples have a lower incidence of infection compared with those closed with sutures.23 Disadvantages of staples include the potential for staple track formation, bacterial migration into the wound bed, and discomfort during staple removal. The absorbable staple (Insorbâ ; Incisive Surgical, Inc., Minneapolis, MN, USA) is a novel device which deploys U-shaped absorbable staples into the dermal layer of tissue. These staples contain an absorbable copolymer of predominantly polylactide and a lesser component of polyglycolide.24 They maintain 40% of their strength at 14 days and are completely absorbed over a period of months (tissue half-life of 10 weeks). The Insorb staples are associated with a significantly lower infection rate.25 Glue Tissue adhesives are a valuable alternative for mechanical tissue fixation by sutures or staples. Box 4 summarises the classification of adhesives and glues. Box 4. Adhesives and glues Types: biological: include fibrin-based glues, gelatin-based hydrogels, and composite glues synthetic: cyanoacrylates and polymeric sealants Ànon-resorbable: limited to surface applications Àresorbable (biodegradable): deployed for both surface applications and internal use genetically engineered protein glues Advantages: faster, no need for suture removal cyanoacrylates have been shown to have antimicrobial properties (especially against Gram-positive organisms) Currently, 2-octylcyanoacrylate (Dermabond, Ethicon) is the only US Food and Drug Administration-approved surgical adhesive. The cyanoacrylates polymerise upon Table 1. Characteristics of various sutures Suture types Filament type Tissue reaction Tensile strength Absorption (days) Handling Absorbable Catgut Twisted Moderate Poor 80 – Polyglycolic acid (DexonTM ; Covidien Inc., Mansfield, MA, USA) Braided or monofilament Low Good 90–120 – Polyglactin (VicrylTM ; Ethicon Inc., Menlo Park, CA, USA) Braided Low Good 60–90 – Polyglactic 910 (VicrylRapideTM ; Ethicon Inc., Menlo Park, CA, USA) Monofilament Low Good 7–14 – Polydioxanone (PDSTM ; Ethicon Inc., Menlo Park, CA, USA) Monofilament Low Greatest 180–210 – Polyglecaprone (MonocrylTM ; Ethicon Inc., Menlo Park, CA, USA) Monofilament Low Good 90–120 – Polytrimethylene carbonate (MaxonTM ; Ethicon Inc., Menlo Park, CA, USA) Monofilament Low Good 180–210 – Non-absorbable Surgical silk Braided or twisted High Low – Good Nylon Monofilament Low High – Poor Polypropylene (ProleneTM ; Ethicon Inc., Menlo Park, CA, USA) Monofilament Least Good – Poor Polyester (MersileneTM ; Ethicon Inc., Menlo Park, CA, USA) Braided Low High – Good Polytetrafluoroethylene (Gore-Texâ ; W.L Gore Associates, Inc., Newark, DE, USA) Monofilament Low High – Excellent ª 2014 Royal College of Obstetricians and Gynaecologists 17 Raghavan et al.
  • 6. contact with blood, forming a solid film that bridges the wounds and holds the apposed wound edges together.26 It is likely that this usage will expand as the technology improves. The established indication in gynaecology is for closure of port wounds, while emerging indications include control of active bleeding during laparoscopic surgery.27 Adhesive strips Adhesive strips can be used to approximate wound edges after buried sutures are placed. This could relieve tension at the wound edges, improve the aesthetics of the wound and reduce wound care. One disadvantage is that the tape may not adhere to moist areas or to mobile areas under tension.23 Recent advances Laser welding Laser welding has the potential to become an effective method for wound closure and healing without sutures. Closure of skin incisions by laser welding with a combination of two near-infrared lasers (980 and 1064 nm) has yielded effective closure with minimum thermal damage. Further investigations are in progress for clinical use.28 Steri-Strip STM Surgical Skin Closure (3M, St Paul, MN, USA) The Steri-Strip STM Surgical Skin Closure is a new wound closure device with configuration and application significantly different from those of standard Steri-Strips. It has shown better patient comfort and scar quality when used on abdominal wounds.29 Conclusion As scientific evidence accumulates to refute traditional dogma, surgical techniques have undergone significant changes. Surgeons should now be able to create and close abdominal wounds based on scientific evidence rather than on the dictum of ‘Do what I always do’. Disclosure of interests None declared. References 1 Rock JA, Jones III HW. TeLinde’s Operative Gynecology. 10th ed. revised. Philadelphia: Lippincott Williams and Wilkins; 2011. p. 285–307. 2 Cruse PJE, Foord R. The epidemiology of wound infection: a 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980;60:27– 40. 3 Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg 1971;121:251–4. 4 Hasselgren AO, Harberry E, Malmer H, S€alj€o A, Seeman T. One instead of two knifes for surgical incision. Arch Surg 1984;118:917–20. 5 Hendrix SL. SchimpV, Martin J, Singh A, Kruger M, McNeeley SG. The legendary superior strength of Pfannensteil incision: a myth? Am J Obstet Gynecol 2000;182:1446–51. 6 Joel-Cohen S. Abdominal and Vaginal Hysterectomy: New Techniques Based on Time and Motion Studies. London: Heinemann; 1977. 7 Guillou PJ, Hall TJ, Donaldson DR, Broughton AC, Brennan TG. Vertical abdominal incisions: a choice? Br J Surg 1980;67:359. 8 Myerscough PR. Caesarean section: sterilization:hysterectomy. In:Munro Kerr’s Operative Obstetrics. 10th ed. London: Bailliere Tindall; 1982. p. 295–319. 9 Karanth KL, Sathish N. Review of advantages of Joel-Cohen surgical abdominal incision in caesarean section: a basic science perspective. Med J Malaysia 2010;65:204–8. 10 Houston MC, Raynor BD. Postoperative morbidity in themorbidly obese parturient woman: supraumbilical andlow transverse abdominal approaches. Am J Obstet Gynecol 2000;182:1033–5. 11 Ellis H, Heddle R. Does the peritoneum need to be closed at laparotomy? Br J Surg 1977;64:733. 12 Seiler CM, Bruckner T, Diener MK, Papyan A, Golcher H, Seidlmayer C, et al. Interrupted or continuous slowly absorbable sutures for closure of primary elective midline abdominal incisions: a multicenter randomized trial (INSECT: ISRCTN24023541). Ann Surg 2009;249:576–82. 13 Weiland DE, Bay RC, Del Sordi S. Choosing the best abdominal closure by metaanalysis. Am J Surg 1998;176:666–70. 14 Morrow CP, Curtin JP. Incisions and wound healing. In: Gynaecologic Cancer Surgery. New York: Churchill Livingstone; 1996. p. 152. 15 Gallup DG, Talledo OE, King LA. Primary mass closure of midline incisions with a continuous running monofilament suture in gynaecologic patients. Obstet Gynecol 1989;73:675–7. 16 Pitkin RM. Abdominal hysterectomy in obese women. Surg Gynecol Obstet 1976;142:532–6. 17 Anonymous. A consensus document concerning laparoscopic entry techniques: Middlesborough, March 19–20 1999. Gynaecol Endosc 1999;8:403–6. 18 Patri P, Beran C, Stjepanovic J, Sandberg S, Tuchmann A, Christian H.V-Loc, a new wound closure device for peritoneal closure—is it safe? A comparative study of different peritoneal closure systems. Surg Innov 2011;18:145–9. 19 Kenady DE. Management of abdominal wounds. Surg Clin North Am 1984;64:803–7. 20 Osther PJ, Gjode P, Mortensen BB, Mortensen PB, Bartholin J, Gottrup F. Randomised comparison of polyglycolic acid and polyglyconate sutures for abdominal fascial closure after laparotomy in patients with suspected impaired wound healing. Br J Surg 1995;82:1080–2. 21 Van’t Riet M, Steyerberg EW, Nellensteyn Bonjer HJ, Jeekel J. Meta-analysis of techniques for closure of midline abdominal incisions.Br J Surg 2002;89:1350–6. 22 Moy RL, Waldman B, Hein DW. A review of sutures and suturing techniques. J Dermatol Surg Oncol 1992;18:785–95. 23 Hochberg J, Meyer KM, Marion MD. Suture choice and other methods of skin closure. Surg Clin North Am 2009;89:627–41. 24 Pineros-Fernandez A, Salopek LS, Rodeheaver PF, Drake DB, Edlich RF, Rodeheaver GT. A revolutionary advance in skin closure compared to current methods. J Long Term Eff Med Implants 2006;16:19–27. 25 Shapiro AJ, Dinsmore RC, North JH Jr. Tensile strength of wound closure with cyanoacrylate glue. Am Surg 2001;67:1113–15. 26 Coulthard P, Esposito M, Worthington HV, van der Elst M, van Waes OJ, Darcey J. Tissue adhesives for closure of surgical incisions. Cochrane Database Syst Rev 2002;(3):CD004287. 27 Cuschieri A. Tissue adhesives in endosurgery. Semin Laparosc Surg 2001;8:63–8. 28 Hu L, Lu Z, Wang B, Cao J, Ma X, Tian Z, et al. Closure of skin incisions by laser-welding with a combination of two near-infrared diode lasers: preliminary study for determination of optimal parameters. J Biomed Optics 2011;16:038001. 29 Kerrigan CL, Homa K. Evaluation of a new wound closure device for linear surgical incisions: 3M Steri-Strip S Surgical Skin Closure versus subcuticular closure. PlastReconstr Surg 2010;125:186–94. 18 ª 2014 Royal College of Obstetricians and Gynaecologists Abdominal incisions and sutures

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