1) The document reviews various incision and closure techniques used in obstetrics and gynecology, including transverse (e.g. Pfannenstiel), vertical (e.g. midline), and laparoscopic incisions.
2) It discusses factors to consider when selecting an incision such as patient characteristics, pathology, and risk of adhesions or malignancy. It also reviews various suturing and closure methods like continuous versus interrupted sutures.
3) The ideal closure method provides good approximation with minimal risk of complications like infection, hemorrhage or wound dehiscence while allowing for the best cosmetic outcome. Layered versus mass closure techniques are evaluated.
hysteroscopy is a procedure with a very rare incidence of major side effects . a thorough knowledge of how to tackle them is must for anyone practicing hysteroscopy......
Uterine prolapse (also called descensus or procidentia) means the uterus has descended from its normal position in the pelvis farther down into the vagina.Cervicopexy is fertility conserving surgical management of prolapse.
The first laparoscopic hysterectomy (LH) was performed in January 1988 by Harry Reich in Pennsylvania. There has been a great increase in interest following the introduction of LH but most surgeons now perform laparoscopically-assisted vaginal hysterectomy (LAVH) and the total laparoscopic hysterectomy (TLH).
hysteroscopy is a procedure with a very rare incidence of major side effects . a thorough knowledge of how to tackle them is must for anyone practicing hysteroscopy......
Uterine prolapse (also called descensus or procidentia) means the uterus has descended from its normal position in the pelvis farther down into the vagina.Cervicopexy is fertility conserving surgical management of prolapse.
The first laparoscopic hysterectomy (LH) was performed in January 1988 by Harry Reich in Pennsylvania. There has been a great increase in interest following the introduction of LH but most surgeons now perform laparoscopically-assisted vaginal hysterectomy (LAVH) and the total laparoscopic hysterectomy (TLH).
ABDOMINAL INCISIONS AND LAPAROTOMY-1.pptxAbhijitAzeez
The theoretical advantage of a paramedian over a midline incision is
a diminished risk of wound dehiscence and incisional hernia
In practice, when these incisions are reopened, the medial edge of the rectus muscle is frequently adherent to the anterior or posterior sheath incision and does not effectively buttress the wound.
A “lateral paramedian incision” refers to a vertical incision created several centimeters lateral to the location of the traditional paramedian incision.
In the patient who has had prior abdominal surgery, the cosmetic advantages of reentering the abdomen through a preexisting scar must be balanced against the challenges associated with dissection in a reoperative field. Close proximity of a new incision to an old one should be avoided in order to minimize the risk of ischemic necrosis of intervening skin and fascial bridges.
Mass closure of the abdominal wall is usually advocated, using large bites and short steps in the closure technique and either non-absorbable (e.g. nylon or polypropylene) or very slowly absorbable suture material (e.g. polydioxanone suture (PDS)). It has been estimated that, for abdominal wall closure, the length of the suture material should be at least four times the length of the wound to be closed to minimise the risk of abdominal dehiscence or later incisional hernia.
A Prospective Study to Compare the Suture Technique (Continuous Versus Interr...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Avoiding and Managing Complications During Gynaecological SurgeryAlex Swanton
All surgery involves a delicate balance of risk management, from the benefits and disadvantages of when a surgical option is appropriate, to the immediate post-operative care.
PREVENTIONandTreatment of Sleeve Gastrectomy Leaks
Dr Rutledge
Where does it occur?
ONE PLACE!
This is “Tiger Country” – remember that!
Managing ComplicationsFIRST Prevent Complications
Managing LeaksFirst Prevent Leaks!!
Examples of ComplacencySleeve Gastrectomy Leak
“Sleeve Gastrectomy & Risk of Leak: Systematic Analysis of 4,888 Patients”
“Risk of leak is low at 2.4%"
Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec 17. Aurora AR, Khaitan L, Saber AA. Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
Peritoneal adhesions are a common cause of bowel obstruction, pelvic pain, and infertility. More often than not, these adhesions need to be released surgically for the management of these complications.
In this introductory remark at workshop on vaginal hysterectomy where Dr Shirish Seth was operating faculty.
I spoke “lets promote and propagate vaginal hysterectomy which is an indigenous surgery in line with PM Modi’s mission of MAKE IN INDIA.
Vaginal hysterectomy is like Aam admi surgery which is in the best interest of patients and has best scientific evidences in its favour."
Let us not be driven by glamour,gadgets and gimmicks."
Anastomotic dehiscence after colorectal surgeryKETAN VAGHOLKAR
Anastomotic dehiscence after colorectal surgery can have disastrous consequences. Various factors determine the
chances of anastomotic failure. The technical and systemic factors which a surgeon needs to be aware of are presented
in this article.
Basics of laproscopic surgery..
by dr navdeep s kamboj presented at sgrdumsar amritsar.
topics covered--
1 basics of laparoscopy
2 lap cholecystectomy
3 lap appendixcectomy
pneumoperitonem
merits and demerits of laproscopy
ligasure
endoscopy,
laparoscopic instruments
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
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ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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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.
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18 ª 2014 Royal College of Obstetricians and Gynaecologists
Abdominal incisions and sutures