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A COMPARATIVE STUDY BETWEEN INTERMITTENT SMEAD JONES RECTUS CLOSURE AND CONTINUOUS RECTUS CLOSURE
IN MIDLINE LAPAROTOMY WOUND 221811056
A DISSERTATION SUBMITTED TO
THE TAMIL NADU Dr MGR MEDICAL UNIVERSITY
in partial fulfilment of the regulations for the Award of the degree of M.S. (GENERAL SURGERY)
BRANCH – I
DEPARTMENT OF GENERAL SURGERY STANLEY MEDICAL COLLEGE AND HOSPITAL TAMILNADU Dr. MGR MEDICAL UNIVERSITY CHENNAI
MAY 2018-21
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CERTIFICATE
This is to certify that, the dissertation entitled “A COMPARATIVE STUDY BETWEEN INTERMITTENT SMEAD JONES RECTUS CLOSURE AND CONTINUOUS RECTUS CLOSURE IN MIDLINE LAPAROTOMY WOUND” is the bonafide work done by Dr.ISWARYA. D during her MS (General Surgery) course 2018-2021, done under my supervision and is submitted in partial fulfilment of the requirement for the M.S.(BRANCH-I)- General Surgery of The Tamilnadu Dr.MGR Medical University, May 2021 examination.
Prof Dr T. SIVAKUMAR, M.S., Prof Dr. A.ANANDI, M.S., Professor & HOD Professor of surgery
Department of General Surgery Department of General Surgery Stanley Medical College Stanley Medical College
Chennai-1 Chennai-1
Prof Dr. P.BALAJI M.S., FRCS, Ph.D., FCLS., DEAN
Stanley Medical College Chennai-1
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DECLARATION
I, Dr. ISWARYA. D certainly declare that this dissertation titled “A COMPARATIVE STUDY BETWEEN INTERMITTENT SMEAD JONES RECTUS CLOSURE AND CONTINUOUS RECTUS CLOSURE IN MIDLINE LAPAROTOMY WOUND” represents a genuine work of mine.
The contributions of any supervisors to the research are consistent with normal supervisory practice, and are acknowledged.
I also affirm that this bonafide work or part of this work was not submitted by me or any others for any award, degree or diploma to any other University board, either in India or abroad. This is submitted to The TamilNadu Dr. M.G.R Medical University, Chennai in partial fulfilment of the rules and regulations for the award of Master of Surgery Degree Branch I (General Surgery).
Place : CHENNAI
Date : 26/12/2020 (Dr. ISWARYA. D)
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ACKNOWLEDGEMENT
As I walk down the memory lane I realize with a deep sense of humility that what I have done now would not have materialized, but for certain luminaries, who have enlightened my path to wisdom.
Surgery is learnt by apprenticeship and not from textbooks, not even from one profusely illustrated” – Ian Aird. While I put these words together it is my special privilege and great pleasure to record my deep sense of gratitude and indebtness to t he D ean Pr o f. Dr . P. BAL A JI , M . S. , p e r mi t t i n g me t o co ndu c t th i s s tu d y a nd us e t he r es ou rc es of t h i s co l l eg e.
I c on s i de r i t m y pri v i l ege t o ha ve d one t h i s s tu d y un d er t he s up er v i si on of o ur HEA D OF THE
DEP A R TM EN T b e l ov e d Pr of Dr. T . S I VAK U M AR. ,M .S ., Professor and Guide Prof. Dr .A.ANANDI,M.S.,
Prof. Dr .A.K.RAJENDRAN, M.S.,
Prof. Dr. K.SHANTHAKUMAR, M.S., but for whose constant guidance, help and encouragement this research work would not have made possible. The unflinching academic, moral and psychological support will remain ever fresh in my memory for years to come. Words cannot simply
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express my gratitude to them for imparting to me the surgical skills I have acquired.
All along the way I have been supported and encouraged by all my associate professors who helped me to reach where I am.
I would like to express my heartfelt thanks to Dr.Kumaresan,M.S., Dr.Jothiramalingam,M.S., Dr.Rani Suganya, M.S., and Dr.Vivekanand,M.S., Dr.Thirumuruganand,M.S., Assistant Professors of Surgery for all of them have given me invaluable advice, guided me on and have been most kind and patient to me.
I also thank my fellow postgraduates, friends and colleagues who have extended their co-operation in my work.
With deep reverence, I salute my parents and I thank the Almighty for blessing me a wonderful family to whom I have dedicated this thesis and leave unsaid what they mean to me.
What good is a potter without his clay and what good is a study without the active participation of the patients. My heartfelt thanks go to each and every patient who agreed to be a part of this study and also my apologies to them in case of any inconvenience caused.
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CERTIFICATE BY GUIDE
This is to certify that this dissertation work titled “A COMPARATIVE STUDY BETWEEN INTERMITTENT SMEAD JONES RECTUS CLOSURE AND CONTINUOUS RECTUS CLOSURE IN MIDLINE LAPAROTOMY WOUND” of the candidate Dr.ISWARYA.D with registration number 221811056 for the award of M.S General Surgery Degree.
I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion pages and result shows 6% of plagiarism in the dissertation.
Prof. Dr. A. ANANDI M.S., Guide and Supervisor
Professor of Surgery
Department of General Surgery Stanley Medical College Chennai 600001
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ETHICIAL COMMITTEE CERTIFICATE
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PLAGIARISM CERTIFICATE 221811056
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TABLE OF CONTENTS
S.No. Topic Page No.
1 Introduction 10
2 Aims And Objectives 12
3 Methodology 14
4 Review Of Literature 17
5 Results 65
6 Discussion 75
7 Conclusion 81
8 References 83
9 Annexure 89
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INTRODUCTION
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The quest for the best closure technique for abdominal incisions continues. The surgeon’s endeavour is to eliminate consequences of wound failure which includes wound dehiscence in the acute form and incisional hernia as the late manifestation.
To achieve this goal, several modifications in opening the abdomen and closing the wound have been tried. There are many studies in the literature comparing various methods of wound closure, with conflicting results.
The continuous method of closure has some advantages, namely quick closure with a smaller number of knots, thereby lessening the chances of sinus formation. However, an in-depth review of the literature has demonstrated an advantage of interrupted closure in reducing the risk of abdominal dehiscence.
It was because of this state of controversy that this study was embarked upon .
Aim was to estimate dehiscence and incisional hernia using the interrupted method as compared with the continuous closure method.
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AIMS AND OBJECTIVES
13 AIM OF MY STUDY :
Continuous rectus closure and Smead Jones intermittent rectus closure techniques were compared for each of the two primary outcomes of burst abdomen and incisional hernia separately in this study and the superior abdominal closure technique will be identified based on the results of this study.
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METHODOLOGY
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STUDY DESIGN: Prospective study
SAMPLE SIZE: 80 (2 groups)
Inclusion criteria:
• Patients >18 yrs age
• Patients requiring midline LAPROTOMY
Exclusion criteria:
Pregnant women
Patients not consenting to participate in the study
Patients not surviving for more than a week because of other factors and complications post operatively
16 METHODOLOGY:
• Patients will be randomly allotted into 2 groups and will alternatively be undergoing SMEAD JONES interrupted closure and continuous rectus closure
• Post operatively patient will be followed for a week as inpatient and watched for burst abdomen
• Followed up after 6 weeks and after 6 months as outpatient and watched for Incisional hernia
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REVIEW OF
LITERATURE
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A basic knowledge about the anatomy and physiology of the abdomen is essential .
BASIC ANATOMY:
THE ABDOMEN is an ovoid space which is bound cephalad by the diaphragm and by Inferior thoracic margin, caudally by the pelvic brim, posteriorly by the lumbar spine along with quadratus lumborum, psoas major and iliacus, and anterolaterally by the remainig musculature of the abdominal wall. The ventilation is mainly supported by the abdominal muscles , to increase intrathoracic pressure the diaphragm is forced cephalad to aid expiration, to decrease pressure for inspiration it is allowed to contract into the abdomen.
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The majority of the digestive tract such as the liver, biliary tree, pancreas, kidneys and ureters lies in the abdominal cavity.
Anatomy of the abdominal wall
The triad of muscles forming the lateral abdominal wall are the external oblique (E.O), running inferomedially like the fingers of the hands placed into the pockets of one’s jeans; the internal oblique (I.O) running orthogonally to its external relation, and transversus abdominis (T.A) with its fibres lying horizontally. Scarpa’s fascia lies superficial to the external oblique
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fascia, subcutaneous fatty layer Camper then the skin.The transversalis fascia lying Deep to transversus abdominis, encircles the preperitoneal fat and parietal peritoneum.
Incisions on the anterolateral wall will, breach the following structures:
Skin
Subcutaneous fatty layer
Membranous fascia
External oblique
Internal oblique
Transversus abdominis
Transversalis fascia
Preperitoneal fat
Parietal peritoneum
On progressing1 medially the fibres of the lateral abdominal wall muscles give rise to aponeurosis which are fibrous sheets of tissue , allowing a far wider area of insertion than would be achievable with the typically round tendons of the muscles of the appendicular skeleton. The aponeurosis of the internal oblique is unique in that itdivides into an anterior and posterior leaf. These aponeuroses combine and interdigitate and invest the paired rectus abdominis muscles, forming the rectus sheath,the anterior midline structure .
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22 The rectus sheath
The origin of the paired rectus abdominis muscles is from the anterior bony pubic bones toward the midline and run cephalad to get inserted onto the xiphisternum and costal cartilages of ribs 5-7. Their blood supply is from the superior and inferior epigastric arteries from the internal thoracic and external iliac arteries respectively, and their innervation from the spinal nerve roots T7- T12 anterior rami.2
The rectus sheath may be considered as having three distinct sections:
For most of the length, the external oblique and anterior leaf of the internal oblique aponeuroses forms the anterior sheath of the paired recti. Three paired tendinous intersections anchor the paired recti to the anterior sheath, one found close to the xiphisternum, other at the level of the umbilicus and then the middle one halfway between the two.
The posterior leaf of the internal oblique and the transversus abdominis aponeuroses form the posterior sheath and also bears the superior and inferior epigastric arteries and their anastomotic network. The linea alba is formed by the aponeurotic components of the sheath interdigitating in a thickened fibrous midline raphe between the two recti (‘white line’).divarication of recti if due to an elastic defect in this raphe which causes the fascia to stretch and abdominal contents to bulge forward. This is often mistaken for an epigastric hernia as it
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produces a distinct ridge in the midline on increasing intra-abdominal pressure.
Epigastric hernias are mainly due to the small defects in the aponeurotic intersections of the linea alba, containing preperitoneal fat but often are disproportionately painful due to their high tendency to strangulate.
Above the level of the costal margin Posterior sheath is absent, as the recti insert directly onto the underlying costal cartilages and remain covered anteriorly by the external oblique aponeurosis and insert directly onto the underlying costal cartilages.3
The arcuate Line (of Douglas)lies roughly one third to halfway between the umbilicus and the pubic symphysis, this is the point at which the posterior elements of the sheath perforate to join the anterior sheath and leaving the thickened transversalis fascia to lie in direct contact with the rectus muscles.
Lateral to the sheath lies the Linea Semilunaris, the longitudinal margin at which the internal oblique aponeurosis bifurcate to form anterior and posterior leaflets. Defects in the integrity of the internal oblique give rise to the formation of Spigelian Hernias, causing protrusion of the peritoneal sac into the rectus sheath. On examination, the patient presents with a palpable lump close to the lateral border of the rectus sheath, most commonly at the level of Douglas. As these are superficial hernias they are easily diagnosed by ultrasonography.
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Transversalis Fascia, Peritoneum, and Bladder Reflection
A layer of fibrous tissue called the transversalis fascia lies deep to the muscular layers, and superficial to the peritoneum, lining the abdominal cavity.
During abdominal incisions it is visible as the layer just underneath the rectus abdominis muscles. Variable layer of adipose tissue separates it from the peritoneum and is frequently incised or bluntly dissected off the bladder prior to opening the peritoneum. The peritoneum itself is a single layer of serosa along with a thin subserosal layer of connective tissue. It was thrown into five vertical folds by underlying ligaments or vessels that converged toward the umbilicus .The urachus causes the single median umbilical fold . Lateral to this we have the paired umbilical ligaments raised by the obliterated umbilical arteries that connect the umbilicus to the internal iliac vessels. The deep inferior epigastric arteries and veins finally cause the lateral most ridge.
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The reflection of the bladder onto the abdominal wall is triangular in shape, with its apex blending into the medial umbilical ligament. Because the bladder extends highest in the midline, the peritoneum is incissed somewhat off the midline which makes it is less likely to result in bladder injury and can provide better exposure.
Vessels of the Abdominal Wall
The superficial epigastric begins as a single artery branches extensively, and runs a diagonal course in the subcutaneum from femoral vessels towards the umbilicus. Its position can be landmarked on a line between the palpable femoral pulse and the umbilicus lying superficial to Scarpa's fascia.
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The deep inferior epigastric artery and its accompanying veins originate from the external iliac vessels lateral to the rectus muscle. They run diagonally towards the umbilicus and crossin the muscle's lateral border in the middle between the pubis and the umbilicus . Below the point at which the vessels intersect the rectus, they are lateral to the rectus deep to the transversalis fascia.
After crossing the lateral border of the muscle, they lie on the dorsal surface, between the muscle and the posterior rectus sheath. They branch extensively once the vessels enter the rectus sheath that they no longer represent a single trunk. The apex of Hasselbach's triangle is formed by the angle between the epigastric vessel and the lateral border of the rectus muscle and the base is the inguinal ligament.
Structure Significance
Superficial inferior epigastric vessels Isolated and ligated on line from femoral vessels to umbilicus
Insertion of pyramidal muscle Midline identification
Deep inferior epigastric vessels Isolated and ligated during maylard incision .
Tendinous inscriptions Sharp dissection done to elevate rectus sheath while making Pfannenstiel incision
Arcuate line Posterior rectus sheath repaired above this line
Bladder reflection onto peritoneum Enter lateral to midline Hypogastric and ilioinguinal nerves To be Identified and spared Femoral and genitofemoral nerves Avoid retractor injury
27 WOUND HEALING
Most wound complications are due to failure of the healing process in eliminating the bacteria that are invariably introduced into the wound, or failure of the healing process in synthesizing adequate quantities of collagen in restoring abdominal wall strength. The fundamental processes that are responsible for these functions should be understood to best create and close an abdominal incision
There is a generalised misconception that infectious complications are primarily due to unsterile technique. Sterile technique has received a great deal of attention, yet surgical technique still plays a critical role.4 The wound healing process still remains to be a balance between the amount of damage being done to the tissue during an operation, and capacity of the body to decontaminate and repair it. The surgeon remains in a position to influence this balance significantly and affects both the rate of wound infection and
dehiscence.
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Exposure of blood and platelets to connective tissue with the initial incision, begins the inflammatory response that will sterilize and heal the wound. In the initial phases of this process, the small vessels in the region of the injury becomes permeable to both molecular and cellular mediators of the inflammatory response5. These processes are responsible for elimination of the bacteria through opsonization, phagocytosis, and cellular killing, as well as for recruit of wandering tissue macrophages that are responsible for subsequent events. This is the decisive phase because it establishes the inflammatory process that is to follow. Various Clinical studies have shown that injection of vasoconstrictive agents both pre and intraoperatively limits this response and is responsible for increased number of infections.6 This may seem paradoxical because the infections do not appear for several days well after the vasoactive effects are gone. The vasoconstriction causes the prevention of the outpouring of the factors that initiates the inflammatory response. This leads to a period of
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time for bacteria to multiply exponentially and be established in numbers that leads to overwhelming of host defense, thus explaining this phenomenon and drawing attention to the importance of these early events.
After this initial phase, the polymorphonuclear neutrophils (PMNNs) and tissue macrophages begin digesting of damaged tissue, bacterial killing, and synthesizing the chemotactic factors that repairs the wound . These cells complete the groundwork for fibroblast that will reestablish wound strength.
Although these cells are capable of very minimal activity in an anaerobic environment, their proper function in the wound is possible only in the availability of the oxygen supply to tissue. This emphasizes one of the key
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surgical implication of wound healing; namely, protecting the capacity of adjacent tissues which perfuse the healing wound after the operation by avoiding unnecessary damage to this tissue.
The next critical factor in wound healing is the amount of necrotic tissue being created. Actual repair should begin from healthy tissue. If a ligature is placed around a piece of adipose tissue, it becomes necrotic. Healing then begins from the uninjured tissue behind the area of damage. Before reaching the edge of an incision, the healing process disinfects, digests, and removes the dead tissue, before healing can begin. During this delay, bacteria in the ischemic tissues multiplies, further increasing the need for cleanup, delays repair, and increases the likelihood of infection. Hemostasis, achieved either by ligation or electrocautery, abrasion, and desiccation of tissue are all the injuries that can occur in any incision. The more these damaging elements are present, the more necrotic tissue body must eliminate before the edges of the wound are joined . This gives more time and space for bacteria to multiply and overwhelm the host.
Multiple knife strokes made while incising the subcutaneous tissue, leaves more damaged tissue behind than a single, clean stroke and is shown to increase the risk of wound infection.
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Healing is under the direction of the inflammatory response, particularly the macrophage, and agents influencing inflammation also influence healing.
For example, the: anti-inflammatory effect of steroid hormones can impair both
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PMNNs and macrophage function and will decrease the development of wound strength.
The re-establishment of abdominal wall strength mainly depends upon the synthesis of new connective tissue. This is accomplished by fibroblasts and requires, protein precursors for collagen synthesis and occurs most rapidly in a normally oxygenated environment which contains the enzymes and cofactors needed for collagen synthesis are present. Factors reducing the availability of these critical substances and conditions delays and impairs the development of wound strength and increases the likelihood of wound disruption. Ischemia caused by tight sutures, foreign bodies, lack of nutritional factors such as protein or ascorbic acid, or inhibitors of cell division can adversely influence found healing.
Collagen, the primary structural protein of the body, is synthesized by the fibroblast. It begins to appear in the wound on the second day, as an amorphous gel devoid of strength. Maximum collagen synthesis occurs around the fifth day. It depends especially upon the presence of oxygen, vitamin C, and amino acid precursors. Deficiency of these factors in the wound can inhibit healing, resulting in an increased incidence of wound dehiscence. Maximum strength development does not occur for several months and depends upon the interconnection of the collagen subunits. Approximately 80% of original
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strength is reached in about 6 weeks and can be significantly delayed if the normal factors for wound repair are not present.
It is important to recognize that perfusion of the wound is the most important factor in wound healing. Integrity of the microvasculature and flow is responsible for the oxygenation needed for cellular metabolism. Damage to tissue that impairs the delivery of oxygen to the wound increases the number of wound infections and the likelihood of dehiscence. Adopting an attitude in the operating room where tissue damage is minimized has been shown to decrease complications in surgery.
Abdominal incisions
A surgical incision acts an aperture into the body to permit the work of the operation to proceed.
Principles of Surgical Incisions
Any surgical incision will depend on the under lying pathology, site, patient factors, and the surgeon’s preference and experience7.
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The key principles of making surgical incisions are:
Incisions should try to follow Langer’s lines where possible, for maximal wound strength with minimal scarring
Muscles should be split and not cut (where possible)
Once the operation is over, surgical incissions are closed by sutures,
OPENING THE ABDOMEN: SKIN PREPARATION, INCISION, AND HEMOSTASIS
Skin Preparation
The concept of cleaning the skin for surgery began with Maimonides in the 11th century and has evolved significantly during this century. The choice of approach and agent for cleansing is often derived from tradition and salesmanship rather than proven efficacy.8 Widely accepted goals, however, include cleansing away dirt and contaminants by physical means and rapid antisepsis to reduce bacterial density, followed by application of a long-acting bactericidal agent to deal with resident bacte:ria brought to the skin's surface by sweat.
Handwashing has been shown to reduce bacterial counts significantly, but to an inadequate degree. In fact, prolonged handwashing with plain soap may increase bacterial density due to chapped skin. Nonetheless, handwashing
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remains an important element of preoperative preparation by removing gross contaminants and dirt9.
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Numerous antiseptics are available, but with variable properties and effectiveness. Alcohol has repeatedly been shown to be an excellent choice due to its immediate and broad activity against gram-positive and gram-negative organisms. Although not sporicidal, alcohols also act against many fungi and viruses as well as mycobacteria. A 1-minute scrub with alcohol has been shown to be as effective, as a 4- to 7-minute scrub with other antiseptics.10 A 70%
solution is most commonly used as a compromise between effectiveness and desiccation of the skin. Ethanol, propyl, and isopropyl are all effective. The World Health Organization's draft guidelines in 1987 designated alcohol as the gold standard against which all other skin antiseptics should be compared.10 Surgeons must be aware of alcohol's highly flammable nature, however, taking special precautions to assure complete drying where electrocautery or laser will be used.
Other popular scrubs include the iodophors, hexachlorophene, and chlorhexidine gluconate. The iodophors are highly effective, but their anti- microbial action declines rapidly upon drying. Hexachlorophene is active against gram-positive bacteria but less so against gram-negative bacteria, mycobacteria, and viruses. Chlorhexidine gluconate has a broad spectrum of antibacterial activity, but is relatively more effective against gram-positive bacteria than gram-negative bacteria, with fair activity against the tubercle bacteria and poor activity against viruses. It does have extended effectiveness,
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remaining chemically active for approximately 5 hours. It is also available as an alcohol-based hand-rinse, combining the rapid and effective action of alcohol with the long action of chlorhexidine gluconate.
Preparation of the patient's skin involves similar considerations to those noted above. If necessary, hair removal should be accomplished immediately prior to surgery by clipping, not shaving, as the latter has been shown to damage the skin's defenses and increases the risk of wound infection.5
Incision
The incision should be accomplished with the least possible tissue damage. A scalpel should be used, and the fewest possible strokes will limit tissue damage.7 Electrocautery tends to produce much larger zones of damage and increases infection rates.12 Hemostasis can be obtained with well-directed cautery and fine ligatures (4-0 absorbable suture is adequate), taking care to isolate bleeding vessels and to exclude any unnecessary tissue from the ligature.
In general, when discrete vessels are encountered, isolation with a hemostat and ligation will provide the least volume of necrotic tissue. Absorbable sutures such as polyglycolic acid or polyglactin are preferred to catgut, which causes inflammation.
38 Wound drainage :
In cases where diffuse oozing persists or wound contamination is greater than normal, drains may be considered. Seromas and hematomas significantly delay approximation and healing of the subcutaneous tissue. Because a surgical drain is a foreign body, it has the potential to increase wound infection by its presence. 13 In addition, it can provide access for bacteria to enter the wound after the skin has been closed.14 Subcutaneous drains, therefore, should be used only when there is sufficient risk of hematoma or seroma formation so that it can do more good than harm, as is true in the massively obese patient. 15 The
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best choice is a closed suction drain brought out through a separate stab incision since this option offers a lower infection rate than Penrose drains, or drains brought out through the incision.11
Midline Laparotomy Closure
The midline or paramedian vertical incision is the simplest of abdominal incisions, and it offers the greatest ease of extension into the upper abdomen as well as the least blood loss . Although the pararectal approach that goes lateral to the rectus muscle might be acceptable in terms of exposure, the resultant denervation of the rectus muscle that occurs weakens this incision, 19 leaving the midline vertical as the commonly used.However, it must be kept in mind that the actual layers composing the abdominal wall vary, depending on the location of the incision.
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The main considerations in choosing the vertical incision include the need for speed, a relatively bloodless approach, and possible need for exposure of the upper abdomen. In addition, because of its lack of dead space, the vertical incision is preferable in patients taking anticoagulants or in the presence of disseminated intravascular coagulation. Also, for patients with cirrhosis of the liver who may have greatly enlarged abdominal wall vessels that follow a longitudinal course, vertical incision minimizes the number of vessels that must be transected.
In the lower abdomen, the incision is made from just above the pubis to below the umbilicus in the midline. Although it is customary to carry the incision lateral to the umbilicus if extension to the upper abdomen is required, the incision can equally well be made through the umbilicus without any increased risk of disruption and is technically simpler to perform.20 Below the umbilicus the linea alba tends to be narrow, and the rectus sheath is usually entered on one side or the other, thus making this a paramedian incision rather than a true midline approach. The transversalis fascia and peritoneum are also opened in a vertical direction; entry should begin at the superior extent of the incision to obviate the possibility of bladder entry. As is true of all peritoneal entry, great care must be taken against the possibility of encountering adherent bowel. Closure considerations are discussed below.
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Layers of abdomen, from interior to exterior: peritoneum, extraperitoneal fascia, muscle, deep fascia, superficial fascia, subcutaneous tissue, and skin.
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(A) Fascial closure. (B) Looping of 0 polydioxanone (PDS) at vertex. (C) Continuous suture. (D) Two PDS ends meeting in middle of incision, tied together, and cut
Conventional closure with polypropylene number 1 size loop suture.
Conventional closure included closure of rectus fascia with muscle first in a continuous fashion. The sutures were placed 2 cm from the edge of the linea alba on both sides and 1 cm was maintained between two adjacent sutures.
Following this skin was closed with interrupted ethilon 2-0 sutures
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SMEAD JONES Near far intermittent rectus closure
PRINCIPLES OF ABDOMINAL WALL CLOSURE
Regardless of the type or direction of incision, the factors involved in closure are similar and will be discussed together. Maintenance of tissue per- fusion, minimizing necrosis, creating good initial strength, protection against late hernia formation, and assuring a cosmetic result are factors all incisions share in common.
44 Tight Sutures and Ischemia
All sutures used to close the musculofascial wall must be tied with enough tension to approximate the edges of the incision. If greater tension is applied, the tissue will become ischemic, and a certain amount of necrosis will develop. If the extent of necrosis is marked, the tissue will not hold the suture, resulting in dehiscence or hernia formation. This is illustrated by the fact that dehiscence rarely occurs immediately after the surgery but is usually delayed for several days,21 during which interval the tissues' weakness from ischemia develops.
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The choice of suture technique and the way that the sutures are tied determine the extent of necrosis that will occur. In much the same way that a suture tied around the base of a pedunculated skin lesion will allow it to become
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necrotic and fall off, abdominal wall sutures create ischemia, necrosis, and tissue disruption. Experiments studying the difference in the strength of wounds closed with tightly tied sutures, as opposed to those tied just tightly enough to coapt wound edges demonstrate that the wounds with more loosely tied sutures are stronger.22,23 These same studies demonstrate that tightly tied sutures create lower breaking strength, increasing the likelihood of disruption. Therefore, whatever suture is chosen, it should not be placed so tightly a to cause ischemia.
48 Suture Placement
A second element that is important to wound strength is the distance between the wound edge and suture placement. First, the inflammatory process at the wound edge produces collagenases to help with removal of necrotic debris. This zone of collagen degradation extends for approximately 1.5 cm from the edge. 24 The fascia in this region is partially digested during the immediate postopera-tive period. Secondly, there is a purely mechanical factor:
The farther from the edge the suture is placed, the greater the amount of fascia the suture would have to tear through in order to pull free25 and the more secure the closure would be. Therefore, sutures should be placed at least 1 to 1.5 cm fi- om the wound edge. In patients at increased risk of wound disruption, sutures should be placed 2 cm from the edge.
Choice of Closure
There are several techniques that can be used to suture the wound edges together. In general, these can be divided into running and interrupted closures.
Running sutures have the advantage of speed, since knots need only be tied at two or three points. In the past, these had often been considered to be weak closures because disruption of any portion of the suture would open the entire wound. More recently, it has been appreciated that these can be strong closures. Compared to the nature of interrupted sutures, the helical nature of an unlocked running stitch evenly distributes tension along the entire wound and
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allows for superior perfusion. Large studies of gynecology patients who are at high risk for dehiscence have demonstrated the safety of this type of closure.
Interrupted and figure-of-eight sutures have an advantage; if one is insecurely tied, or breaks, the whole incision will not come apart. If tied only tightly enough to approximate the tissue, but loosely enough to permit adequate perfusion of the fascia within the suture, such sutures can provide a secure closure without necrosis. There is, however, an inherent tendency to pull forcefully on these sutures as they are being tied. This is unquestionably the
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reverse of what is best. If interrupted sutures are not done properly, they can be a greater impediment to a strong closure than a running suture that produces inherently less ischemia. Further aspects of wound closure will be discussed in the section on wound dehiscence below.
Peritoneum
Closure of the peritoneum has been a topic of controversy, but several points are now clear. The peritoneal mesothelium does not heal like skin.31 Rather than healing only from the edges toward the center of a defect, as is true of epidermis and dermis, a new layer arises from the exposed bed of connective tissue. Therefore, it makes little sense to bring edges of peritoneum together to hasten healing. If the underlying tissue is undamaged, adhesions do not form in the absence of mesothelium before it can regrow; moreover, this process of regrowth occurs rapidly (usually within 48–72 hours).
On the other hand, rarely is the mesothelium alone incised or damaged. In opening the abdomen, the peritoneum is incorporated in the lower abdomen with the transversalis fascia. Above the arcuate line, the posterior rectus sheath also lies under the rectus abdominus muscles, and these structures are incised along with what is clinically referred to as the peritoneum. Closure of the transversalis fascia and posterior rectus sheath can add to overall wound strength and should be accomplished to make a more secure wound.32
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Experimental studies of adhesions frequently use a suture tied around a piece of tissue as a reliable stimulus for the formation of adhesions. Therefore, if a ligature is exposed to the intraperitoneal contents as it would be in a Maylard incision, where the ligatures on the deep inferior epigastric vessels are exposed, covering them by approximating peritoneum with a fine or 4-0 non- reactive suture seems preferable to leaving this nidus for adhesions to remain exposed to bowel.
WOUND COMPLICATIONS
Dehiscence
Dehiscence is defined as the separation of the sutured layers of the abdominal wall and may be classified as partial or complete. In the case of a partial dehiscence, one or more, but not all of the sutured layers may separate.
This situation may also be referred to as wound disruption. Complete dehiscence is marked by separation of all layers resulting in exposure of the peritoneal cavity. Synonyms include evisceration and burst abdomen. The incidence of this complication has been quoted as 0.3% to 3% of all pelvic surgeries, but it is currently thought to occur in less than 1% of cases.33,34,35 Historically, the incidence was thought to be greater for vertical as opposed to transverse incisions, but more recent studies have shown them to be equal.35,36
52 ETIOLOGY AND PREVENTION.
The main causes of dehiscence include failure of the suture to remain anchored in the fascia, suture breakage, and knot failure. Of these, tissue failure and improper suture choice are the most common.35,37 Since closure techniques involving permanent suture and wide bites of tissue exist that effectively prevent dehiscence, the central problem becomes one of recognizing the patient in whom the extra time taken to use a more secure closure is justified.
Inherent strength of abdominal wall tissue affects the risk of dehiscence and, in turn, is also affected by such factors as age, sex, metabolic disease, and the presence of malignancy. Patients over the age of 60 are at increased risk, as are males with a ratio of 2.6 to 6.7 over females.36 Uremia and diabetes are associated with poor healing, as is vitamin C deficiency in the malnourished patient. These underlying conditions should be corrected if possible. White and co-workers found half of their cases of burst abdomen occurred in patients with malignancy.38 The presence of these risk factors indicates the need for a closure that is resistant to disruption such as a mass closure, Smead-Jones closure, or placement of retention sutures.
53 Risk Factors for Dehiscence
Systemic factors
Malnutrition Hypoproteinemia Chronic anemia Vitamin C deficiency Systemic steroids Malignancy Advanced age Obesity
Infection
Previous radiation therapy Chemotherapy
Increased stress on wound Chronic coughing
Ileus with GI distention Ascites
54 Local wound factors
Infection Hematoma Improper closure
Intraoperative technique Incision type
Suture type Closure technique Pressure necrosis
The method of closure plays an important part in wound security . In layered closure each layer peritoneum, fascia, subcutaneous tissue, and skin is closed separately, as opposed to mass closure where all layers, usually excluding skin, are closed in a single unit. Ellis cites mass closure as one of the most significant advances in reducing the risk of burst abdomen. One of the key elements in mass closure is the obligatory use of wide tissue bites (1.5–2 cm from the wound edge) when placing the suture. Recall that the edge of the fascial incision is often necrotic to some degree, resulting in tenuous tissue strength and increased risk of disruption. if sutures are placed near the cut edge. In a review, Wadstrom and Getdin27 found no studies proving an advantage to layered closure. Similar arguments are forwarded in concluding that a continuous
55
closure is superior to interrupted sutures; no clinical advantage of interrupted closure has been shown in the large majority of studies comparing the two. In view of the shorter operating time for continuous closure, it would seem to be the obvious choice. Additionally, one could argue that it is easier to tie two or three knots precisely than to tie precisely the many knots required in interrupted closure. As noted above, to prevent necrosis and subsequent wound disruption, sutures must not be placed under undue tension.
In patients at unusually high risk of wound dehiscence, special consideration should be given to using a closure that is, perhaps, somewhat more time-consuming, but lessens the risk of disruption.39,40 When a wound dehiscence occurs, and permanent suture has been used, the separation usually occurs where the sutures are inserted into the tissue. Therefore, unless a weak or absorbable suture has been used, it is usually not the suture that is at fault, but rather the way that the sutures are anchored in the tissue.37 As previously mentioned, the further a suture is placed from the edge of the wound, the more force is required to pull it out, making wide suture placement a stronger technique. An additional factor that can be used to increase the strength with which the suture can be anchored to the tissue comes from distributing the tension that the suture places on the tissue between at least two points. The Smead-Jones suture takes advantage of this distribution by placing two bites on each side of the wound edge in a far-near near-far arrangement as shown in
56
Originally described, this technique was a mass closure that incorporated both the muscle, fascia, and peritoneum of the abdominal wall. This closure, incorporating all layers, is extremely strong, but it is usually modified to have a separate peritoneal closure, with the Smead-Jones stitches including only the musculofascial layer. This suture gains its strength from the fact that before the suture can tear out of the tissue, it would have to rupture the tissue at two points rather than just one41 and can be done either as an interrupted technique or running suture.
The most secure closure of the abdomen includes both closure of the musculofascial layers and placement of retention sutures through all layers of the abdominal wall, including the skin and usually (although not always) the peritoneum. It is virtually impossible for dehiscence to occur while these sutures are in place because of the great amount of tissue they would have to disrupt in order to pull out. They are usually placed with a number 1, or greater, suture, and are especially useful in treating a wound that has already undergone dehiscence.
Proper suture selection will decrease the risk of dehiscence in patients at normal risk. Clinical studies have shown that wound disruption is most likely to occur in the early postoperative period, usually 5 to 8 days after surgery. Both theoretical concerns about maintenance of suture strength and clinical studies agree that there is no place for catgut sutures in fascial closure. Other
57
absorbable sutures, such as polyglycolic acid (Dexon) and polyglactic acid (Vicryl), even losing up to 80% of its tensile strength in 2 weeks,42 seem to compare favorably to permanent sutures, such as Prolene, in healthy patients undergoing elective surgery who are at no unusual risk for dehiscence. Next of concern will be about the more distant complication wound hernia. In patients at risk for dehiscence, permanent sutures are needed.
In addition to the way in which a wound is closed, the tension placed upon it are important. Mechanical factors such as abdominal distension from ileus, vomiting, and chronic cough may also play a role and should, therefore, be treated when present or prevented when possible in the patient already at risk due to other risk factors.
Other factors that may weaken a wound include the presence of hematoma, wound infection, and obesity. A hematoma will disrupt tissues, preventing approximation as well as providing an excellent nidus for infection.
More often than not, wound dehiscence is associated with a combination of events that, when recognized, calls for meticulous preoperative preparation, wound closure, and postoperative care.
58 DIAGNOSIS AND TREATMENT.
Due to the increased morbidity and mortality associated with dehiscence, diagnosis and treatment should be prompt. Mortality as high as 15% to 20% has been reported in the literature, although more recent studies demonstrate a rate around 10%. Mortality is not solely due to the dehiscence, however; these patients are often ill with other chronic disease.
Wound disruption usually occurs on the sixth to eighth postoperative day.
Evisceration will be apparent on simple inspection. When this is the case, the intestines should be covered with a saline-moistened towel and immediate steps taken to close the incision in the operating room. Although lesser degrees of
59
disruption may be asymptomatic, many patients have a sense of something
“giving way.” The most common complaint is that of a profuse serosanguinous discharge from the wound. When disruption is strongly suspected, careful exploration may best be accomplished in the operating room with suitable anesthetic. In any event, the wound should be opened as necessary to aid in diagnosis and the fascial closure critically evaluated for disruption. A broad- spectrum antibiotic should be started as soon as cultures have been obtained.
Once the patient is in the operating room, the wound must be cleansed carefully and thoroughly. Debridement of the subcutaneous tissue and fascia should be accomplished as necessary. Permanent material of suitable size (number 1 or larger) should be used along with, possibly, retention sutures, depending on the patient's general health and other etiologic factors. Undue suture tension must be avoided to reduce the possibility of necrosis, and bites at least 2 cm from the edge should be used. Retention sutures may be left in place for 14 to 21 days.
Underlying conditions should, of course, be treated (e.g., an NG tube placed if ileus is present). When malnutrition is present or develops, hyperalimentation should be considered and followed by careful dietary support once oral alimentation is resumed.
60 Wound Hernia
Wound herniation is defined as an incomplete dehiscence in which the peritoneum, subcutaneous tissue, and skin remain intact, but the muscle or fascia do not. As opposed to dehiscence that occurs and is recognized in the early postoperative period, wound herniation follows apparently satisfactory healing only to present with an incisional defect at a later date. Although it has been said that most such defects occur before 6 months and nearly all before 1 year, several studies with longer patient follow-up have found occurrences up to 5 years after the initial operation. For low midline incisions, the most often quoted incidence is about 1% in uncomplicated cases; after wound infection, the risk rises to about 10% and, after repair of a dehiscence, to about 30%. Ellis maintains that the reported low incidence of wound hernias is due in part to the lack of prolonged follow-up in most studies. In a review of their own patients for up to 5 years after operation in a group free from hernia at 1 year, an additional 5.8% incidence was found.44 These defects range from the small and insignificant to the large and unsightly. When the fascial defect is small, the risk of volvulus and infarction of the hernial contents is increased, but still uncommon.
ETIOLOGY AND PREVENTION.
Late wound separation is more common in the lower abdomen because of increased hydrostatic pressure and the lack of the posterior rectus sheath below
61
the arcuate line and, for vertical incisions, the greater lateral forces provided by the bulkier oblique muscles inferiorly. The underlying cause is inadequate healing of the fascial layer--perhaps more related to degree than representing a true difference in etiology when compared to dehiscence. Causes may include fascial necrosis from initial excessive suture tension or, secondarily, from abdominal distension associated with ileus, postoperative nausea and vomiting, or pulmonary disease resulting in chronic cough. Necrosis may, in turn, be followed by suture pull-through due to the inadequate tissue strength.
These causes of late wound separation can be largely eliminated by placing wide tissue bites and by approximating the tissue without undue tension.
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Poor tissue vitality is also the common factor in wound hernias associated with wound infections and after repair of dehiscence. One element in reducing the risk of wound infections would be selection of a permanent monofilament suture. Another strong association is fascial closure with catgut suture due to its inadequate continuation of strength during the period critical to healing 45,46 DIAGNOSIS AND TREATMENT.
Consideration should be given to the diagnosis of hernia when, with the patient lying supine and legs raised, an incisional bulging is noted. The hernia is often asymptomatic, although the patient may complain of a bulging, or even note apparent peristalsis with resolution upon lying down followed, in turn, by recurrence when standing. The bulge may increase with a Valsalva maneuver.
On examination the fascial defect is often palpable. Because torsion and infarction are uncommon, colic, distension, nausea, and vomiting are unusual symptoms, and repair is usually elective. Small, asymptomatic hernias need to be repaired; those that are symptomatic, large, or disfiguring also deserve operation. The principles of repair are:
1. Meticulous isolation of the hernia sac
2. Wide exposure of the fascia
3. Careful closure, possibly with use of a graft in the case of very large defects.
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Usually, the old skin scar is excised followed by careful dissection of the subcutaneous tissue until the hernia sac is encountered. Wide isolation of the sac is continued until the fascial edges are encountered and adequately undermined. The sac may then be opened, and attention turned to any adhesions of peritoneum, bowel, or omentum that are carefully separated until the hernia sac can be closed with a purse string suture, and excess sac excised. This dissection can be confusing, with apparent secondary hernia sacs formed by multiple bowel adhesions which, in turn, must be separated until sufficient normal anatomy can be restored to permit a safe closure. The next task is isolation of the fascial edges and freshening of them if the size of the defect will allow primary closure. Several satisfactory approaches may be used, including Smead-Jones closure, mass closure, and overlapping of fascia (pants-and-vest closure). Theoretical considerations would point to the selection of a permanent monofilament suture. Appropriate selections would include 0 or 1 Prolene, nylon, or other permanent sutures. Wire, although important historically, has no advantages over the newer, nonreactive, monofilament sutures.
Large defects may need to be closed with the use of prosthetic mesh (e.g., Merselene, Marlex, Gortex) to bridge the hiatus where approximation of the fascial edges is not possible or causes undue tension.
Other indications for the use of a graft would include repair of a recurrent hernia, grossly attenuated tissues, and fascia that is too weak for adequate
64
repair. Most commonly, the graft is placed anterior to the peritoneum and transversalis fascia, and posterior to the rectus muscles. The material must be anchored to the posterior aspect of the recti “on stretch” to prevent folding when the muscles are approximated in the midline. The anterior rectus sheath is approximated as closely as possible. In some instances, dissection between the hernial sac and the fascia may prove exceedingly difficult or impossible, in which case the Marlex mesh may be anchored to the anterior aspect of the rectus muscles and, again, the anterior rectus sheath would be approximated as closely as possible. This location of the dissection is not as satisfactory, however, in that the already increased risk of wound infection due to the presertce of the graft is further increased by its proximity to subcutaneous tissue and skin.
Postoperatively, predisposing conditions for wound failure should be addressed fastidiously, including control of nausea and vomiting, aggressive and early treatment of ileus and pulmonary complications, and attention to adequate nutrition.
65
RESULTS
A Comparative study between continuous rectus closure and smead jones rectus closure in midline laparotomy wounds was done in a tertiary health care centre and the results were compared in terms of occur
incisional hernia in the post operative period in 1 week, 6 week and 6 months .The study was done with 80 patients for a p
randomly allocated into 2 groups. In group 1 standard continuous rectus closure was done and in group 2 smead jones method of rectus closure was done .
Upto 40 years 41 - 50 51 - 60 years Above 60 years Total
The above table shows age distribution were 10.0% is u 41-50 years, 38.8% is 51-60 years, 18.8% is a
66
A Comparative study between continuous rectus closure and smead jones rectus aparotomy wounds was done in a tertiary health care centre and the results were compared in terms of occurrence of burst abdomen and
sional hernia in the post operative period in 1 week, 6 week and 6 months .The study was done with 80 patients for a period of 10 months. People were randomly allocated into 2 groups. In group 1 standard continuous rectus closure was done and in group 2 smead jones method of rectus closure was done .
Age distribution
Frequency Percent
Upto 40 years 8 10.0
50 years 26 32.5
60 years 31 38.8
Above 60 years 15 18.8
80 100.0
Mean ± SD = 52 ± 8 yrs
age distribution were 10.0% is upto 40 years, 32.5% is 60 years, 18.8% is above 60 years.
A Comparative study between continuous rectus closure and smead jones rectus aparotomy wounds was done in a tertiary health care centre
rence of burst abdomen and sional hernia in the post operative period in 1 week, 6 week and 6 months
eriod of 10 months. People were randomly allocated into 2 groups. In group 1 standard continuous rectus closure was done and in group 2 smead jones method of rectus closure was done .
Figure 1
pto 40 years, 32.5% is
Gender distribution
Female Male Total
The above table shows Gender distribution were 32.5% are Female, 67.5% are Male.
67
Gender distribution
Frequency Percent
Female 26 32.5
Male 54 67.5
Total 80 100.0
The above table shows Gender distribution were 32.5% are Female, 67.5% are Male.
Figure 2
The above table shows Gender distribution were 32.5% are Female, 67.5% are Male.
Diagnosis distribution
The above table shows diagnosis distribution were
Acute small bowel obstruction, 7.5% is Appendicular perforation, 3.8% is bull gore injury, 5.0% is CA anal canal with large bowel obstruction, 2.5% is CA Rectum with large bowel obstruction, 15.0% is Duodenal perforati
perforation, 7.5% is ileal perforation, 16.3% is RTA with blunt injury abdomen, 10.0% is Stab injury abdomen.
Acute cholecystitis
Acute small bowel obstruction Appendicular perforation bull gore injury
CA anal canal with large bowel obstruction CA Rectum with large bowel obstruction Duodenal perforation
Gastric perforation GB perforation ileal perforation
RTA with blunt injury abdomen Stab injury abdomen
Total
68
Figure 3
iagnosis distribution were 10.0% is Acute cholecystitis, 7.5% is Acute small bowel obstruction, 7.5% is Appendicular perforation, 3.8% is bull gore injury, 5.0% is CA anal canal with large bowel obstruction, 2.5% is CA Rectum with large bowel obstruction, 15.0% is Duodenal perforation, 10.0% is Gastric perforation, 5.0% is GB perforation, 7.5% is ileal perforation, 16.3% is RTA with blunt injury abdomen, 10.0% is
Diagnosis
Frequency Percent
8 10.0
Acute small bowel obstruction 6 7.5
Appendicular perforation 6 7.5
3 3.8
CA anal canal with large bowel obstruction 4 5.0
CA Rectum with large bowel obstruction 2 2.5
Duodenal perforation 12 15.0
8 10.0
4 5.0
6 7.5
RTA with blunt injury abdomen 13 16.3
Stab injury abdomen 8 10.0
80 100.0
10.0% is Acute cholecystitis, 7.5% is Acute small bowel obstruction, 7.5% is Appendicular perforation, 3.8% is bull gore injury, 5.0% is CA anal canal with large bowel obstruction, 2.5% is CA Rectum with large bowel on, 10.0% is Gastric perforation, 5.0% is GB perforation, 7.5% is ileal perforation, 16.3% is RTA with blunt injury abdomen, 10.0% is
Comparison between Age with Groups
Age
Upto 40 years Count
% 41 - 50 years Count
% 51 - 60 years Count
% Above 60 years Count
%
Total Count
%
# No Statistical Significance at p > 0.05 level
The above table shows comparison between 2 groups regarding with age.
Group 1 has 15% and group 2 has 5 %. Upto 50 years group 1 has 27.5 % and group 2 has 37.5 %. Upto 60 years group 1 has 45 % and group 2 has 32.5 %. Above 60 group 1 has 12.5
% and group 2 has 25 %. By Pearson’s chi
shows no statistical significant association between
69 Comparison between Age with Groups
Groups
Total ꭓ 2 - value p-value Group I Group II
6 2 8
5.089 0.166 #
15.0% 5.0% 10.0%
11 15 26
27.5% 37.5% 32.5%
18 13 31
45.0% 32.5% 38.8%
5 10 15
12.5% 25.0% 18.8%
40 40 80
100.0% 100.0% 100.0%
# No Statistical Significance at p > 0.05 level
Figure 4
The above table shows comparison between 2 groups regarding with age. Upto 40 years Group 1 has 15% and group 2 has 5 %. Upto 50 years group 1 has 27.5 % and group 2 has 37.5 %. Upto 60 years group 1 has 45 % and group 2 has 32.5 %. Above 60 group 1 has 12.5
% and group 2 has 25 %. By Pearson’s chi-squared test were ꭓ2=5.089 , p=0.166>0.
shows no statistical significant association between Age andGroups.
value
0.166 #
Upto 40 years Group 1 has 15% and group 2 has 5 %. Upto 50 years group 1 has 27.5 % and group 2 has 37.5 %. Upto 60 years group 1 has 45 % and group 2 has 32.5 %. Above 60 group 1 has 12.5
=5.089 , p=0.166>0.05 which
Comparison between Gender with Groups
Gender
Female Count
%
Male Count
%
Total Count
%
# No Statistical Significance at p > 0.05 level
The above table shows comparison between Gender with
37.5 % and in group 2 is 27.5 %. Males in group 1 is 62.5 % and in group 2 is 72.5 %.By Pearson’s chi-squared test were
significant association between Gender andGroups.
70 Gender with Groups
Groups
Total ꭓ 2 - value p-value Group I Group II
15 11 26
0.912 0.340 # 37.5% 27.5% 32.5%
25 29 54
62.5% 72.5% 67.5%
40 40 80
100.0% 100.0% 100.0%
# No Statistical Significance at p > 0.05 level
Figure 5
The above table shows comparison between Gender with both Groups. Females in group 1 is 37.5 % and in group 2 is 27.5 %. Males in group 1 is 62.5 % and in group 2 is 72.5 %.By squared test were ꭓ2=0.912 , p=0.340>0.05 which shows no statistical
Gender andGroups.
value
0.340 #
Groups. Females in group 1 is 37.5 % and in group 2 is 27.5 %. Males in group 1 is 62.5 % and in group 2 is 72.5 %.By
=0.912 , p=0.340>0.05 which shows no statistical
