its about common laparotomy procedures incisions and some recent advances

1. Abdominal Wall: Incisions &
Closures
MODE R A TOR: DrM Shivaprasad
PR E SE NTOR :DrVinayaka
R E C E N T A D V A N C E S

2. Anatomy
• The antero-lateral abdominal wall is MUSCULO-
APONEUROTIC
• Five bilaterally paired muscles
 External Oblique,
 Internal Oblique,
 Transversus Abdominis.
 Rectus Abdominis
 Pyramidalis
• Rectus Sheath,
• Linea Alba

3. Contd…

4. Contd…

5. Types of Incisions
I. Vertical
• Midline Incision
• Paramedian Incision
• Vertical Muscle-Splitting Incision
II. Transverse
III. Oblique

6. Choice of Incisions
• Based on:
– Access to the site of pathology
– Without compromising wall function and
cosmesis
– Post op recovery and morbidity-mortality

7. Common Abdominal Incisions
• A = midline;
• B = paramedian;
• C = gridiron;
• D = Lanz;
• E = Pfannenstiel;
• F = suprapubic;
• G = transverse upper
abdominal;
• H = subcostal ‘Kocher’;
• I = oblique iliac muscle-
cutting.

8. Transverse v/s Vertical
• Transverse and oblique incisions generally
follow Langer’s lines of tension and usually allow
a more cosmetic closure
• The fascial fibers of the anterior abdominal wall
are oriented transversely or obliquely
• The segmental nerve supply derived from
intercostal nerves

9. Midline Incisions
• Advantages
– Rapid access
– Adequate exposure of all organs and retroperitoneum
– Little blood loss
– No transection of muscle fibers or nerves.
• When broad exposure is required, as in an
exploration for trauma, the midline incision can
be extended to the xiphoid process superiorly
and to the pubic symphysis inferiorly.

10. Disadvantages of Midline Incisions
• COSMETIC ISSUES: it crosses the natural crease
lines of the skin and a hypertrophic scar is
common, especially in young children
• the thickening and shortening of the scar at the
waist crease may be irritated by clothes.
• The UMBILICUS presents an additional cosmetic
challenge.
• LINEA ALBA is less vascular, heals slowly, and
potential weak point

11. Contd…
• INCISIONAL HERNIAE occurs in 10 to 23% of
midline laparotomy
• It may be
– due to patient factors like obesity, post op infections
– due to operative factors like suture material, suture
technique

12. Paramedian Incisions
• Advantages
• Like midline incisions, paramedian incisions
– obviate division of nerves and the rectus muscle
– may be made in the upper or lower abdomen
• Advantage over a midline incision is
– a diminished risk of wound dehiscence and incisional
hernia owing to the presence of rectus muscle
interposed between layers of divided fascia.
• In practice, when these incisions are reopened,
the medial edge of the rectus muscle is frequently
found to be adherent to the posterior sheath
incision and does not effectively buttress the
wound.

13. Vertical Muscle-Splitting Incision
• Advantages
– This wound can be opened and closed quickly
and is of particular value in reopening a previous
paramedian incision where dissection of the
rectus muscle away from the rectus sheath can
be difficult.
• Disadvantages
– Longer incisions should be avoided, however,
because they result in significantly more bleeding
and sacrifice of nerves that may lead to
weakening of the corresponding area of the
abdominal wall.

14. Kocher Subcostal Incision
• Advantages
– A right subcostal incision: for operations of
the gallbladder and biliary tree.
– The left-sided subcostal incision: mainly for
splenectomy.
– A bilateral subcostal incision: for hepatic
resections, liver transplantation, total
gastrectomy, and for anterior access to both
adrenal glands.

15. McBurney and Rockey-Davis Incisions
• The muscle-splitting right iliac fossa
incision
• For appendectomy
• McBurney incision has largely been
supplanted by the Rockey-Davis incision,
which is oriented transversely as opposed
to obliquely, allowing for better cosmesis

17. Pfannenstiel Incision
• Used frequently for
– gynecologic operations
– access to the retropubic space (eg, for extraperitoneal
retropubic prostatectomy).
• Advantage
– it affords a cosmetic closure because it is placed in a
skin crease at the level of the belt line;
• however, exposure may be somewhat limited.

18. Laparoscopic Incisions
• Laparoscopic incisions are
– placed anywhere on the abdominal wall,
– allow optimal exposure
– without unnecessarily compromising abdominal wall
function or cosmesis
• Access is most often obtained at a site just
above or below the umbilicus;
– the thinnest portion of the abdominal wall
– a central location from which all quadrants of the
abdominal cavity can be visualized

19. Closure Of Abdominal Incisions
• Care taken to avoid
A. Wound Infection---> most common early
complication
B. Incisional Hernia ---> the most common long-term
complication

20. Closure of the Fascia
• The abdomen can be closed in
I. Multiple Layers: the anterior and posterior
aponeurotic sheaths separately with the posterior
layer generally incorporating the peritoneum
II. En Mass: a single-layer closure of all layers and
may or may not include the peritoneum.
• No difference in the incidences of these
complications.
• Given the shorter time required to close the
fascial layers en mass, this method is generally
preferred.

21. Common types of fascia closure
A. Layered closure
B. Smead jones closure
C. En mass closure
D. Retention suture

22. Suture Material
Resorbable v/s Non-resorbable:
• closure with non-resorbable suture:
– higher rates of suture sinus formation
– increased postoperative pain;
• closure with resorbable suture:
– increased incidences of dehiscence
– hernia formation
(Because linea alba less vascular and take time to heal)
• multifilament permanent suture:
– higher rates of suture sinus formation
(abet bacterial ingrowth and infection)

23. Rate Of Resorption Of Different Suture Materials
SUTURE MATERIAL TIME UNTIL TOTAL RESORPTION
(DAYS)
 Rapidly resorbable
• Catgut 15
• Chromic catgut 90
• Polyglycolic acid (Dexon) 20
• Polyglactin 910 (Vicryl) 60-90
 Slowly resorbable
• Polydioxanone (PDS) 180
• Polyglyconate (Maxon) 180
 Non-resorbable
• Nylon (Nurulon) --
• Polypropylene (Prolene) --
• Polyethylene (Ethibond)
• Polyamide (Ethilon) --

24. Suture materials

25. Suture Technique
• Continuous V/S Interrupted
• The continuous, running closure will result
– more durable wound
– more even distribution of tension across the
suture line
– less resultant tissue strangulation and wound
disruption
– an equivalent or lower risk of hernia formation
– the ease and speed with which it can be
performed
• The obvious disadvantage of a continuous
closure is its dependence on a single suture.
• A running closure is to be preferred.

26. Procedure ….
• When closing a midline laparotomy incision,
– two size #0 looped or size #1 non-looped slowly
resorbable monofilament sutures
– One suture is anchored at the upper extent and one at the
lower extent of the wound.
– Sutures are passed through the fascia a minimum of 1 cm
from the wound edge at 1 cm intervals.
– An assistant holds steady tensions on the suture while the
closure progresses. Repetitive relaxation and application
of tension of the suture is avoided to limit injury to the
fascia. Likewise, it is unnecessary and probably
counterproductive to overly tighten the suture as closure
progresses, as this may lead to fascial necrosis.
– The two sutures are run toward one another and then tied
together in the center of the wound.
• Video clip 01

27. Contd…
“STITCH multicenter RCT”
o Small bites approach
– 5 mm apart and 5 mm deep
– Maintaining suture to wound length ratio ideal
to 4:1
– Rate of hernia incidence 13% compared to
conventional technique 21%

28. 5 mm
5 mm
10 mm
10 mm
Small bite approach
Conventional approach

29. Contd…
“HART trial”
o Hughes Far – Near and Near – Far closure
– Interrupted suturing with two horizontal and
two vertical mattress in single suture
– Suture load distributed both along and across
the suture line
– Effective as mesh repair
– Prevents abdominal dehiscence
– Video clip 02

30. Hughes Far – Near and Near – Far closure

31. Skin Closure
• clean (class I) or clean-contaminated (class
II) operations;
1. Interrupted Suture,
2. Stapled
3. Subcuticular Suture: less postoperative pain &
superior cosmetic result
4. Glues: Advantages of glues include ease and
rapidity of application and simplification of
wound care; generally, no additional dressing is
required.
• contaminated (class III or class IV wound),
– the skin should be left open to heal by secondary
intention or by delayed primary skin closure

32. Retention Sutures
• The purpose of retention sutures:
– to relieve tension along the suture line
– to prevent significant wound disruption and
evisceration in the patient at high risk
• The preoperative variables that are significantly
associated with fascial disruption, including
– hypoalbuminemia,
– anemia,
– malnutrition,
– chronic pulmonary disease, and
– emergent operation.
• For patients with three or more of these
preoperative risk factors, this group recommended
internal retention suture closure.

33. Contd…..
• local mechanical factors and closure technique
appear to have a greater influence
– Placement of drains or ostomies through the main
incision.
– Wound sepsis and increased intra-abdominal
pressure, (ileus, bowel obstruction).
• The potential disadvantages of retention
sutures,
– entrapment of underlying viscera,
– increased postoperative pain,
– poor cosmesis,
– leakage of intraperitoneal fluid through the wound

34. Contd….
• Procedure:
– retention sutures are placed across the wound prior to
formal fascial closure.
– Interrupted permanent monofilament sutures are
passed through skin and fascia approximately 2 cm
from the wound margin at intervals of several
centimeters.
– Placement is facilitated by the use of a long cutting
needle.
– It may be advantageous to omit the peritoneum from
the retention closure in order to protect underlying
viscera from injury or entrapment.
– After conventional closure of the fascia, the sutures
are threaded through rubber tubing bolsters or
commercially available plastic bolster devices and

35. PROPHYLACTIC MESH REPAIR
“PRIMA trail”
• Advised in high risk patient like obese individual
• Incidence of incisional hernia in on-lay mesh
repair v/s conventional approach was 1.5% to
35.9%
• Drawbacks are chronic pain, infections and
fistulas
• Unresolved questions are type of mesh, on lay
v/s sub lay, method of mesh fixation, in case of
emergency setting

36. Closure of Laparoscopic Incisions
• While small fascial defects may be left open,
• any fascial defect 10 mm or greater in the
midline or below the arcuate line should
generally be closed to reduce the risk of port-site
hernia formation.

37. Temporary Closure of the Abdomen
• “Damage Control Surgery” and outlined a three-
phase approach
I. The first phase: rapid control of hemorrhage and
contamination followed by temporary abdominal
closure;
II. The second phase: the restoration of normal body
temperature, correction of coagulopathy, and
optimization of ventilation;
III. The third phase: removal of abdominal packs,
definitive operation, and abdominal closure.

38. Contd….
• damage control approach useful in
– those at risk of developing abdominal
hypertension; eg,
ohypothermia,
ocoagulopathy,
oacidosis,
olarge transfusion requirement
– those who require a second-look laparotomy;
eg,
ointestinal ischemia

39. The Bogota Bag
• The Bogota bag utilizes
a large IV bag, secured
to the skin or fascia.
– Impermeable plastic
drapes may be used.
– fast, inexpensive,
minimizes fluid losses,
and is easily removed.
– less durable than other
closures;
– tearing of sutures through
the periphery of the bag
can result in evisceration.

40. Absorbable Meshes
• Absorbable meshes such as Vicryl; and Dexon;
can be sutured to the skin or fascia.
– allows for a degree of flexibility as definitive closure
can subsequently be undertaken without removal of
the mesh.
– Alternatively, the mesh can serve as a bed for the
elaboration of granulation tissue.
– If reapproximation of the fascia is not feasible or
needs to be substantially delayed, a skin graft can be
placed over the granulation bed

41. Wittman Patch
• A variation on mesh
closure utilizes the
Wittman patch, a device
made of two adherent
sheets of biocompatible
polymeric material.
• The edges of the patch
are sewn to the
surrounding abdominal
fascia.
• As edema resolves, the
fascial edges are
gradually re-approximated
by drawing the two sheets
closer together and
cutting away excess
material.

42. Vacuum-assisted Closure (VAC)
Systems
• The abdominal VAC comprises
1. A barrier enveloped in nonadherent plastic, which is
placed over the intra-abdominal contents below the
fascial edges.
2. A polyurethane sponge is cut to the size of the
wound and placed over the barrier.
3. The sponge is then covered with an adherent
dressing.
4. A small defect is created in the dressing and suction
tubing with an adherent appliance is applied over
this defect and attached to a vacuum device.
5. Drainage is drawn out through the sponge through
the vacuum tubing and into a vacuum canister.
– Video 03 and 04

43. Contd…
• This system is particularly useful
– multiple re-explorations are anticipated.
– loss of abdominal domain is minimized by the
negative pressure exerted on the dressing.
– facilitate a more delayed definitive closure,
• the risk of injury to underlying viscera and fistula
formation does increase with additional dressing
changes.

44. Management Of The Postoperative
Wound
• Dressing the Wound
– a sterile dressing is typically applied to the wound
before removal of the sterile drapes
– this dressing prevents bacterial colonization of the
wound during the initial 24–48 hours of healing,
allowing for epithelialization and the formation of
coagulum
– Before application of the dressing, excess antiseptic
solution should be washed off with sterile saline
– simple dry dressing composed of gauze secured with
sparing use of tape is generally sufficient
– the dressing can be removed within 48 hours of
application

45. • Wound Dehiscence and Evisceration
• Separation of abdominal wounds (ie, dehiscence)
with or without protrusion of intraabdominal
contents (ie, evisceration)
– mean time to wound dehiscence is 8–10 days after
operation.
– Classically, dehiscence is heralded by a sudden rush
of pink serosanguinous discharge from the wound
– Occurs due to ‘cheese wiring’ effect
– Excessive tension in suture
– Factors which precipitate incisional henria also cause
dehiscence
• Principal factor is wound suture ratio
– If it is >1:4, there is less risk

46. Contd…
• The Treatment For A Disrupted Wound
• Re-closure of the wound; this is particularly true when
dehiscence occurs early in the postoperative period.
• If evisceration is present, the wound and protruding
viscera should be bathed with warm normal saline
solution and covered with a large sterile dressing prior
to prompt transport to the operating room.
• In the operating room, the prolapsed bowel is replaced
below the level of the fascial edges.
• Residual suture material is extracted, and necrotic
wound edges are debrided.
• Re-closure of the fascia is then performed, typically
using a monofilament nonabsorbable suture such as
prolene with running suture technique.

47. Incisional Hernia
(“postoperative ventral abdominal wall hernia”)
• result of a failure of fascial tissues to heal and
close following laparotomy
• can occur after any type incision, although the
highest incidence is seen with midline and
transverse incisions
• Associated with Loss of abdominal domain

48. Incidence
• Modern rates of incisional hernia range from 2%
to 11%.
• majority of incisional hernias presented within
the first 12 months following laparotomy

49. Risk Factors
• Patient-specific risks include
o Advanced age,
o Malnutrition,
o Presence of ascites,
o Corticosteroid use,
o Diabetes mellitus,
o Cigarette smoking,
o Obesity
o Emergency surgery
o Wound infection

50. Contd,….
• Technical aspects
o Suturing technique:
– excessive tension suturing of fascia.
Therefore, a continuous closure is advocated to
disperse the tension throughout the length of the
wound.
1 cm bites of fascia on either side of the incision and
advanced 1 cm at a time along the length of the
incision.
o The type of incision:
– transverse incisions are associated with a reduced
incidence compared to midline vertical laparotomies

51. Treatment
• Three general classes of operative repair
I. Primary suture repair of the hernia,
II. Open repair of the hernia with prosthetic mesh,
III. Laparoscopic incisional hernia repair.
• Recurrence of hernia
– Primary repair >> mesh repair >> lap repair
• The choice of repair
– Primary repair of incisional hernias can be performed
for hernia defects less than 4 cm in diameter with
strong, viable surrounding tissue.
– For larger hernias or hernias associated with multiple
small defects, mesh repair is indicated

52. Primary Suture Repair
• ↓ GA --- > to achieve full relaxation of the
abdominal wall musculature.
• Steps:
– The skin is opened through the previous incision
– dissection through the subcutaneous tissues.
– The sac is identified and cleared of its attachments to
the fascia using electrocautery.
– the sac is fully reduced into the abdominal cavity.
– The fascia is then cleared of soft tissue both anteriorly
and posteriorly for at least a 3–4 cm margin

53. Contd,…
– The fascia is then closed using an interrupted layer of
nonabsorbable suture by taking large bites
– The sutures are usually placed sequentially and then tied
after the entire layer of suture has been placed.
– The fascia is then inspected to confirm that no additional
defects are present and that the repair sutures are not
pulling through the tissue due to excessive tension.
– The skin is closed over the fascia using either staples or a
running subcuticular layer.

54. Contd,…
• If the hernia contents have created a large
pocket in the soft tissue above the anterior
fascia, placement of a closed suction drain for
evacuation of early seroma fluid can be
considered.
• If there is tension upon attempted closure of the
abdominal wall, a separation of components can
be performed in order to mobilize the fascia
toward the midline
• Order of component separation based on need
– Skin  subcutenous tissue  external oblique fascia
 external oblique muscle lateral to rectus sheath 
posterior rectus sheath longitudinal

55. Component Separation

56. Mesh Repair
• Dissection similar to primary repair
• The mesh is cut to the shape of the hernia
defect with a margin added circumferentially
around the mesh to suture to healthy
surrounding fascia
• The mesh can now be placed either anterior to
the fascia or posterior from within the intra-
abdominal cavity

57. Variation In Mesh Placement

58. Variety Of Mesh Products
I. Synthetic meshes
1. Polypropylene
o Macroporous (>75 micron) and allow for ingrowth of native
tissue into the mesh, leading to incorporation
o Long term complications more; infections, fistula, erosion
2. Expanded poly-tetra-fluro-ethylene (ePTFE)
o More microporous (<10 micron) and do not promote as much
ingrowth. This leads to less adhesions, but also requires that
there is adequate fixation in order to prevent disruption and
thus recurrence
o Infections requires mesh removal,
3. Polyglactene (vicryl)
o Short term purpose, in infected cases

59. Prolene mesh ePTFE mesh

60. Contd….
• Biologic meshes
– Derived from
1. human tissue
2. animal tissue, (porcine, and fetal bovine )
– Based on
1. dermis
2. submucosa.
– the biologic meshes have been shown to be more
resistant to infection than their synthetic
predecessors
– are more appropriate for use in infected or
contaminated fields

61. Porcine Xenograft

62. Contd….
• Disadvantage of biologic mesh
– Weakening over time because of elastin breakdown.
– Can lead to eventration, recurrence, or the possibility
of pseudorecurrence.
– Durability of grafts increased by glutaraldehyde and
hexamethylene diisocyanate, cross-linking agents
which make the material, more resistant to
breakdown by enzymatic degradation.
o But also to increasing the susceptibility of these grafts to
microbiologic attack.
o Crosslinking limits the ability of the host to incorporate the
graft and make it essentially a part of the native tissue.

63. Laparoscopic Repair
• the defect is repaired posteriorly and no
dissection within the scarred layer of anterior
fascia is required.
• also allow for identification of additional hernia
defects in the anterior abdominal wall during the
repair
• Video 05

64. Conclusion
• Continuous suturing
• Monofilament slowly absorbable suture
• Wound to suture ratio >1:4
• Small bites approach
• Single layer closure
• Prophylactic mesh repair in high risk patient

65. Thank You