Closure techniques

Question 1

Primary suture line

Answer 1

• It holds the wound edges in approximation during healing by first intention. It can either be continuous or interrupted
• 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

Question 2

Secondary suture line

Answer 2

• It is called retention sutures
• It 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
• 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)

Question 3

Fascial closure

Answer 3

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

Question 4

Layered versus mass closure

Answer 4

• Evidence is in favour of mass closure technique using looped delayed–absorbable suture, with a wound:suture length ratio of at least 1:4
• In general, subcutaneous sutures should be avoided because the subcutaneous tissue does not provide support

Question 5

Smead–Jones closure

Answer 5

• 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
• The fascial dehiscence rate with running mass closure of the abdomen is 0.4%

Question 6

Gallup closure

Answer 6

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