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A COMPARATIVE STUDY BETWEEN MASS CLOSURE VERSUS
CONVENTIONAL LAYERED CLOSURE OF ABDOMINAL
WOUNDS WITH MIDLINE AND PARAMEDIAN INCISIONS
By
Dr. M. KESHAVA MURTHY
A dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka
Bangalore, in partial fulfillment of the requirements for the degree of the
M. S. (GENERAL SURGERY)
Under the guidance of
Dr. S. I. S. KHADRI MS
DEPARTMENT OF GENERAL SURGERY
BANGALORE MEDICAL COLLEGE
BANGALORE.
2006
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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation entitled “A COMPARATIVE STUDY
BETWEEN MASS CLOSURE VERSUS CONVENTIONAL LAYERED
CLOSURE OF ABDOMINAL WOUNDS WITH MIDLINE AND PARAMEDIAN
INCISIONS” is a bonafide and genuine research work carried out by me under the
guidance of Dr. S. I. S. KHADRI M. S., Professor of Surgery, Bangalore Medical
College, Bangalore.
Date: Signature of the Candidate
Place: Bangalore Name: Dr. M. KESHAVA MURTHY
ii
CERTIFICATE BY THE GUIDE
This is to certify that this dissertation titled “A COMPARATIVE STUDY
INCISIONS” is a bonafide research work done by Dr. M. KESHAVA MURTHY in
partial fulfillment of the requirement for the degree of M. S. in General Surgery,
Bangalore Medical College.
Date: Signature of the Guide

Place: Bangalore Name: Dr. S. I. S. KHADRI M. S.
Professor
Bangalore Medical College
Bangalore.
iii
ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE
INSTITUTION
This is to certify that this dissertation entitled “A COMPARATIVE STUDY
INCISIONS” is a bonafide research work done by Dr. M. KESHAVA MURTHY,
Postgraduate Student in General Surgery, under the guidance of Dr. S. I. S. KHADRI,
Professor, Department of General Surgery, Bangalore Medical College, Bangalore.
Seal and Signature of the HOD Seal and Signature of the Principal
Dr. N. SRINIVASAN M. S., F. R. C. S. Dr. T. RAJESHWARI MS

Professor and HOD Principal
Department of General Surgery Bangalore Medical College
Bangalore Medical College Bangalore.
Bangalore.
Date: Date:
Place: Place:
iv
COPYRIGHT
DECLARATION BY THE CANDIDATE
I herby declare that the Rajiv Gandhi University of Health Sciences, Karnataka
shall have the rights to preserve, use and disseminate this dissertation/thesis in print or
electronic format for the academic/ research purpose.
Place: Name: Dr. M. KESHAVA MURTHY
 Rajiv Gandhi University of Health Sciences, Karnataka
ACKNOWLEDGEMENT
It gives me immense pleasure to express my heart-filled thanks to my Guide,
Dr. S. I. S. Khadri M. S., Professor, Department of General Surgery, Bangalore Medical
College, Bangalore, for his invaluable guidance, advice, constant support and
encouragement during my course of study.
I am extremely thankful to Dr. N. Srinivasan M. S., F. R. C. S., Professor and Head,
Department of General Surgery, Bangalore Medical College, Bangalore for his support,
valuable advice and guidance in completing this dissertation.
I am extremely thankful to my Professors, Dr. Rajeeva Shetty, Dr. Nagraj,
Dr. Sheshasayi and my Assistant Professors, Dr. Shanmukhappa, Dr. Sheshagiri Rao,
and my Lecturers Dr. Suresh Chandu, Dr. Ravikar, Dr. Noor ul Hasan for their constant
support and help.
I thank all the postgraduates who have helped me to complete my dissertation.
I also thank the OT staff who have helped me during the study. Lastly, my special thanks
to all the Patients without whom this dissertation study would not have been successful.
Place: Name: Dr. M. KESHAVAMURTHY
vi
LIST OF ABBREVIATIONS USED
A/G ratio  Albumin/Globulin ratio
ACTH  Adenocortico Trophic Hormone
BMI  Body Mass Index
BP  British Pharmacopoeia
BT  Bleeding Time
CDLC  Continuous Double Loop Closure
CT  Clotting Time
DC  Direct Count
DM  Diabetic Mellitus
DNA  Deoxyribose Nucleic Acid
EDGF  Epidermal Cell Derived Growth Factor
EGF  Growth Factor
Ei  Expected frequency
ESR  Erythrocyte Sedimentation Rate
FBS  Fasting Blood Sugar
GOO  Gastric Outlet Obstruction
Group I  Single Layered Closure
Group II  Conventional Layered Closure
Hb%  Hemoglobin %
HbSAg  Hepatitis-B S Antigens
HIV  Human Immuno Compromised Virus
IGF-I  Insulin like Growth Factor – I
vii
IH  Incisional Hernia
IL-I  Interleukin-1
IL-II  Interleukin-2
LFTs  Liver Function Tests
NSAIDs  Non-steroidal anti -inflammatory Drugs
Oi  Observed frequency
P  Pain over the Scar
PA view  Postero Anterior view
PDGF  Platelet Derived Growth Factor
PDS  Polydiaxonone Sulfate
PO2  Partial Pressure of Oxygen
PPBS  Postprandial Blood Sugar
SD  Standard Deviation
SM-C  Somatomedian – C
SPSS  System Analysis Programmed Statistical System
SS  Suture Sinus Formation
TC  Total Count
TGFA  Transforming Growth Factor Alpha
TGFB  Transforming Growth Factor Beta
TK  Tyrosine Kinase
WD  Wound Dehiscence
WI  Wound Infection
X2  Chi square Test
viii
ABSTRACT
BACKGROUND
The ideal method of abdominal wound closure should be technically simple and it
should be free from postoperative wound complications of wound infection, wound
dehiscence, incisional hernia, suture sinus formation and should leave a reasonably
aesthetic scar.
The present study is a prospective comparative study between single layered
closure versus conventional layered closure of ventral abdominal wounds with midline
and para midline incisions, the study is conducted on patients admitted from November
2003 to April 2006 in the Department of Surgery, Bowring and Lady Curzon Hospitals,
attached to Bangalore Medical College, Bangalore.
OBJECTIVES
The objectives of the study is to find out the superiority of single layered closure
over the conventional layered closure of ventral abdominal incisions in preventing post
operative wound complications.
METHODS
Out of 109 major laparotomies from November 2003 to April 2006, 53 cases were
randomized to have their ventral abdominal incisions closed by single layered closure and
remaining 56 cases by conventional layered closure, they were grouped as Group I and
Group II respectively, In Group I there were 6 cases (11.32%) of wound infection, 1 case
(1.88%) of wound dehiscence, 1 case (1.88%) of incisional hernia, 2 cases (3.8%) of
ix
suture sinus formation and 5 cases (9.4%) of pain over the scar. In Group II there were
12 cases (21.42%) of wound infection, 4 cases (7.14%) of wound dehiscence, 2 cases
(3.57%) of incisional hernia, 2 cases (3.6%) of suture sinus formation and 7 cases
(12.5%) of pain over the scar.
RESULTS
The current study has shown that the single layered closure technique of ventral
abdominal incisions results in lower incidence of wound infection, wound dehiscence and
incisional hernia as compared to conventional layered closure technique.
INTERPRETATIONS AND CONCLUSIONS
Finally, the observations tabulated from our comparative study proved to be
similar to other studies conducted by various authors thus proving that single layered
technique had the following advantages in:
 Reduces the time consumed for closure. Closure is even more secure in cachectic
patients and this allows early mobilization.
 Reduces the incidence of wound infection, thus decreasing the hospital stay and
morbidity.
 Reduces the incidence of wound dehiscence.
 Reduces the incidence of incisional hernia.
 Reduces the incidence of suture sinus formation and scar complications by using
monofilament suture material.
Thus, this method holds the promise for a safe technique of closure with minimal
complication.
KEYWORDS
Single-layered closure; Conventional layered closure.
TABLE OF CONTENTS
Sl. No. Particulars Page

Nos.
1. INTRODUCTION 1
2. OBJECTIVES OF THE STUDY 3
3. REVIEW OF LITERATURE 4
4. METHODOLOGY 81
5. OBSERVATIONS AND RESULTS 92
6. DISCUSSION 113
7. CONCLUSION 123
8. SUMMARY 124
9. BIBLIOGRAPHY 126
10. ANNEXURES
 PROFORMA 135
 MASTER CHART 140
 KEY TO MASTER CHART 145
xi
LIST OF TABLES
Page Nos.
1. Age distribution 92
2. Sex distribution 94
3. Primary etiology 96
4. Type of Surgery 97
5. Type of wound 99
6. Time taken for closure 101
7. Factors affecting wound healing 103
8. Duration of follow up 107
9. Postoperative complications 108
10. Postoperative complications and follow-up status 109
11. Type of closure 111
12. Mean pattern of Hospital stay in days 112
xii
LIST OF FIGURES
Sl. Page
No. Nos.
1. Regions and planes of abdomen 9
2. Musculoaponeurotic layer of anterior abdominal wall 14
3. Rectus muscle and sheath 21
4. Single layered closure of midline incision 88
5. Single layered closure of paramedian incision 88
6. Conventional layered closure of midline incision 89
7. Conventional layered closure of paramedian incision 89
xiii
INTRODUCTION
In abdominal surgery, wisely chosen incision, correct method of making and
closing such wounds are factors of great importance. The ideal method of abdominal
wound closure should be technically so simple that the results are as good in the hands of
trainee as in those of master surgeons. It should be free from complications of burst
abdomen, incisional hernia, and persistent sinuses. It should be comfortable to the
patients and should leave a reasonably aesthetic scar.
Until recently layered closure of the abdomen wounds were considered ideal with
great emphasis placed on peritoneal layered. It is now fully realized; both from clinical
observation and animal studies, that healing of incisions takes place by a dense fibrous
scar that unites the opposing faces of laparotomy wound enmasse.1
Therefore, this study is intended to show that continuous enmass closures of
laparotomy wounds is preferred to conventional layered closure.
This study is a prospective comparative study between mass closure versus
conventional layered closure of abdominal wounds with midline and paramedian
incisions. The data collection for our study included patients from Bowring and Lady
Curzon Hospitals, attached to Bangalore Medical College attending the outpatient and
emergency services and subsequent admission as in-patient during the period,
November 2003 – April 2006.
The study group included patients who were randomly selected irrespective of
their age, sex and nature of disease. Out of 109 patients, 53 patients were randomized to
have their ventral abdominal incisions closed in single layered mass closure and
56 patients in conventional layered closure. These patients are grouped as Group 1 and
Group 2 respectively.
In Group 1 (53 out of 109 patients) ventral abdominal incisions were closed in
single layered mass closure using, polypropylene No. 1 by continuous interlocking.
In Group 2 (56 out of 109 patients) ventral abdominal incisions were closed in
conventional layers using No. 1-0 chromic catgut for peritoneum and polypropylene
No. 1 for linea alba or the layers of rectus sheath by continuous interlocking skin was
closed with non absorbable material like No. 1.0 cotton thread or mersilk using
interrupted mattress suture in both groups. Six Patients in the former and twelve patients
in the latter had wound infection. Four cases of burst abdomen occurred in layered
closure and one in mass closure. Two cases of incisional hernia occurred in layered and
one in mass closure. Thus, minimal complication and good patient compliance seem to
justify the use of mass closure in place of layered closure in all types of abdominal
operations.
OBJECTIVES OF THE STUDY
The study aims to show that mass closure of laparotomy wounds:
 Is easier, faster and cost effective.
 Has a lesser rate of complications like burst abdomen, incisional hernia and sinus
formation.
 Has better patient compliance.
 Leaves a reasonably aesthetic scar.1
HISTORICAL REVIEW
For a surgeon, the study of surgical history can contribute towards making this
educational effort more pleasurable and can provide constant invigoration. Tracing the
evolution of what one does on a daily basis and understanding it from a histological
prospective become enviable goals.2 The history of Indian surgeons dates back to
Sushruta who was credited for endeavor in organizing the subject of surgery. Sushruta
used sutures made from flax, hamp, bark, fiber of hair. One of the earliest Indian texts
written by Sushruta “Sushruta Samhita” describes in detail about suture material and also
about the needles deployed by him, which is now-a-days of specialty in the plastic
surgery.3
Ancient surgery has gone through the era of great surgeons of the past.
Hippocrates, Aulus Cornelius Celsus, the father of the concepts of inflammation. He in
his third book “De Medicina” has described how hand has a role in curing a disease apart
from the medicines and diet. He says “the surgeons should be youthful or at any rate
nearer to the youth than age, with a strong and steady hand, which never trembles and
ready to use the left hand as well as the right, with a vision sharp and clear and spirit
undaunted, filled with pity, so that he wishes to cure his patients, yet is not moved by the
cries to go too fast or cut less than necessary, but he does everything just as if the cries of
pain cause him no emotion.”
History of Incisions
The type of abdominal incisions may be completing a full cycle from midline to
the transverse, and back to midline Meyer in 1869 has quoted “during the increase in
abdominal surgery in the latter decades of the nineteenth century, the midline incision
was used most frequently”.4 At the turn of the century, three things may have led to the
change from the midline incision to the transverse incision.
There were reports of dehiscence in the vertical portion of the combined
transverse and vertical incisions.4, 5

This observation may have influenced surgeons to
change to transverse rather than vertical incisions.
The physiological observation that abdominal aponeurotic fibers approximate
with muscle contraction, thereby tending to close transverse incisions. This tendency to
close was used as a reason to account for the lower dehiscence rate of transverse incisions
at that time.
The work to Trendelenburg6 and Pfannensteil describing transverse incisions for
bladder and pelvic surgery with good results.
These three factors fostered the increased utilization of transverse incisions at the
turn of the century despite their advantages of limited exposure, difficulty to extend and
time consumption for opening and closing.
Vertical incisions became popular again in the 1930s and 1940s. The paramedian
and not the midline incision were used. However, rapidly increasing use of the midline
incision started with the development of reconstructive abdominal aortic surgery (1950s),
surgery in the Vietnam War (1960s), and the great increase in the civilian abdominal
trauma surgery (1960s). Surgeons in these fields recognized the advantages the midline
incision offered to their work, namely, rapidity of opening and closing and ease of
extension. It was shown that the incision has clear merits and its closure can be made as
secure as any abdominal incisions.7
History of closure
Almost since the beginning of abdominal surgery the masters of the techniques,
have preached the importance of meticulous layer-by-layer closure of the abdominal wall
and indeed, this certainly has a strong esthetic appeal.
In 1941, Jones and Associates15 reported a burst abdomen rate of 11% with
catgut, and 7% with catgut for peritoneum and interrupted steel wire for the anterior
rectus sheath. Only 1 burst abdomen occurred in 81 operations after steel wire closure
with interrupted mass far and near sutures incorporating all layers of the abdominal wall
apart form the skin. Smead, a resident to Finney in Baltimore, first used the “far-near”
stitch in 1900. During the course of a complicated operative procedure, Smead suggested
that the operation be finished with a closure that was safe and rapid. Finney agreed, and
Smead performed what is believed to be the first far near mass closure of the abdomen, a
technique often referred to as the Smead – Jones method.
Dudely and Jenkins8,9 in the year 1970 and 1976 respectively, put forward
theoretical arguments supporting the value of closure, employing non-absorbable sutures
that include all layers of abdominal wall, apart from skin and that incorporate wide bites
of the tissues on either sides of the incisions. When put to the practical test this technique
was not found wanting.
In paramedian elective laparotomies, Goligher 10 (1976) reported one burst
abdomen and no hernias among 108 cases using all coats interrupted wire sutures. Kirk 11
in 1972 had no wound disruption in 186 laparotomies closed with, continuous all coat
nylon. Martyk and Curtis7 (1976) closed 180 midline wounds with, all coats continuous
nylon, again without a single wound dehiscence, and a similar finding was reported by
Leaper and associates in 1976, in 120 laparotomies subjected to mass closure using steel
wire.
Jenkins9 recorded, only one dehiscence in a series of 1505 closures; using all coat
nylon, Bucknall13 et al 1982, used nylon continuous sutures to close the full thickness of
abdominal incisions apart from the skin, which is sutured separately. Bites are taken at
least one centimeter from the edges of the wound and are placed close together
(maximum of 1 cm apart). The introduction of this technique produced quite dramatic
improvements in the results. 341 single layered closures were performed, with an
incidence of 3.7% burst abdomen.
Horald Ellis in his text on closure of laparotomy incision says “my preferred
technique of closure of laparotomy incision i.e., by mass closure, using nylon. 1
THE QUADRANTS OF THE ABDOMEN
For clinical purpose the abdominal wall may be divided into nine quadrants by
two vertical and two horizontal conventional lines. The superior of the two horizontal
lines passes between the inferior margins of the costal flares, the inferior line passes
between the highest points of the iliac crests. The two vertical lines bisect the two
inguinal ligaments. The three central regions are the epigastrium, the umbilical and
hypogastrium. The lateral regions are the hypochondriac, the lumbar and iliac regions.
Surface anatomy16,17,18,19,20
The abdomen presents practical and reliable landmarks. The linea alba extends in
the midline from the Xiphoid to the symphysis. It is divided by the umbilicus as
supraumbilical and infra umbilical segments of about equal length. The rectus muscles
form bulging bands on either sides of the linea alba.
Fig 1: Regions and planes of abdomen
BASIC ANATOMY
Definition
The abdomen can be defined as the region of the trunk that lies between the
diaphragm above and the inlet of the pelvis below.
Structure of the abdominal walls
Inferiorly, the abdomen cavity is continuous with the pelvic cavity through the
pelvic inlet. Anteriorly, the abdominal wall is formed above by the lower part of the
thoracic cage and below by the rectus abdominis, external oblique, internal oblique and
transversus abdominis muscles and fasciae.
Posteriorly the abdominal wall is formed in the midline by the five lumbar
vertebrae and their intervertebral discs; laterally it is formed by the twelfth rib, the upper
part of the bony pelvis, the psoas muscles, the quadratus lumborum muscles, and the
aponeurosis of origin of the transversus abdominis muscles. The iliacus muscles lie in the
upper part of the bony pelvis. The abdominal walls are lined by a fascial envelope and the
parietal peritoneum.
10
EMBRYOLOGY21
The development of abdominal wall begins quite early in the embryo, but
achieves a definite structure only after separation of the umbilical cord from the foetus
after birth. Most of the abdominal wall of the embryo forms during closure of the midgut
and reduction in relative size of the body stalk. The primitive wall is somatopleura,
composed of ectoderm and mesoderm without muscles, vessels or nerves. It is
secondarily invaded during the sixth week by mesoderm from the myotomes lying on
either side of the vertebral column. The segmental pattern of mesoderm mass is lost and it
migrates laterally and ventrally as a sheet. The leading edges of the advancing sheets
differentiate while still widely separated to form the right and left rectus abdominis
muscles, whose final approximation in the midline will close the body wall.
While the primordia of the rectii are still separated, the main body of the
mesodermal sheet splits into three layers, the external layer differentiates into the external
oblique muscle ventrally and the serratus group dorsally; the middle layers forms the
internal oblique muscle; and the inner layer forms the transversus abdominis. All of these
muscles can be recognized by the middle of the seventh week. The approximation of the
two rectii proceeds form both cranial and caudal ends, becoming essentially closed by the
twelfth week, except for the umbilical ring itself. At the ring, the body wall with its
developing muscles gives way to undifferentiated somatopleura over the surface of the
umbilical cord.
11
Critical events in body wall closure. Duhamel (1963), has described failure of
closure of the four folds of the anterior body wall as Celosomias.
1. Failure of the cephalic fold to close (upper Celosomia) sternal defects.
2. Failure of the caudal fold to close (lower Celosomia) Exostrophy of bladder and
cloaca.
3. Failure of lateral folds to close: Umbilical hernia and in the extreme case,
Omphalocele.
Wolff (1948) related absence of the limbs (ectromelia) to defects of the body wall.
The defects of primary closure of the body wall have been well reviewed by Hutchin in
1965.
Surgical anatomy of abdominal wall
The abdominal wall is a musculoaponeurotic structure through which the
surgeons can often feel diseased organs that lie within the abdominal cavity. An intact
abdominal wall is essential for the support of the abdominal contents. A defect or
malfunction of the wall can allow the abdominal contents to bulge forward and form a
hernia. The abdomen wall also provides the surgeon with a site for access to deep lying
diseased structures.20
The anatomic principle governs the incisions used for laparotomy. Thus
prevention of herniation of abdominal contents through the incisional wound, resulting in
burst abdomen or herniation through a week scar, resulting in incisional hernia, are the
12
main aims of a surgeon closing laparotomy incisions. During respiration, coughing,
sneezing, a temporary rise in intraabdominal pressure, if occurs, following surgery, can
result in any of the above complications, if due attention is not paid to prevent them.
Across them stretch the linea transversae, tendinous intersections which, in more
muscular persons, produce palpable transverse depressions. These depressions are
accentuated in active rectus contraction or in reflex muscle spasm associated with
irritation of the peritoneum.
At the lateral margin of each rectus muscle is a depression, the linea semilunaris,
directed towards the symphysis, the pubic tubercle are palpable at the medial attachments
of the inguinal ligaments, located about two finger breadth above the suspensory
ligament of penis and about 2.5 cm lateral to midline.
The abdominal wall is composed of nine layers
1. The skin
2. The subcutaneous fatty layer
3. The Scarpas superficial fascia
4. The external oblique muscle
5. The internal oblique muscle
6. The transversus abdominis muscle
7. The transversalis fascia (endoabdominal fascia)
8. The extra peritoneal adipose and loose areolar tissue and
9. The peritoneum
13
Fig 2: Musculoaponeurotic layer of anterior abdominal wall
1. The Skin
The skin of the abdomen is attached loosely to the subjacent structures: except at
the umbilicus, where it adheres firmly. As in other parts of the body, the lines of tension
of the skin are produced by the course of fibrous tissue bundles and the deposition of
elastic fibers in the corium. Attention to their direction is important in making surgical
incisions. The incisions made in the lines of the skin cleavage and accurately
approximated leave a hairline scar. The incisions across these lines leave a broad scar
particularly when infection develops.
14
2. The Subcutaneous Fatty Layer
It is also known as Camper's fascia and it contains the bulk of subcutaneous fat.
Generally the fatty content increases with age. It contains little fibrous connective tissue,
hence affords little strength in closure of abdominal incisions. It rests on the
membranous Scarpas fascia.
3. The Scarpas Fascia
It is a layer of fibrous connective tissue, of modest thickness and abundant
adipose tissue. The discrete layers of the fascia can be ordinarily demonstrated in lower
abdominal wall.
The superficial layer of the fascia is thick, areolar in texture and contains in its
meshes varying quantity of fat. The deeper layer of the superficial fascia is thinner and
more membranous than the superficial one, contains considerable quality of elastic fibers.
It is loosely connected by the areolar tissue to the fascia over the, external oblique
muscles. But in the midline it is more intimately adherent to the linea alba, the symphysis
pubis. Above it is continuous with the superficial fascia over the rest of the trunk, below
and laterally it blends with the fascialata of thigh, a little distal and parallel to inguinal
ligament. Below and medially it continues over the penis, on the spermatic cord and into
the scrotum, from there it can be traced back in continuity with membranous layer of
superficial fascia of perineum. This layer affords little strength in wound closure, but its
approximation aids considerably in creation of an aesthetic hairline scar.
15
4. The External Oblique Muscle
It is the largest and thickest of the flat muscles of abdomen, situated in the lateral
and anterior parts of abdomen.
It arises:
 By eight fleshy slips from external surfaces and inferior borders of lower 7-8 ribs.
 From thoracolumbar fascia.
 External lip of iliac crest and
 Inguinal ligament that inserts to the public tubercle.
Insertion: The aponeurosis of external oblique is a thin but a strong membranous
structure; the fibres are directed downwards and medially. In median plane its fibers end
in linea alba.
The fibers of external oblique pass from superio-lateral to inferio-medial and thus
the force generated by contraction of this muscle is superio-lateral. The external oblique
has a fascial sheath on either side, of which the external is well developed.
Nerve supply: The ventral rami of lower six thoracic nerves supply the muscle.
5. The Internal Oblique Muscle
It lies under the cover of external oblique, is thinner and less bulky. It arises from:
 Fleshy fibres from last five ribs.
 Thoracolumbar fascia.
 Intermediate lip of anterior 2/3 of ventral segment of iliac crest.
 Lateral 2/3 of grooved surface of inguinal ligament.
16
Insertion: Its fibres course perpendicular to those of external oblique to give way
to a flat aponeurosis medially, which splits to enclose rectus abdominis. The aponeurosis
reunites medial to the rectus abdominis and inserts into linea alba. Those fibres arising
from inguinal ligament form conjoint tendon to get inserted into os pubis between
symphysis pubis and pubic tubercle.
Nerve supply: It is supplied by ventral rami of lower six thoracic and first lumbar
nerves.
6. The Transversus Abdominis Muscle
It is the smallest of the three flat muscles of abdomen.
Origin
 By fleshy fibres from lateral third of inguinal ligament.
 From anterior 2/3 of the inner lip of ventral segment of the iliac crest.
 Thoracolumbar fascia.
 Inner surface of lower six costal cartilages.
Insertion: Lower fibres form conjoint tendon with those of internal oblique and
are inserted into os pubis between symphysis pubis and pubic tubercle. Rest of the
muscle forms aponeurosis passing horizontally to plane and is inserted to the linea alba.
Nerve supply: It is supplied by the ventral rami of lower six thoracic and first
lumbar nerves.
17
The plane between internal oblique and transversus abdominis is the
neurovascular plane as it contains the segmental blood vessels and nerves.
7. The Transversalis Fascia
The transversalis fascia is poorly named and often misunderstood. It is a
continuous lining of abdominal cavity and is better named as endoabdominal fascia.
Integrity of the transversalis fascia is essential for integrity of the abdominal wall;
if this layer is intact no hernia exists. A hernia may hence be defined as a defect in the
endoabdominal fascia-in connection with oesophageal hiatus hernia, umbilical hernia,
and paraumbilical incisional hernia, inguinal and femoral hernias.
8. Extraperitoneal adipose and Connective Tissue Layer
Extra peritoneal adipose and connective tissue layer of abdominal wall is
surgically relatively unimportant. It is found between endoabdominal and parietal
peritoneum; it contains greater adipose tissue in obese individuals. Above the level of
umbilicus, in midline the extra peritoneal adipose tissue projects between two leaves of
falciform ligament of liver. In the free margin of the falciform ligament is found the
ligamentum teres hepatis, which is the obliterated umbilical vein, which comes from
ligamentum venosum to umbilicus.
18
9. The peritoneum
The peritoneum is the largest serous membrane of the body, divided into two, that
lining the viscera termed visceral peritoneum, and that layer forming the inner most layer
of abdominal, wall termed parietal peritoneum. The parietal peritoneum is richly supplied
with nerves and hence is sensitive to painful stimuli. Surface of this layer of peritoneum
is smooth, lined by a layer of flattened mesothelium and is lubricated by a small quantity
of serous fluid.
The parietal and visceral layers of peritoneum are developed from the
somatopleural and splanchnopleural layer of lateral plate of mesoderm. Thus, the parietal
layer of peritoneum derives its arterial supply from the body wall respectively, veins join
the systemic veins, in the neighboring parts of body wall so do the lymphatics draining to
parietal lymphnodes. Its nerve supply is from the spinal nerves supplying the muscles and
skin of the abdominal wall. As against, the visceral layer derives its blood supply from
the viscera, it ensheaths veins and lymphatics accompanying the corresponding nodes to
which the viscera drains. Visceral peritoneum is supplied by the sympathetic nerves
accompanying the vessels. Thus the parietal peritoneum is a sensitive membrane, even to
touch, temperature and chemical stimuli. Stretch, spasm of muscle, ischemia elicit pain
sensation through the visceral peritoneum.
Healing: Healing of peritoneal defects occur by metamorphosis of in situ
mesenchymal cells and not from edges. Hence large defects heal as rapidly as the small
defects. This is one of the theories, which favors the proponents arguing that closure of
peritoneum is not always essential.
19
The Rectus Muscle and Sheath
The rectus muscles extend from fifth rib to symphysis pubis. Each muscle is
composed of long parallel fascicles interrupted by three tendinous insertions. They serve
to support abdominal wall and to flex the vertebral column. Each muscle is contained
within a sheath termed rectus sheath, which is derived from the aponeurosis of the three
flat muscles of abdomen. The semicircular line of Douglas is situated between the
umbilicus and symphysis pubis. Above the semicircular line the posterior sheath is
strong, composed of fascia of internal oblique, transversus abdominis and endoabdominal
fascia. Anterior layer is formed of aponeurosis of internal oblique and external oblique
muscle. At the semicircular line the inferior epigastric artery enters the rectus sheath.
Below the semicircular line the rectus is covered posteriorly by endoabdominal fascia
only and all the aponeurotic parts pass anterior to the rectus abdominis.
20
Fig 3: Rectus muscle and sheath
21
Blood supply of the Abdominal Wall
1. The superior epigastric artery is a terminal branch of internal thoracic artery,
which enters the rectus sheath. It has extensive collateral branches within the
rectus muscle and with the inferior epigastric artery.
2. Branches from femoral artery supply skin and subcutaneous tissue of the lower
abdomen.
The arterial blood supply is quantitatively different in the component parts of the
abdominal wall. The skin and subcutaneous fat receive their arterial supply from
perforating vessels through the fascia from deeper sources. These various perforating
sources form a random arcade of vascular inter communications that make it difficult to
cause ischemic necrosis by combinations of interdigitating incisions. The blood supply of
the subcutaneous fat is the least among the abdominal wall components. Accordingly,
bacterial contamination of the subcutaneous fat represents the anatomic focus for the
development of most wound infections.
This is the simple and adequate description for all practical (including surgical)
purposes. It can however, be elaborated in the light of a detailed and extensive study of
human cadaveric and other mammalian material by Rizk (1980). The revised view that it
offers is summarized briefly here in a simplified way.
 Obliqus externus, obliqus internus and transversus abdominis each have a
bilaminar aponeurosis.
22
 Of the six laminae formed in this way, three pass anterior to rectus and three
posterior.
 A given aponeurosis lamina does not stop at the midline but decussates there with
other aponeurosis and continues as an aponeurotic layer of the contralateral
muscle or of another muscle. Thus, sheets of collagenous fibres cross each other
at the midline, and the linea alba is formed by compaction of these linear
decussations.
 The continuation of aponeurotic laminae across the midline effectively combines
the bilateral oblique and transverse muscles in pairs, so that these could be
regarded as digastric muscles, albeit with their central tendon firmly anchored in
the linea alba.
The bilaminar aponeuroses of the obliqus externus consist of deep and superficial
layers; their fibres are approximately at right angles to each other. The deep layer forms a
sheet of parallel, straight fibres, over the top of which the superficial layer forms a series
of parallel, wide S-shaped curves. At the midline the fibres from the deep layer on each
side decussate to continue as the superficial layer in the contralateral half of the
abdominal wall.
From these and similar observations a more detailed picture emerges of the
structure of the rectus sheath. From the costoxiphoid margin to the umbilical level the
anterior wall of the rectus sheath is trilaminar. It consists (externally to internally) of
23
 The anterior lamina of the external oblique aponeurosis
 The posterior lamina of the external oblique aponeurosis
 The anterior lamina of the interna1 oblique aponeurosis.
In the first and third of these layers the fibres are parallel, and course obliquely
upwards and medially as they approach the midline. The fibres in the second layer,
sandwiched between them, are at right angles to this. This construction is similar to the
cross-grain of plywood. In most individuals the same arrangement is present in the
posterior wall of the sheath which (continuing in the same direction) consists of:
 The posterior lamina of the internal oblique aponeurosis (fibres directed upwards
and medially).
 The anterior lamina of the transversus abdominis aponeurosis (fibres directed
downwards and medially).
 The posterior lamina of the transversus abdominis aponeurosis (fibres directed
upwards and medially)
Between the level of the umbilicus and the iliac crest the layers change in their
superficial-to-deep sequence and near the pubis they are modified by the formation of the
falx inguinalis. Note that in this newer account the posterior layer of the sheath does not
undergo a sudden transition at an accurate line; instead it is slowly attenuated, with fibres
transferring progressively to the anterior layer and to the falx inguinalis, and the
transversalis fascia thickening posteriorly, to compensate.
24
ABDOMINAL INCISIONS AND CLOSURE
It is definitely not an exaggeration, to state that, in abdominal surgery a wisely
chosen incision, correct methods of making and closing such wounds, are factors of great
importance. A badly placed incision cutting the motor nerves supplying abdominal
musculature, inept methods of suturing, ill judged selection of suture materials and bad
technique of closure may all result in serious complications like haematoma formation,
infection, stitch abscess, ugly scar formation, incisional hernia or worst of all the
complete disruption of wound.
The surgeons aim; to employ the type of incision depends on the surgery being
performed. However the three essentials of an incision are that it should have
 Accessibility
 Extensibility and
 Security
General principles
 The incision must give ready and direct access to the anatomy to be investigated.
It must also provide an adequate room for procedure being performed.
 The incision should be extensible, if need arises in a direction that will allow for
any probable enlargement of the scope of operation. However it should interfere
as little as possible with, the function of abdominal wall in future.
25
 The security is the most important principle governing any abdominal surgery.
Hence closure of abdominal wound, must be reliable. Ideally it should leave
abdominal wall as strong after operation as before.
 Strict aseptic precautions taken would prevent contamination of wound and thus
infection.
The abdominal wall incisions
The incisions used to explore abdominal cavity can be classified as
I. Ventral Incisions
A. Ventral midline incision
B. Ventral paramedian incision
 Rectus retracting paramedian incision
 Rectus splitting paramedian incision
Location: Supra umbilical
Infra umbilical
Both
II. Transverse incisions
A. Supraumbilical
B. Infraumbilical
 Maylard’s incision
 Pfannensteil Incision
26
III. Transverse oblique incisions
 Kocher’s incision
 Inverted V shaped incision
 Mc Burney’s incision
 Rockey Davis incision
 Lanz incision
IV. Abdominothoracic incision
V. Alphabetical incision
S Incision of Bevan
 Czerny incision
 Bardenbever incision
Sloan incision
Mixter incision
V Sprengel incision
Maingot’s incision
T Incision
Among these incisions, except T incision, all the incisions are rarely in vogue
now.
27
Description of individual incisions
a. Midline incisions1,2,3
Midline incision can be used for almost all the operations in the abdomen or retro
peritoneum. It is thus a universally applicable incision. The advantages of this incision
are that:
 It can be used for opening and closure quickly,
 It is virtually bloodless
 It is easily extensible with a curve around umbilicus.
In the upper abdomen, the incision is made in midline, extending from the xiphoid
process, ending immediately above the umbilicus. The skin, fat, linea alba, extra
peritoneal fat and peritoneum are divided in that order. Division of peritoneum is best
performed, at the lower limits of the incision, just above the umbilicus, so that the
falciform ligament can be seen and avoided. If necessary, for adequate exposure, the
ligament can be divided between clamps and ligated.
The infraumbilical midline incision divides the linea alba, as the linea alba is
anatomically narrow in the regions, the rectus sheath may also be opened unintentionally,
however is of no consequence. In the lower abdomen, the peritoneum should be opened
in the uppermost area of incision, below the umbilicus to avoid injury to the bladder.
Special care should be taken to open peritoneum in cases with intestinal obstruction or in
reoperations.
28
b. The Paramedian Incisions1,23
The paramedian incisions have two advantages, theoretically.
 It provides better exposure to lateral structures like kidney and spleen.
 Theoretically the closure is more secure. The rectus muscle can act as a buttress
between their approximated posterior and anterior rectus planes.
The incision is placed 2-4 cms lateral to midline. The skin and subcutaneous fat
are divided along the length of the wound. Flaps of skin and subcutaneous fat are
separated medially from the underlying fascia. The anterior layer or rectus sheath thus
exposed is incised. Its medial edge is grasped and lifted to favour separation of the rectus
from the sheath, to which it adheres. The segmental blood vessels encountered should be
secured. Since the rectus is freely mobile over the posterior sheath, it can be easily
retracted once it is separated from the anterior sheath. The posterior sheath and
peritoneum which are adherent to each other are picked up and incised vertically taking
care, to avoid coils of intestine particularly in intestinal obstruction. The incision can be
extended, vertically for the entire length of abdomen, in the same anteroposterior plane as
the anterior fascial incision. The deep inferior epigastric vessels are encountered below
the umbilicus, then require ligation and division if they course medially along the line of
incision.
The infraumbilical paramedian incisions are made in similar manner and can be
extensions of supra umbilical incisions. The main differences are that the inferior
epigastric vessel is exposed in the posterior compartment of rectus sheath. The
aponeurosis of transversalis is in the anterior layer of the fascia below the semicircular
line of Douglas.
29
The paramedian incisions can be:
1. The rectus retracting type
2. The rectus splitting type
In the rectus splitting type, the muscle is split longitudinally, near the medial
border, and the peritoneum is opened longitudinally in the same line. The advantage of
this incision is that, it can be made and also closed quickly. Bleeding is a common
problem however is a minor one. It is particularly useful in reopening the previous
paramedian incisions, when it is often difficult or nearly impossible to dissect the rectus
muscle off the anterior layer of the sheath and away from the scar tissue. However, in
these incisions the medial portion of the muscle looses its nerve supply and blood supply,
and may become, atrophied.
The Mayo-Robson extension of the paramedian incision is accomplished by
hockey stick like curving the incision towards the xiphoid process. Incision of the fascial
planes may be continued in the same direction to obtain a larger fascial opening.
Principles of suture selection
In the past the plain and chromic catguts were the suture materials of choice for
the fascial closure. A high incidence of wound dehiscence was reported with their use
alone. Goligher recommends not to use catgut for fascial closure unless retention
(tension) sutures are used.73
30
The selection of suture materials is based on the rate of healing of tissues
involved. The skin and fascia heal slowly than the visceral tissues. So, the sutures used
should keep the wound edges opposed until the scar formed, achieves adequate strength.
The newer synthetic absorbable suture materials like polyglycolic acid and
polygalactin 910 are degraded by hydrolysis. They maintain the tensile strength for an
adequate period of time. In unused state they are as strong as the non-absorbable
materials.
The monofilament non-absorbable suture materials like nylon and polypropylene
are good choices for closing fascia. The nylon looses 16% of strength by 70 days and
20% by 200 days. Studies conducted by Irvin DJ et al and Corman ML, Veidenheimer
MC et al showed wound dehiscence rates of 10% and 6% when Dexon, Vicryl or Prolene
were used, respectively, for fascial layer closure.24,32
Silk and cotton are good suture materials but promote infection. Stainless steel
also potentiates infection. Wire sutures eventually break and may present a nidus for
infection. Polypropylene, nylon and other synthetic non-absorbable have lowest
incidence of infection in contaminated wound. The formation of suture sinus tracts
resulting from infection can be avoided by closing the wounds with polyglycolic acid
suture material.
31
With these observations it could be derived that experience and personal
preference often dictate the choice of suture material by the individual surgeon. Factors
such as handling, tensile strength, knotting characters, tissue reactivity, visibility, and
capillarity and absorption characters all play a part in surgeon's final choice.
However, no single ideal suture material is available now. The surgeon must
hence select the material that nearly meets the requirements of the particular operative
site. Factors like potential for infection, existing infection and even anticipated
postoperative complication, and the rate of healing will all influence the choice.
The following outline of principles can be derived:
1. When a healing wound has reached its maximum tensile strength sutures are no
longer needed thereafter.
a. The tissues that heal slowly, such as skin, tendons and fascia should be closed
with non-absorbable sutures, again the choice being governed by personal
preference for a particular material, that handles well in that operating hand.
b. The tissues that heal rapidly such as stomach, intestine and bladder should be
closed with absorbable sutures.
2. Presence of foreign bodies in biliary and urinary tract favours formation of stones,
hence absorbable sutures should be used.
3. Foreign bodies in the tissues that have the potential to become contaminated may
convert that contamination into active infection, therefore.
32
a. Avoid multifilament sutures, since bacteria can lodge within the interstices
following the placement of sutures and can lead to infection.
b. Use monofilament sutures, such as nylon, polypropylene or steel, especially if the
potential for contaminated could result in burst abdomen.
c. Use monofilament absorbable sutures, if infection is actually present.
4. If cosmetic results are important, avoid prolonged apposition of wound surfaces
and avoid using irritants, to produce best results. Therefore,
a. Use the smallest inert monofilament sutures such as nylon or polypropylene.
b. Avoid skin sutures and close incision intradermally.
c. Use skin adhesive tapes between sutures or following early removal of sutures.
5. The size of the suture material is also important in that the sutures in layers
constitute foreign bodies. Placing of too many knots for security makes the
foreign body larger, therefore, use smaller sized suture material.
If sudden strains on wound are likely to result from, coughing or from abdominal
distension, then suture line may be reinforced with retention sutures.
6. Suture handling and knotting are important factors in the use and placement of
sutures by the surgeon and the consequent safety of the patient.
33
Therefore,
a. With synthetic materials such as nylon, prolene and polyester always put a triple
throw on the knot.
b. In general, the easier a suture slides through the tissue, the more rapidly the knot
will slip after placement, so put a triple throw on the knot.
c. Some materials will lock, when one is trying to tighten the first throw of a knot by
tightening on the second throw. Always bend, the first throw of the knot down,
sufficiently tightly to obtain the required opposition of tissues and secure this with
second throw, failure to do this would result in post-operative haemorrhage.
34
SUTURE MATERIALS
Suture is a Latin word means sewing together a seam. Selection of suture for a
particular surgery is based on knowledge of
1. Healing characteristics of the tissues to be approximated.
2. The physical and biological properties of the suture materials.
3. The condition of the wound to be closed.
4. The probable postoperative course of the patient.26
History
One of the earliest Indian texts written by Sushruta describes in detail, the
different types of sutures. Galen in 150 AD, comments for the first time on the use of
catgut. Catgut made from twisted intestine of the herbivorous animals is still in use today.
Lister in 1869 published an article observation of ligature of arteries on the
antiseptic system he had tried two types of sutures one of ox peritoneum, the other of
catgut. These were used to tie the carotid artery of the calf. After 30 days the calf was
killed off and to listers surprise he discovered that the ligature had been completely
absorbed and replaced by the calf’s own tissues.
The introduction of sterilization by irradiation in 1960 using cobalt 60 isotope
allowed sutures to be sealed in their formal package. With technological achievement,
polyester, polyamide, polypropylene, Polygalactin were discovered.
35
Classification
Sutures Absorbable Non-absorbable
Monofilament Catgut Polyamide
Plain Polypropylene
Chromic Stainless steel
Collagen Polyester
Plain
Chromic
PDS
Multifilament Polyglycolic acid Silk
Polygalactin 910 Linen
Polyester braided
Polyamide
Stainless steel
An idea/suture material should have following properties27
1. Adequate tensile strength
2. Produce minimal tissue reaction
3. Easy to handle
4. Good knotting security
Though none of the sutures bare all ideal properties, chromic catgut is the near
ideal suture material.
36
Absorbable Sutures
The suture materials are absorbed in one of the two ways:
1. Absorption occurs by enzymatic digestion. Catgut and collagen are absorbed by
this mechanism.
2. Suture material undergoes hydrolysis on contact with water. It does not require
the cellular environment for this purpose. The synthetic absorbable materials
undergo degradation by this process, Rise in temperature and pH increases the
process of hydrolysis.1
Advantages of absorbable suture materials
1. They get absorbed after they do their job and subsequently no foreign body is left.
2. They are a must for anastomosis in urinary and biliary tracts.
3. They are ideal where healing is rapid as in gastrointestinal anastomosis.
4. They are preferred in contaminated tissues like female genital tract.
Non-absorbable sutures
Advantages of using non-absorbable sutures are:
1. They have high tensile strength, which is retained for a longer time.
2. They are suitable for suturing wherever healing is a slow process and support is
required for a long time.
The only disadvantage is that it acts as a permanent foreign body.
37
The monofilament sutures are smooth and strong. They do not harbour bacteria
within them and hence can be used even in presence of infection. Their physical property
serves in distributing the force equally along the knot and does not cause tissue necrosis.
However they have poor knotting property, which can be overcome by using
triple throw knots.
Polypropylene
It is a synthetic non-absorbable monofilament suture material, chemically
extracted from a purified and a dyed polymer. It has an extremely high tensile strength,
the strength is retained indefinitely on implantation and has an extremely low tissue
reactivity, it can expand upto 30% before breaking and thereby prevents tissue
strangulation in case of post operative tissue swelling. It is sterilized by ethylene oxide
and no preservatives is used, it is secured by square knots of alternate type and relatively
longer cut ends can be left behind for safety.
38
TISSUE REACTION OF SUTURE MATERIALS26
Except in cardiovascular surgeries, the sutures have no role to perform, after a
span of 6 months. By that time wound would have acquired adequate tensile strength, for
prevention of hernia. However, late development of incisional hernias after 5-10 years
following surgery in certain studies shows the necessity of non-absorbable sutures. So it
would be necessary to know the local tissue reaction the sutures would produce.
Ideally a suture must produce tissue reaction just adequate for healing. Minimal
cellular and fibrous reaction was observed with Nylon, Dacron and Polypropylene while
it was more with cotton and silk. Since silk is a protein, the tissue reaction was expected.
Among the absorbable suture materials, the absorbable synthetics and natural
suture materials produced, little tissue reaction.
Tensile strength
The sutures must have adequate strength to hold the tissues together till the
intrinsic tensile strength is regained. Though most of the tissues regain the required
intrinsic tensile strength within 70 days and the maximum strength by 6 months; the
sutures, have a role to play till 6 month. However the late occurrence of incisional hernias
after 5 years show that non-absorbable sutures have a definite role to play for a longer
period if need arises.
39
Studies conducted have shown that tensile strength of:
Fascial Layers
1. Peritoneum is 1 lb
2. Intestine is 1 lb
3. Fascia is 6 lbs
4. Fat is Nil
5. Anterior rectus sheath alone is 5 lbs
6. Full thickness musculoaponeurosis 9 lbs
Tensile strength of a tissue should be known so that for suturing it, suture material
with identical tensile strength can be used. It is also important to know how a wound
gains tensile strength. In the process of wound healing, wound does not gain any strength
during first five days. 20% of normal (control) tensile strength is gained by 20 days; 40%
at 40 days and about 60% by about 100 days. 70% of the strength is gained by one year
but it never reaches the normal strength.
Tensile strength of a suture material is directly proportional to its diameter.
The Thread sizes29
May be recorded as British Pharmacopoeia (BP) or in metric gauge. Metric size
number divided by 10 gives minimal thread diameter in millimeters.
Metric 0.1 0.2 0.3 0.4 0.5 0.7 1 1.5 2 3 3.5 4 5 6 7
BP 10/0 9/0 8/0 7/0 6/0 5/0 4/0 3/0 2/0 0 1 2 3 and 5 7
4
40
Comparison of thread sizes. At the top are metric sizes, with the equivalent BP
gauges below:
Knotting properties26,27
Every suture has its own knotting properties. Knotting property of a suture is said
to be good, if it is secure with two knots. If a suture has good knotting properties, they
can be cut short, leaving as less of foreign body as possible. Multifilament and braided
suture materials like silk, cotton have good knotting properties.
Monofilament and non-braided suture materials require special knotting
technique. The first knot has to be surgeons knot, followed by at least two knots. Because
of poor knotting property they have to be cut long.
Tissue factors
1. Rate of Healing of tissue
The sutures are not required after the wound has gained maximum strength,
therefore:
a. The tissues that heal rapidly may be closed with absorbable suture materials,
b. The tissues that heal slowly like fascia, tendon and skin need to be closed with
non-absorbable material.
2. Presence of Contamination
Suture material acts as a foreign body. In presence of infection the suture material
may hence act as nidus for infection. It may also convert contamination to infection.
41
Hence,
a. Multifilament sutures are better avoided in presence of infection.
b. Monofilament sutures are ideal in the presence of infection. Since absorbable
sutures are rapidly absorbed in presence of infection, synthetic non-absorbable
monofilament sutures would be ideal to prevent wound disruption and incisional
hernia.
TECHNIQUES OF CLOSURE OF INCISIONS
“Never judge the surgeon, until you have seen him close the wound”.
The ideal method of abdominal wound closure should be technically so simple
that the results are as good in the hands of a trainee as in those of the master surgeon, it
should be free from the complications of burst abdomen, incisional hernia and persistent
sinuses, it should be comfortable to the patient and should leave a reasonably aesthetic
scar.1
General considerations
Aims and objectives of wound closure
 Adequate tensile strength until the would has healed.
 Approximation of tissues to allow healing
 To secure wound edges even when infected
 Utilize sutures that are well tolerated and is expedient.
42
Sutures that loose tensile strength and become weak can be avoided by using
Dexon, vicryl or prolene instead of catgut.
Breakage can result from30:
 Defective use of suture material
 Use of suture that is too fine for the tissues that is being closed.
 Damaging suture with a haemostat
 Fraying the suture by improper tying.
Lord Moynihan has said that even unnecessary stitch in a bad surgeons and
avoidance of unnecessary step of peritoneal closure leads to a saving in time and cost.
Usual Techniques of Closure of Incisions31
I Closure of midline incisions
Mass closure
The mass closure technique of midline incisions consists of suturing of the cut
edges of peritoneum and linea alba together, care is taken to take wide bites of the cut
edges at least 1 cm from the edge of incision and a hand held 5/8 cutting needle is used
and continuous locking sutures taken using polypropylene No.1. The skin is sutured with
fine interrupted nylon, deep tension sutures are not used.
Layered closure
In this technique the peritoneum is closed with chromic catgut No. 1-0 by
continuous interlocking sutures. The linea alba is closed similarly with polypropylene
No. 1 by continuous interlocking sutures.
43
II. Closure of Paramedian incisions
Mass closure: In this technique the peritoneum, endo abdominal fascia, posterior
layer of rectus sheath, rectus abdominus and anterior layer of rectus sheath are all sutured
as a single layer. The bites are taken atleast 1 cm from the edge of the incision and a hand
held 5/8 cutting needle is used. Continuous locking sutures were employed using
polypropylene No.1.
Layered closure: In this the peritoneum and the posterior layer of rectus sheath
were closed with chromic catgut No.1 by continuous interlocking sutures. The anterior
layer of rectus sheath was closed with chromic catgut no.1 by continuous interlocking.
Drains when used are inserted through a stab wound away from the incision, and
a colostomy or ileostomy, when performed is always fashioned through a separate
incision.13 Following surgery the wounds were cleaned with spirit and dressed. No local
antibiotic dressings were employed. Time taken for closure of abdomen was recorded in
all cases.
It is now fully realized, that healing of incised wound takes place by formation of
dense fibrous scar that unites with opposing faces of the laparotomy wound enmass. The
purpose of the suture is to coapt the wound edges and to act as a splint while this dense
fibrous scar deposits and matures. Wide bites must be taken at a minimum of 1 cm from
the wound edge, and placed at the interval of 1 cm or less. The suture length should
measure at least 4 times the wound length to ensure an adequate reserve of suture length
in the wound when the suture is placed on tensions, as may occur during abdominal
distension.
44
REVIEW OF LITERATURE OF CLOSURE OF INCISIONS
Almost since the beginning of abdominal surgery the masters of technique have
preached the importance of meticulous layer-by-layer closure of the abdominal wall and
indeed, this certainly has strong aesthetic appeal.
In 1941, Jones and associates reported a burst abdomen rate of 11% when
incisions were sutured with two layers of catgut, and 7% when sutured with catgut for
peritoneum and interrupted steel wire for the anterior rectus sheath. However, only one
burst abdomen occurred in 81 operations after steel wire closure with interrupted mass far
and near sutures incorporating all layers of the abdominal wall apart from the skin.
It is interesting that the far near stitch was first used in 1900 by Smead, a resident
to Finney in Baltimore, during the closure of a complicated operative procedure, Smead
suggested that the operation be finished with a closure that was safe and rapid. Finney
agreed and Smead performed what is believed to be the first far-near mass closure of the
abdomen, a technique often referred to as the Smead Jones method.1
Gilbert and Ellis68 study of peritoneal closure in lateral paramedian incision,
wound disruption rates did not alter in both groups in whom peritoneum was closed with
No.1 chromic catgut and in those in whom peritoneum was not closed. However layer by
layer closure abdominal wall incisions has a strong aesthetic appeal. Hence, is technically
easy to accommodate, the peritoneum may be closed with synthetic absorbable material
such as Polygalactin or polyglycolic acid.
45
Data from a retrospective study conducted by GA Higgins33 et al from the records
of veterans administration hospital for a 11 year period between July 1957 and July 1968,
had permitted an excellent clinical comparison between the conventional layered closure
of abdominal incisions and the mass far and near, buried sutured closure of the Smead
Jones type. During this 11 year period 51 wounds dehisced in a total of 2377 laparotomy
incisions. The incidence of layer-by-layer technique was 3.7% as compared to 0.7% in
those with mass suture technique. Thus this paper was therefore concerned with
presentation of clinical data as well as the laboratory studies, the analysis of the clinical
data is highly suggestive of superiority of the mass far and near closure technique over
the conventional layer closure, although the lack of comparability of the two groups of
patients did not justify any absolute and definite conclusions. For these reasons, the
controlled studies to be described were carried out in the laboratory. The laboratory
studies were based on tensile strength of the incisions closed in mass and layered closure
at four periods of healing.
Group I: Three days, Group 2: Seven days, Group 3: 14 days and Group 4: 21
days, following killing of animals (white male rabbits) on the designated post incision
days, the strength of the vertical incision was studied as follows: The skin, subcutaneous
tissue and panniculus carnosus was discarded and a block of abdominal was excised. The
specimen was then divided into six transverse strips, each 1 cm in diameter and
containing a 1 cm portion of each of paramedian incision. One strip was set aside for
chemical and histopathological study.
46
Tensile strength of the remaining five strips was then tested using a tensile testing
machine with a jaw separation rate of 5 cm/min, linked to a standard righting recorder to
determine the weight in grams necessary to disrupt the closure. One strip from each block
of abdomen was placed in the tensiometer to determine which closure separated first.
After disruption, the remaining intact portion was then tested in a similar fashion the
remaining four strips of tissue were divided at linea alba and each half was tested
individually, tensile strength of full incision were also tested by placing in the
tensilometer of excised abdominal closure wounds.
Days
3 7 14 21
2000+
Graphical representation of tensile
SJ strength of sutured ventral incisions at
Wt. in gms four periods of study (L – Layered
closure, SJ – Mass far and near Smead
Jones closure
L
800
The healing properties and resistance to infection as well as the anatomical
configuration of the abdominal wall of the laboratory animal is quite different from that
of man. However, these studies do add confirmatory evidence to the statistical findings of
the clinical study.
47
The technique of closure of abdominal wounds, like much of surgery, has tended
to develop as a practical, experiential matter, rather than on the basis of hypothesis which
lead either to experimental test in clinical practice and laboratory or to theoretical
evaluation based upon mathematical or other understanding.8
Single and two-layered closure with monofilament steel has been compared in
theory and in an experimental model. There are theoretical reasons for believing that
single layered closure should be more resistant to early disruption.
The choice for comparison was suggested by the apparently favourable results
reported by a number of writers with single layered closure deep to the skin (Atel and
Hunt 1948; Spencer and Sharp 1963).
In his paper, Dudley observed that the distribution of the forces at the suture
tissue interface and therefore the tendency to cut through is inversely proportional to the
size of the tissue bite and the radius of the surface material. Thus multi layered closure
with narrow sutures taking small bites had higher chance of cutting through than
monolayer. The force per unit area decreases as the thickness of the tissue bite increases.
PG Bentley34 et al (1971) after a reappraisal of current methods of abdominal
wound closure chose mass suture with Dexon as technique of choice and used it for all
subsequent cases. A one-layered closure was chosen in order to avoid dehiscence, the
most serious postoperative complication related to the wound. This tragedy was known to
carry mortality of 20-30% and its incidence to be greatly reduced by the use of mass
48
sutures. They stated that both at teaching hospital and district general hospitals, with use
by consultant and junior staff mass suture with Dexon has proved to be a rapid easy and
above all reliable method of wound closure.
In the study conducted by S. K. Mathur36 et al between Jan 1982 and Sept 1984,
300 cases of laparotomies were closed by monolayered interrupted monofilament nylon
over 2½ years, only 1 case of burst abdomen and 3 cases of incisional hernia were
recorded.
Minimal discomfort and good patient compliances were observed. The low rate of
complications and reliability of this method of closure confirmed the merits of the
monolayered closure technique of laparotomy incisions.
In view of only a few studies already conducted with single layered closure and
surgeon’s reluctance to accept this technique in place of closure in layers. A study was
carried out by A Singh(35) (1981), the study was conducted on 60 patients who underwent
laparotomy either as an emergency or in routine. In all cases paramedian incision was
used. The results carried out in group A (conventional method) and in-group B (single
layered closure) were analyzed and conclusions were drawn as follows:
Poor: Cases who got burst abdomen or incisional hernia.
Satisfactory: patients who had stitch abscess or delayed wound healing.
Good: Cases who had no major or minor problems but the strength of the scar was
moderate.
Excellent: Cases who had no complications and the strength of the scar was excellent.
49
Finally it was reported that the rate of complications were much less with a single
layered nylon closure than with the conventional technique, lesser time was required for
closing the wounds.
The results of a controlled clinical trial of two currently recommended methods of
abdominal closure by S. K Chowdhury, S. D. Choudhury37 at Silchar Medical College
and Hospital, Silchar during the period from March 1989 to September 1990 have been
reported as follows, out of 160 patients, 80 cases were randomized to have their
abdominal wall closed in single layered mass closure with monofilament nylon and
80 cases in layered closure with chromic catgut. Eighteen patients (22.5%) in the former
and 38 (47.5%) in the latter had wound infection (p<0.001). Sinus formation occurred in
2 patients (2.5%) in the mass and 20 (25%) in the layered group (p<0.001). Three cases
(3.75%) of burst abdomen occurred in layered closure and none in mass closure. Wound
infection was the most important denominator next to suture material influencing wound
healing. There was a significant association between the rate of infection and sinus
formation. Minimal complication and good patient compliance seem to justify the use of
mass closure in place of layered closure in all types of abdominal operations.
Niggebrugge39 et al (1997) reported a new technique – continuous double loop
closure (CDLC) in animals which resists high intra abdominal pressure.
Niggebrugge et al (1999) reported that CDLC technique reduces compliance of
abdominal wall with postoperative pulmonary complications.
50
In Wasiljew series of 244 cases where wound was closed using continuous vicryl
sutures, 3 dehiscences have been reported. In another large series of Knight CD et al and
Richard PC et al, who used continuous prolene sutures for closing abdominal wounds in
1000 cases, noted only 4 wound dehiscence and 7 incisional hernias. 40,41 Controlled
studies by Richard PC et al have also demonstrated that 20-30 minutes are saved by using
continuous rather than interrupted sutures.41
51
WOUND HEALING
“If you cut well and sew well your patient will get well”.42
Tissue healing is a topic of intense importance in every branch of surgery.
Without this remarkable living phenomenon surgery as we know, would of course, be
impossible. Tissue injury on frank necrosis heals by forming scar tissue. There is no
return to the primary status quo. Humans have no ability to regenerate organs, with the
exception of bone, liver and epithelium.
Wound closure types are divided into 43:
1. Primary repair
2. Secondary repair
3. Delayed primary (Tertiary) repair
1. Primary repair or first intention closure: are those wounds that are immediately
sealed with simple suturing, skin grafting or flap closure. E.g. Repair of an incised
or a lacerated wound.
2. Secondary repair: involves no active intent to seal the wound. This may be a
wound that was too highly contaminated to allow a surgical intervention. This
wound will close by re-epithelialization and contraction of the wound.
Healing by secondary intention depends on formation of granulation tissue,
contraction of the wound, and epithelialization. After the inflammatory phase, the
52
fibroblastic phase of wound healing provides for the development of granulation tissue in
the base of the wound. Through the process of wound contracture, the specialized
myofibroblast cells replace collagen and through their ability to perform smooth-muscle
contraction, pull the peripheral edges of the wound towards its center, thereby contracting
the wound.44
Epithelialization occurs simultaneously with wound contraction. When the wound
is healed by secondary intention, the epithelial cells migrate over the wound so that an
epithelial surface is present over the wound. This process of secondary intention permits
healing of many open wounds that for one or several reasons are not closed by primary
intention. Wounds that are contaminated, wounds containing foreign bodies, or wounds
in compromised tissue, for any number of the reasons are best not closed primarily. The
process of secondary intention permits the wound to heal and reduces the size of the
wound appreciably. After the wound has healed by secondary intention, the decision can
be made whether to excise the old scar and perform a reconstructive procedure or to
accept the secondarily healed wound as the final wound.
3. Delayed Primary (Tertiary) repair: A wound that is known to be infected is first
treated with repeated debridement and systemic or topical antibiotics. When it is
ready for closure, surgical interventions such as suturing, skin graft placement, or
flap design is performed. A wound left open will fill with granulation tissue, and
contractions will enhance wound closure by pulling the surroundings uninjured
tissue over the defect. A fibrin clot will seal the wound, which is permanently
sealed with epithelization. Tensile strength is achieved by deposition of collagen.
53
Phases of wound healing43
The wound healing phases are:
 Inflammatory phase
 Proliferative phase
 Maturation phase
Inflammatory (Reactive phase)
It is the immediate response to injury. During this phase hemostasis and
inflammation occur. This phase represents the tissues attempt to limit damage by
stopping the bleeding, sealing the surface of the wound and removing any necrotic tissue,
foreign debris or bacteria present. This phase is characterized by increased vascular
permeability, migration of cells into the wound by chemotaxis, secretion of cytokines and
growth factors into the wound and activations of migrating cells.
Proliferative phase
As the acute response begins to resolve, the scaffolding is laid for repair of the
wound with angiogenesis, fibroplasia, and epithelization. This stage is characterized by
the formation of granulation tissue, consisting of a capillary bed, fibroblasts,
macrophages, a loose arrangement of collagen, fibroblasts and hyaluronic acid.
54
Angiogenesis is the process of new blood vessel formation and is necessary to
support a healing wound environment.
Maturation phase
Wound contraction is the centripetal movement of the whole thickness of the
surrounding skin, reducing the amount of disorganized scar. The scar contracts by
collagen cross-linking, shrinking and loss of edema.
All the three phases may occur simultaneously and the phases may overlap.
For example in a large wound such as pressure sore, the eschar or fibrinous
exudate reflects the inflammatory phase. The granulation tissue is a part of proliferative
phase. The contracting or advancing edge is a part of maturation phase.
Molecular biology of wound healing
Normal wound healing requires a well-orchestrated complex interplay of several
biochemical and cellular mediators. Originally, polypeptide growth factors were defined
as molecules that promote cell proliferation. It is now recognized, however, that these
factors may possess additional, non-mitogenic functions, such as chemotaxis, induction
or inhibition of cellular differentiation, transformation, and induction or inhibition of
protein synthesis, they are more accurately described as cytokines.
These cytokines have a variety of cellular sources and targets. The list of these
factors is ever enlarging but now comprises of transforming growth factor-beta (TGF-),
55
platelet-derived growth factor (PDGF), epidermal growth factor (EGF), transforming
growth factor alpha (TGF-a), epidermal cell-derived growth factor (EDGF), insulin like
growth factor-I / somatomedian-C (lGF-I/SM-C) and interleukin-1 and interleukin-2
(IL- I, IL-2).
The action of these factors on their target cells is mediated through binding to
specific and high-affinity receptors. The receptor binding leads to activation of TK,
which results in phosphorylation of a number of cytoplasmic and nuclear proteins. This
process leads to the induction of multiple gene transcription that ultimately prepares the
cell to replicate its DNA and subsequently to divide.
The cells present during the acute phase of injury to tissue, that is, platelets,
macrophages, and lymphocytes, are the primary sources of these previously described
cytokines. In addition to their importance in expanding cell populations, such as
fibroblasts, which migrate into the wound, they also indirectly play an important role in
the synthesis of collagen and other extracellular matrix components by fibroblast.
Because some of these factors also posses inhibitory functions on fibroblast, they
become an important feed back mechanism whereby the body can regulate wound
healing.45 A perturbation in the normal control mechanisms could, therefore, lead not
only to failure of wound healing but also to abnormal fibrosis with hypertrophic scarring
and Keloid formation.
56
Equally important are the processes of cell migration into the wound and of
epithelialization. Directed cell movement appears to be the result of specific interactions
of the cells with structural elements of the extracellular matrix such as laminin,
fibronectin, vitronectin, and collagen. Integrin-to-matrix bonding can be inhibition by
monoclonal antibodies directed against receptor subunits or by synthetic peptides
containing the RGD sequence.46 This process provides yet another means by which the
cellular phase of wound healing may potentially be controlled.
Clinical applications of this basic research on the role of cytokines in wound
healing are just beginning to be realized. Brown47 et al reported accelerated
reepithelization on the skin-graft donor-site wounds in patients treated with topical EGF
compared with matched controls. The addition of EGF reduced the time it took to achieve
100% healing by 1.5 days.
It is obvious that the cellular arm of the immune system plays an important role in
the process of wound healing. In patients in whom the function of the immune system is
compromised, wound healing can still occur, but no reserve is available to overcome
wound complications such as infection or ischemia. In such patients, essentially one
opportunity exists for successful wound healing. When complications develop, wound
healing will not occur. Patients may be immunocompromised on the basis of underlying
conditions such as sepsis, malnutrition, advanced age, or acquired immune deficiency
syndrome (AIDS). They may also be compromised on the basis of treatment with
chemotherapy, immunosuppressive drugs, or radiation. These patients pose difficult
clinical challenges to the achievement of successful wound healing. Wound healing has
57
been found to be appreciably delayed or complicated by an increased incidence of
infection that leads to non-healing.47
Hypoxia and Ischemia
Some degree of local hypoxia is normal and inevitable after injury and actually
serves as a stimulus for many of the biochemical and cellular events of wound healing.
The increased metabolic demands for molecular oxygen by inflammatory cells during the
acute phase of healing results in a decrease in local tissue oxygen tension, an elevation of
lactate levels, and a fall in pH.48 Elevated levels of lactate stimulate fibroblasts to
increase collagen synthesis and induce macrophages to produce an angiogenesis factor
that cause endothelial cell chemotaxis. Even when supplemental oxygen is breathed,
central wound oxygen tension does not reach a sufficiently high level to inhibit this
process. Only when capillary in growth to the central portion of a wound has been
completed, this process is inhibited. When tissue oxygen tension is low (<30 torr),
however, secretion of newly synthesized collagen from fibroblast is impaired.
Molecular oxygen
Is a central factor in wound healing. It is required for energy dependent processes,
such as replication of cells, synthesis of protein, export of protein, and the hydroxylation
of prolene and lysine that must occur before these amino acids are incorporated into
collagen alpha chains. Most important is the requirement for high tissue Oxygen tension
to resist infection. The mechanism of this action is through the non-specific immune
system.49 Molecular oxygen is needed to produce toxic super oxide radicals, which in
turn are used to kill bacteria that have been phagocytosed by granulocytes.
58
Epithelialization requires oxygen as well. Thus, adequate blood supply and
perfusion to a healing wound are vital.
The production of toxic radicals is directly proportional to local oxygen tension
when local PO2 is low. This is true in the range of 0 to 30 mmHg and the wound PO2
usually falls within this range.50
Until tissue p02 can be measured directly, wound oxygen tension can only be
estimated by measuring arterial PO2, and assessing peripheral perfusion. Perfusion is
decreased by dehydration51 and tissue oxygen tension can be increased by correcting
hypovolemia. Factors that lead to an elevation in the tone of the sympathetic nervous
system reduce tissue perfusion and must also be corrected. Only when the concentration
of hemoglobin falls below 6 gm/dL does anemia result in a decrease of tissue PO2 when
the patient has a normal heart and lungs.
Increased oxygen delivery to wounds can be accomplished through the
administration of supplemental oxygen, by the placement of well-vascularized flaps, and
by the administration of hyperbaric oxygen. In addition, the cessation of smoking is vital.
Nutrition and wound healing
Nutritional deficiencies can interfere with the wound healing process at any point
by prolonging or inhibiting healing. Malnutrition is known to alter regeneration of tissue,
the inflammatory reaction, and the immune function. In the surgical patient depleted
nutritional status will result from poor oral intake. Malabsorption, the catabolic effects of
59
illness and drug-nutrient interactions adversely affect nutritional status as well. A loss of
greater than 10% of the usual body weight is associated with an impaired physiologic
response. One study52 has shown that patients classified with mild, moderate, or severe
protein-energy malnutrition had a suboptimal wound healing response, that is, less
hydroxyproline content in the wound, compared with well-nourished control patients.
Carbohydrate provides the substrate (glucose) for cell proliferation and
phagocytic activity; fat is an important component of cell membranes, and protein
provides amino acids for repair and synthesis of tissues. Recent attention has focused on
glutathione, a tripeptide that is a potent free radical scavenger. Glutathione appears to act
synergistically with vitamins C and E to prevent damage caused by free radicals that are
formed when reperfusing oxygen reacts with byproducts of ischemic metabolism in skin
flaps.53
Vitamin C is essential for synthesis of collagen, formation of fibroblasts, bacterial
killing, and production of neutrophil superoxide. In patients with depleted levels of
vitamin C, wound dehiscence is eight times more prevalent. Accepted doses for
supplementation range from 100 to 2000 mg/day, depending on the extent of injury. 54
The most important contribution of vitamin A to the process of wound healing is
probably its ability to counteract the inflammatory effects of corticosteroids.
60
Zinc, which is lost in excessive amounts after operation because of stress, sepsis,
diarrhea and fistulas, plays an important role in cell mitosis and proliferation during the
fibroblastic phase of wound healing. Serum levels of less than 100 g/dL are associated
with poor healing; however, extra zinc in the presence of adequate zinc in the body will
not speed the healing process.55
Effect of acquired immune deficiency syndrome on wound healing
Problems with wound healing in patients with AIDS have been reported
presumably on the basis of immunocompromised as evidenced by delayed wound healing
of surgical incisions in 33% to 88% of patients or as wound infections in 5 % to 16%
patients. Delayed wound healing has been a problem especially in patients undergoing
anorectal surgery, in which the rate of wound healing has been found to be inversely
related to white blood cell count. Current recommendations are that although operation
can be performed in patients with AIDS surgery should be conservative, especially in
patients requiring anorectal surgery.56
The healing of aponeurotic incisions59
The strength of the abdominal wall is chiefly vested in its aponeurotic layers. The
ease with which muscle and peritoneum tear if more than a very light strain is placed on
them is familiar experience. Skin is of no value in maintaining the integrity of the
abdominal wall; it is so readily stretched that once a gap in the aponeurotic layers has
developed it forms no bar to the progressive enlargement of a hernia.
61
Aponeurosis seems to unite much more slowly than does skin. Skin wounds reach
maximal strength in 10 to 14 days. The same figure for aponeurosis is 200 to 300 days.
A consideration of the histology and function of the two tissues make this quite
understandable. Skin is composed of rapidly growing epithelium and dermis, the rich
blood supply of which serves to repair many small defects in the skin. Aponeurosis on the
other hand, is one of the most avascular tissues in the body. Its function is to give
attachment to muscle and in the abdomen to give strong support to the viscera.
Under normal conditions it is not subject to injury. It would not therefore be
expected to be capable of rapid healing, and once damaged might have poor powers of
regeneration.
Secondly, in large majority of instances the wounds were weaker than the parent
tissues even at the end of a year. In other words, the infliction of a wound to aponeurosis
under the conditions left a weakness, which was in all probability permanent. The clinical
fact that postoperative herniation in obese patients is almost always through the wound,
and seldom if ever through the intact parities, suggest that the same may be true.
Relative ability of tissues to regenerate60 :
1. There is complete regeneration of epithelium except for specialized tissues such
as hair follicles and sweat glands
2. Subcutaneous fat is replaced by cicatrix
3. Fascia is almost perfectly regenerated
4. Striated muscles is almost always replaced by cicatrix, rarely by striated muscles.
5. Peritoneum first heals by fibrous union and then is covered by endothelium.
62
Factors responsible for poor healing of tissues61
Local factors Possible General factor
Blood supply Age
Local Infection Anemia
Apposition Malignant disease
Absence of movement Diabetes
Absence of tension Systemic Infection
Irradiation Jaundice
Technique of wound closure Uremia
Steroids
Cytotoxic drug
Protein deficiency
Vitamin deficiency
The different factors are dealt in detail later.
63
Classification of factors responsible for poor wound healing57
Patient factors Disease factors Surgical factors
Age Intra-abdominal sepsis Type of incision
Sex Malignant disease Type of closure
Anemia Wound infection Emergency
Uremia Chest infection Sutures
Diabetes Prolonged paralytic ileus Tension
Jaundice Type of anaesthesia
Obesity Trauma to tissues
Malnutrition Ostomies in incision site
Protein deficiency
Vitamin deficiency
Use of steroids
Age
Disruption of abdominal wounds is more common in patients over 60-years of age
than in younger patients. It is of course not possible to control the age of the patients.
Although patients of advancing years are generally considered to be more prone to poor
wound healing, dehiscence has occurred in the very young. Furthermore older patients
often fall into the groups with constitutional disease, frequently neoplastic in nature. 60
Howes and Harvey have presented experimental evidence, which shows an
increase in the velocity of fibroplasia in a healing wound in the young as compared to the
old animal. The latent period was also found to be longer in the old age group. In
64
humans, Korenchevsky and Bourne found that cell proliferation was less in the aged. The
evidence as a whole is convincing that old people are more prone to wound disruption
because of their age.60
Sex
The sex incidence shows predominance for males the ratio being about 4:1. The
male predominance is attributed to abdominal breathing, greater physical activity and less
elasticity of the abdominal wall.62
Anemia
The role of anemia in wound healing has a debatable subject for many years.
Suppressed wound healing leads to wound dehiscence. There are reasons to believe that
acute or chronic anemia would lead to delayed wound healing. The work of Sandburg
suggest that acute anemia delays healing, probably by decreasing oxygen delivery to the
wound area. He could reverse the delayed healing with denervation, which would suggest
that, the inadequate tissue perfusion was secondary to vasospastic phenomenon.63
Chronic anemia or iron deficiency anemia delays wound healing, by decreasing the iron
enzymes cytochrome C, cytochrome oxides, aconitase and succinic dehydrogenase in the
tissues.64 The decrease in these enzymes affects the normal reparative process. Ferrous
ion serves as a co-factor in the enzymatic hydroxylation of prolene and lysine in
procollagen, implying that iron deficiency might greatly limit the production of mature
collagen necessary for healing, despite this reports other studies have not found any
statistical significance of anemia delaying wound healing.
65
Uremia
Uremia inhibits wound healing. A 1965 research study produced uremia in dogs
and showed that abdominal wound breakdown occurred in these uremic animals that
could be prevented by adequate renal dialysis65 In rats rendered to uremic researches
demonstrated significant diminution in the bursting strength of laparotomy wounds and
of small bowel anastomosis.66 Using fibroblasts in culture there is marked inhibition of
fibroblast growth in uremic serum. There is little clinical observation on wound healing
in uremic patients.
Diabetes
Wound healing is suppressed in diabetic patients because glucose-laden tissues in
the body are a good medium for the bacteria to grow, thus resulting in wound infection,
which in turn increases the incidence of post operative wound complications. Another
factor is the microangiopathy in these patients, which causes tissue ischemia and necrosis
leading to dehiscence.
Jaundice
Obstructive jaundice in the rat was shown to decrease the strength of abdominal
incisions and to delay fibroplasias and angiogenesis in the healing wound. 67 In a clinical
study of healing of laparotomy wound in 326 consecutive patients, 21 patients were
jaundiced during or after surgery. Of these patients, three suffered complete disruption of
the abdominal wound, and an additional four subsequently developed incisional hernia: a
total wound failure of 33%. This compared with 6 disruptions and 10 further incisional
hernias at the time of review of the 305 non-jaundiced patients, giving a total wound
failure rate of 5%. This difference was highly significant statistically.
66
Obesity
Obesity is associated with a high percentage of dehiscence and postoperative
hernias, as well as with recurrences, following repair of these hernias. Cutting through
large masses of fat and the increased retraction needed may raise the infection rate in,
these patients and lead to recurrence. Tissues infiltrated with fat may not be able to hold
the sutures, especially since the excess of intra and extra-abdominal accumulations of
many kilograms of fat may add enormous tension on the sutures causing the tissues to
tear under the strain and to bring about a defect in the abdominal wall. Furthermore,
obese patients tend to develop postoperative complications such as paralytic ileus,
atelectasis, pneumonia, and deep venous thrombosis that may increase the incidence. 69,70
Malnutrition
Lack of proper nutrition in patients with obstruction to the passage of food,
patients with carcinoma and all debilitated patients has been ascribed a role in the failure
of wound healing.70 Adequate protein is necessary for optimal wound repair. However,
wound disruptions will continue to occur in patients with excellent nutrition. Conversely,
even among patients with the poorest nutrition the wound usually heals without
difficulty. Perhaps one should conclude that with poor nutrition a less potent precipitating
cause is necessary to disrupt a wound. From experimental and clinical evidence, lack of
vitamin C has a role in postoperative wound complications.
67
Protein deficiency
Protein deficiency delays wound healing. A deficit of tissue proteins may exist in
the presence of normal serum protein values, and normal serum protein values in the
presence of low total circulating serum proteins associated with a reduced blood volume.
A fall of serum protein levels is accompanied by a greater loss of albumin than globulin,
so that instead of normal 2: 1 ratio the A/G ratio is nearly 1: 1. In the presence of protein
deficiency normal fibroplasia does not occur.60
Vitamin deficiencies
Vitamin C
It is essential for collagen synthesis. It takes 90 to 120 days to deplete the 2 to
3 gm body pool and produce degrees of vitamin C deficiency, which may be found in
patients with peptic ulcer (who usually avoid fresh fruit and vegetables), in those with
severe dysphagia (e.g. from carcinoma of the esophagus), and in recluses (e.g. those who
exist on a diet of tea, bread, margarine, and jam). It has been demonstrated that there is a
fall in the vitamin C level in the blood of patients after operation and it returns to normal
in about a week.60 Those patients who have received blood during the operation have
been responsible for both the storage and the transportation of ascorbic acid in man.
Hemorrhage depletes this reserve, and it is not replaced by stored blood. The leukocyte
ascorbic acid level falls to a deficiency level after 7 days of storage. It was suggested that
this deficiency may account for the increased incidence of abdominal wound dehiscence,
as well as anastamotic leakage, which has been noted in patients undergoing emergency
surgery for bleeding peptic ulcer.
68
Vitamin B deficiency, pyridoxine and riboflavin may delay wound healing. Long
before symptoms of beriberi appeared, a deficiency of vitamin B results in a lower
resistance, weakened and atonic musculature and particularly intestinal atony. There is an
increased need for vitamin B when hyperthyroidism, diarrhea or diuresis exists.60
Vitamin A deficiency is most marked on epithelial structures and these changes
are associated with keratinizing metaplasia.60
Vitamin K deficiency predisposed to bleeding and formation of haematoma.
Vitamin K is indispensable in the formation of prothrombin. Before a operative
procedure on a jaundice patient normal prothrombin levels should be restored by
administration of vitamin K.60
Effect of ACTH and Cortisone71
Given in large doses over a long period may delay the appearance of connective
tissue in wounds. These substances have an inhibitory effect on proliferation of
fibroblasts, development of capillaries and formation of granulation tissue. However
recent data suggests that these changes occur only in large doses.
Intraabdominal sepsis
Any condition causing intra abdominal sepsis increases the incidence of
postoperative wound complications. Intra abdominal sepsis is seen in peritonitis due to
hollow viscus perforation like duodenal, jejunal and ileal perforations. Ileal perforation is
associated with fecal contamination, which is associated with a higher incidence of
complications.
69
Sepsis is a major cause of early wound failure. It may range from frank acute
cellulitis, with fasciitis and necrosis of the tissues on each side of the incision, to
low-grade chronic sepsis around sutures such as braided or twisted silk. The latter case is
very difficult to overcome, since the infecting organisms lurk in the spaces between the
fibers of the suture thread and constantly re-infect the tissues. The infection causes
inflammation and edema of the tissues, which become soft and weakened so that the
sutures tear the tissues and pull out under the strain of the intra-abdominal pressure.
Malignancy
The role of carcinoma in the disruption of wounds is much harder to evaluate.
Hartzell72 and his associates subjected patients to laboratory determination to evaluate the
clinical impression that patients with carcinoma are likely to be comparative
malnourished because of poor dietary intake and decreased production of proteolytic
enzymes
Increased intra-abdominal pressure
Excessive coughing, sneezing, retching and vomiting, hiccup or intestinal
distention produces abnormal strain on an abdominal incision. Increased intra abdominal
pressure usually a precipitating cause, forcing omentum and finally, bowel through gaps
in the suture line. Increased pressure is produced by intraabdominal fat deposition.
Anaesthesia
Anesthesia has an important indirect bearing on the occurrence of post operative
wound complications. The individualization of an anaesthetic agent and its skillful
70
administration are necessary to obtain proper relaxation of the abdominal wall, adequate
exposure without trauma and closure of the incision without tension. Curare and the
endotracheal tube are valuable assets to help achieve these aims. A badly administered
inhalation anesthesia associated with straining and struggling of the patient and entailing
suture of the abdominal wall under great tension, can be a contributing by inept hands.70
Trauma to Tissue
When tissue is traumatized at operation it result in inflammation, necrosis and
exudation which cause slowing of wound healing by effect on fibroblastic activity and by
mechanical separation of tissue. Trauma from rough retraction, ligation of large pieces of
tissue, rough handling of tissue, too hot water and chemical irritants should be avoided. 70
Ostiomies in incision site
The placing of a colostomy or ileostomy stoma in the incision definitely increases
the risk of dehiscence of the wound and the risk of formation of a ventral hernia.
Wherever possible, the stoma should be fashioned through a separate small
incision. To a rather lesser extent, the same advice applies to the placing of abdominal
drainage tubes.1
Type of Incisions
Many thought that midline incisions, particularly in the upper abdomen, were
more prone to disruption that paramedain incisions, these statements were based on
collected statistics, but they failed to take into account the fact that midline incisions were
71
often employed to gain rapid access to the abdomen in desperate emergency situations. If
other factors also are taken into consideration, there is no significant difference between
median and paramedian wounds.
Suture Material Employed
Catgut is still used extensively for closure of abdominal laparotomy wounds. The
usual practice is to employ a continuous suture of 0 to I chromic catgut for the posterior
rectus sheath and peritoneum, either continuous or interrupted sutures of chromic catgut
for the anterior rectus sheath or linea alba. However, controlled studies have shown a
disastrously high failure rate when catgut alone is employed.73
Many use non-absorbable sutures in the anterior sheath or linea alba. Steel wire,
gives excellent results, but it is undoubtedly difficult to use it. It is easier to uses
monofilament nylon. Many surgeons now employ biodegradable synthetic polyester
sutures. Since the aponeurosis of the abdominal incision is slow to heal, and since braided
sutures if infected, show a high tendency to produce a persistent sinus, slowly absorbable
monofilament polyester should be employed. Examples of this are polydioxanone (PDS)
and polyglyconate (Maxon).
Technique of Laparotomy Closure: (dealt in detail earlier)
Almost since the beginning of abdominal surgery the masters of the techniques
have preached the importance of meticulous layer-by-layer closure of the abdominal wall,
and, indeed, this certainly has strong esthetic appeal. Theoretical arguments have been
supporting the value of closure employing non-absorbable sutures that include all layers
72
of the abdominal wall, apart from skin, and that also incorporate wide bites of tissue on
either side of the line of incision. When put to the practical test, this technique was not
found wanting. Bites are taken at least 1 cm from the edge of the wound and are placed
close together (a maximum of I cm apart). The introduction of this technique produced a
quite dramatic improvement in results.
In closing the lateral paramedian incision, only the anterior sheath or the rectus
need to be closed by this method.
Surgical technique60
In order to confirm wound healing meticulous attention must be paid to surgical
technique. The following are well known but bear emphasis (a) use sharp dissection (b).
Ensure hemostasis (c) non strangulating interrupted sutures induce less tissue reaction
than continuous sutures (d) select sutures of the smallest sizes in order to induce as little
suture material (foreign bodies) into the wound as possible. The tensile strength of the
suture need not be greater than twice that of the tissue it is to suture.
SIZES OF SUTURES ORDINARILY REQUIRED60
Silk Catgut
Hemostasis 4-0 or 3-0 3-0
Peritoneum and posterior rectus sheath 2-0 3-0 or 2-0
Muscle 3-0 3-0
Fascia and anterior rectus sheath 3-0 or 2-0 2-0
Subcutaneous tissue 3-0 3-0
Skin 2-0 --
73
To sum up, prevention of postoperative wound complications depends on
improving the health of the patient preoperatively to optimum level in elective surgery,
reasonably good surgical technique. Smooth recovery from anaesthesia and proper
antibiotics in adequate doses for adequate period to prevent infection. Smooth recovery
during postoperative period adds up to reduction in cause of postoperative wound
complications.
74
SURGICAL WOUND INFECTION74
Definition
The infection that follow surgical procedures that occur in the operative wound or
at a distant site.
Infection occurs at an incisional site usually within 30 days after operation and
involves skin or subcutaneous tissue above the facial layer and from of the following.
 Purulent discharge from the incision or drain located above the facial layer.
 An organism isolated from culture of fluid that has been aseptically obtained from
a wound that was closed primarily.
Classification
 Clean wounds
 Clean contaminated wounds
 Contaminated wounds
 Dirty wounds
Wound dehiscence1
The abdominal wound may disrupt either completely or partially:
The pathognomonic of dehiscence is a pink serosanguineous discharge of the
dressing.
75
Aetiology
 The knot maximum break or undo a technical error that should be avoided.
 The suture material may rupture by incorrect placement.
 The suture cut through the tissues due to pre-existing co-morbid condition which
delay wound healing.
Clinical type
 During immediate postoperative course, it is very stormy.
 After a satisfactory progress when the stitches are removed on day 7 or 8, the
wound will literally fall apart.
 Finally when the wound appears to be soundly healing. Following excessive
strain, the patient may feel a sudden give in the wound, which when examined,
will be found to be torn with the gut eviscerated.
The disruption generally follows removal of the sutures between days 7 and 10,
but it may occur later (on day 14) when supporting or stay sutures have been used, or
even later than this after the wound appears to be soundly healed, especially in cases of
ascites or when suppuration is a late complication.
Prognosis
It is one of the grave complication and the mortality rate with this condition being
between 9% and 44% with an average of 18%.
76
The prognosis is better if recognized earlier and treated, when there is extensive
suppuration of the wound or general peritonitis the prognosis is very grave.
Prevention
 Correction of the malnourished state.
 Treatment of constitutional disease
 Surgical technique60
 Reduction of intra abdominal pressure60
 Use of retention sutures60
Treatment
 Packing the wound, followed by strapping with adhesive plaster
 Temporary packing and strapping followed by secondary suturing76
 Immediate re-suturing
 Polypropylene mesh repair60
INCISIONAL HERNIA (ventral hernia, postoperative hernia)
Definition
An incisional hernia is one that develops in the scar of a surgical incision and is
due to failure of closure lines of postoperative abdominal wall. Thus, it results in
separation of approximated tissues allowing the abdominal organs mainly the bowel and
omentum to bulge through the gap.
77
Classification
Early hernias – appears soon after the original laparotomy closure. It grows
rapidly and becomes large. It often involves the whole length of wound.
Late hernias – Occurs 5 years or more after the surgery.
Leaper classification
 The diffuse type
 The small and sharp edged type
Aetiology
1. Poor general condition of patient
2. Obesity – In obese patients – fat deposits between aponeurotic fibres not only
weakens tissues, it also favours infection.
3. Type of surgery – Patients with grossly contamination wounds and dirty wound
are more prone to develop incisional hernia. Malignancy also predisposes to
development of incisional hernia.
4. Poor surgical technique – like use of non-anatomical incision, faulty suture
technique and layered closure of laparotomy wounds which are the cause for
wound dehiscence can also lead to poor wound healing and incisional hernia.
5. Sepsis – It is one of the major causes of incisional hernia, it can occur both in
early sepsis and in late sepsis that develops during first year after operation. Forty
eight (48%) of patients with incisional hernias have had a wound infection. In
1974 Fischer and Turner found that 88% of patients with incisional hernias
78
requiring repair had a wound infection and Pollock, reported on a trial of single
layered mass closure in 1979, concluded that incidence of incisional hernias
would be reduced by the elimination of wound sepsis.
6. Postoperative complications like chest infection, abdominal distension and wound
infection.
Clinical features
The hernia may occur through a small portion of the scar, often the lower end.
More frequently, there is a diffuse bulging of the whole length of the incision.
A postoperative hernia, especially one through a lower abdominal scar, usually increases
steadily in size and more and more of its contents become irreducible.
Sometimes the skin overlying it is so thin and atrophic that normal peristalsis can
be seen in the underlying intestine.
Repeated attacks of subacute intestinal obstruction are common and strangulation
is liable to occur at the neck of a small sac or in a locules of the large one. Nevertheless
most cases of incisional hernia are a symptomatic and broad necked, and do not need
treatment.
Prospective study was carried out to define the extent of the problem.
Bucknall13 et al (1979) over five years from 1975 to 1980 a total of 1129 major
laparotomy wounds in adult, were assessed at regular interval for 12 months after
operation. There were 19 burst abdomen (1.7%) and 84 incisional hernias (7.4%). The
79
introduction of the mass closure technique reduced the incidence of burst abdomen from
3% in 1975 to 0.95% in 1979. However it did not improve the rate of incidence of
incisional hernias, which was 7.6% in 1979.
Treatment
 Resuture
 Shoelace darn repair
 Mesh closure
80
METHODOLOGY
The study is a prospective study conducted on patients admitted in the
Department of Surgery, Bowring and Lady Curzon Hospitals, attached to Bangalore
Medical College attending the outpatient and emergency services and subsequent
admission as in-patient during the period November 2003 to April 2006 and the data
collection is ready after obtaining written consent from the patient. We included all
patients with ventral abdominal incision i.e. surgery with midline and paramedian
incision undergoing either elective or emergency surgery. We excluded patients
undergoing surgery where in the abdomen is opened by transverse or other non-vertical
incisions. Thus, all the patients who were included in the study had their incisions closed
by either singled layered closure or by conventional technique of layered closure. Out of
109 patients, 53 were randomized to have the abdominal wall closed by single layered
technique and remaining 56 by conventional layered closure technique, they were
grouped as group I and group II respectively.
In group I, ventral abdominal incision were closed in single layered using
polypropylene No. 1. In case of midline incisions linea alba and peritoneum were closed
in single layered by continuous interlocking, and in case of paramedian incisions, the
peritoneum, posterior layer of rectus sheath, rectus abdominis and anterior layer of rectus
sheath were closed in one layer by continuous interlocking.
In group 2, ventral abdominal incisions were closed in layers using chromic
catgut No. 1 for peritoneum and polypropylene No. 1 for other layers. In case of midline
81
incisions peritoneum was closed with chromic catgut No. 1 by continuous interlocking
and linea alba was closed with polypropylene No. 1 by continuous interlocking sutures.
In case of paramedian incisions peritoneum and posterior layer of rectus sheath
was closed with chromic catgut No. 1 and anterior layer of rectus sheath was closed with
polypropylene No. 1 by continuous interlocking sutures.
Skin was closed with non-absorbable material like No. 1-0 cotton thread or
mersilk, using interrupted mattress sutures in both groups of patients.
METHODS
History and clinical examination
Detailed history taking was followed in all cases admitted in our wards.
Particulars regarding the diseases like hypertension, diabetes, jaundice, tuberculosis and
other chest infections were made note of.
Thorough clinical examination of the patients was made and recorded, particular
attention was given to note the anaemia, nutritional status, jaundice, and respiratory tract
infection.
82
Investigations
A thorough preoperative search was made to exclude anaemia, jaundice, uremia,
diabetes mellitus, malnutrition or obesity.
The following investigations were done as a routine:
 Blood: Hb%, TC, DC, ESR, BT, CT, blood grouping and Rh typing.
 Blood: Random blood sugar, FBS and PPBS.
 Blood: Urea and serum creatinine.
 Blood: For HbsAg, HIV.
 Urine: For albumin, sugar and microscopy.
 Stool: It was tested for ova, cyst and occult blood wherever necessary.
 X-ray chest PA view was done routinely in all cases preoperatively.
 Height and weight of the patient: To calculate the BMI = Weight/(Height)2.
Special investigations like:
 Erect x-ray abdomen was used in all acute abdominal conditions.
 Contrast x-rays like barium meal follow through were used wherever necessary.
 In patients with jaundice and hepatobiliary disorders, LFT was done.
 Abdominal ultrasound scanning was used wherever necessary.
 Endoscopy of upper gastrointestinal tract was used in suitable cases for diagnosis.
However, in emergency cases only the investigations necessary for diagnosis
were employed. Complete workup was done in all cases that underwent elective surgery.
83
The positive criteria for the different factors are:
 Anaemia: < 10 gm%
 Jaundice: Bilirubin > 2 mg/dl
 Diabetes: FBS > 120 mg/dl
 Uremia: S. Urea > 40 mg/dl, Serum creatinine: > 1.4 mg/dl
 Wound infection: Presence of pus
 Obesity: BMI > 30
 Malnutrition: BMI < 20
 Postoperative Cough, expectorations and fever
Preoperative preparation of the patient
In patients who underwent emergency surgery, the general condition of the
patients was improved to optimum level. In patients who underwent elective surgery, the
general condition was improved by correcting dehydration, anaemia and electrolyte
imbalance. Diabetes and hypertension were brought under control. In patients with
jaundice, glycogen storage was improved, hydration was corrected, renal and hepatic
functions were tested and corrected to optimum levels. Suitable antibiotics were
administered preoperatively to treat infections.
Operative techniques
In the operation theatre, the part was prepared and draped. General anaesthesia
was used in most of the cases. Drains were used wherever necessary, through a separate
stab incision, away from the main incision.
84
The following points were paid special emphasis on:
 The type of incision: Midline and paramedian.
 The type of closure: Mass closure and two-layered closure.
Technique of closure
1. Group I
A. Midline incisions
Closure performed by suturing the cut edges of the peritoneum and linea alba
together as a single layer. Bites were taken about 1.5 cm from the cut edges and about
1.5 cm from the previous bite. Continuous locking sutures using polypropylene No. 1.
B. Paramedian incisions
The peritoneum, posterior layer of rectus sheath, the rectus abdominis muscle and
anterior layer of rectus sheath were sutured as a single layer. The bites were taken about
1.5 cm from the cut edges and about 1.5 cm from the previous bite. Continuous inter
locking sutures employed using polypropylene No. 1.
Group 2
A. Midline incisions
The peritoneum was closed with chromic catgut No. 1 by continuous interlocking.
The linea alba was closed with polypropylene No. 1 by continuous interlocking sutures.
85
B. Paramedian incision
The peritoneum and the posterior layer of rectus sheath were closed with chromic
catgut No. 1 by continuous interlocking. The anterior layer of rectus sheath was closed
using polypropylene No. 1 by continuous interlocking sutures.
The subcutaneous fatty layer if thick was closed using No. 2-0 chromic catgut
with interrupted sutures. Skin was closed using mattress sutures with mersilk No. 1-0 or
cotton thread No. 1-0 in both the study groups.
The wounds were cleaned with spirit and dressed. No local antibiotics dressings
were employed.
Time taken for closure of abdomen was recorded in all cases.
Postoperative period
The patient was observed postoperatively till all the abdominal sutures were
removed and the patient discharged from hospital.
The postoperative complications like, vomiting, chest infection, abdominal
distension, suture sinus formation, wound infections or wound dehiscence were noted.
All the patients received antibiotics suitable for the case parenterally usually for 6-7 days
till the drains were removed and orally for about5-6 days. Antibiotics were continued for
more than 12-14 days only whenever indicated. As a routine NSAIDs, B-complex and
Vitamin C were given postoperatively as a schedule. Blood transfusion were used
whenever indicated.
86
The wound was examined on 5th, 7th, 9th or 11th day and the wound status noted.
Drains whenever employed were removed after the patient tolerated oral feeds and passed
stools regularly, usually 5 to 6th postoperative days.
Culture and sensitivity testing sent for infected cases. Alternate sutures were
usually removed on 11 to 12th postoperative days and remaining sutures were removed on
13 to 14th postoperative days.
After the patients were discharged from the hospital, regular monthly follow-ups
was done for first three months, once in three months for next one year. During the
follow-up, patients were examined in the first visit specially for wound infection or
wound dehiscence and during subsequent visits attention was paid to wound pain, suture
sinus formation, scar complication, incisional hernia. However, it was imperative that
cases, which were done towards the end of this study, obviously had a shorter follow up.
87
Fig 4: Single layered closure of midline incision
Fig 5: Single layered closure of paramedian incision
88
Fig 6: Conventional layered closure of midline incision
Fig 7: Conventional layered closure of paramedian incision
89
STATISTICAL METHODS
Chi-square and Fisher exact test have been used to test the significance of
proportions of parameters of interest between single layered and conventional layered.
1. Chi-Square Test
 2

 (Oi  Ei) , Where Oi is observed frequency and Ei is Expected frequency
Ei
The formula to derive chi square test is :
Class 1 Class 2 Total
Sample 1 a b a+b
Sample 2 c d c+d
Total a+c b+d a+b+c+d
2. Fisher Exact Test
Class 1 Class 2 Total
Sample 1 a b a+b
Sample 2 c d c+d
Total a+c b+d n
90
(a  b)!(c  d )!(a  c)!(b  d )! 1
Fisher Exact Test statistic= p n!  a!b!c!d!
Statistical software
The statistical software namely SPSS 11.0 and Systat 8.0 were used for the
analysis of the data and Microsoft word and Excel have been used to generate graphs,
tables etc.
Mean = SD =
91
RESULTS
Study Design
A comparative study consisting 109 cases divided in to two groups (Single
layered- 53 cases and Conventional layered - 56 cases) is undertaken to compare the type
of closures, complications etc
Table 1
Age distribution
Single layered Conventional Total

layered
Age in years
Number % Number % Number %
 10 - - 1 1.8 1 0.9
11-20 6 11.3 6 10.7 12 11.1
21-30 16 30.2 13 23.2 29 26.6
31-40 8 15.1 15 26.8 23 21.1
41-50 9 16.9 12 21.4 21 19.3
51-60 6 11.3 5 8.9 11 10.1
61-70 7 13.2 2 3.6 9 8.3
>70 1 1.9 2 3.6 3 2.8
Total 53 100.0 56 100.0 109 100.0
Mean  SD 39.5116.80 38.0415.04 38.7515.87
Inference Age between the two groups is statistically similar with p=0.630.
92
Example: Calculation of mean and standard deviation in single layered closure
Mean = = = = 39.51
SD =
Graph 1
Single layer Conventional layer

35
30
25
Percentages
20
15
10
0
<=10 11-20 21-30 31-40 41-50 51-60 61-70 >70
Age in years
The distribution of age of patients in our study group varied from 11 years to
75 years. In single-layered closure (Group I) with the mean age of 39.5116.80 years. In
conventional layered closure (group II) age varied from 8 years to 82 years with the mean
age of 38.0415.87 years.
93
Table 2
Sex distribution

layered
Sex
Male 40 75.5 48 85.7 88 80.7
Female 13 24.5 8 14.3 21 19.3
Total 53 100.0 56 100.0 109 100.0
Sex distribution between the two groups are statistically similar

Inference
with p=0.175.
Graph 2
Female
24.5% Female
14.3%
Male
Male 85.7%
75.5%
Conventional layer
Single layer
There were 40 males and 13 females in single-layered closure (Group I) as
compared to 48 males and 8 females in conventional layered (Group II).
94
Example of application of Chi-square test
Single Conventional
Total
layered layered
Male 40 (a) 48 (b) 88 (a+b)
Female 13 (c) 8 (d) 21(c+d)
Total 53 (a+c) 56 (b+d) 109 (a+b+c+d)
95
Table 3
Primary etiology
Type of closure
Single layered Conventional
Primary etiology
layered
Number % Number %
A. Perforation
1.Gastric Perforation 1 1.8 2 3.6
2.Deuodenal Perforation 12 22.6 14 25.0
3.Jejunal Perforation 2 3.8 3 5.4
4.Ileal perforation 5 9.4 11 19.6
5.Appendicular perforation 2 3.8 4 7.1
B. Malignancy
1.Colorectal carcinoma 5 9.4 2 3.6
C. Hepatobiliary
1.Ruptured liver abscess 1 1.9 3 5.4
2.Stab liver laceration 1 1.9 - -
3. Pseudopancreatic cyst 3 5.7 - -
4. Acute haemorrhagic 1 1.9 - -
pancreatitis
D. Splenic Abscess 1 1.9 - -
E. Pyloric stenosis with GOO 3 5.7 5 8.9
F. Small bowel obstruction 5 9.4 8 14.3
G. Small Bowel Gangrene 4 7.5 - -
H. Obstructed inguinal hernia 1 1.9 2 3.6
I. Strangulated inguinal hernia 1 1.9 1 1.8
J. Acute intussusception 4 7.5 - -
K. Appendicular abscess 1 1.9 1 1.8
L. Large bowel gangrene - - - -
96
Table 4
Type of Surgery
Emergency/Elective distribution

Emergency layered
/Elective
Emergency 40 75.5 51 91.1 91 83.5
Elective 13 24.5 5 8.9 18 16.5
Total 53 100.0 56 100.0 109 100.0
Number of elective cases are significantly more in single layered

Inference
when compared to conventional layered with p=0.028.
Graph 3
Elective
25% Emergenc Elective
Emergenc y 8.9%
y 91.1%
75%
Conventional layer
Single layer
It is broadly divided into
 Elective surgery
 Emergency surgery
97
In single layered closure
There were 53 patients in this Group I who underwent either elective or
emergency surgery. Among 13 patients who underwent elective surgery, 2 patients
developed wound infection. There was no incidence of wound dehiscence and incisional
hernia. Among 40 patients who underwent emergency surgery, 4 patients developed
wound infection, 1 patient developed wound dehiscence and 1 patient developed
incisional hernia.
In conventional layered closure
There were 56 patients in this Group II, who underwent either elective or
emergency surgery. Among 5 patients who underwent elective surgery. There was no
incidence of wound infection, wound dehiscence and incisional hernia 12 months after
surgery. Among 51 patients who underwent emergency surgery, 12 patients developed
wound infection, 4 developed wound dehiscence and 2 patients developed incisional
hernia 12 months after surgery.
98
Table 5
Type of wound

Type of layered
wound
Clean 7 13.2 6 10.7 13 11.9
Contaminated 46 86.8 50 89.3 96 88.1
Total 53 100.0 56 100.0 109 100.0
Frequency distribution of type of wound is equally distributed

Inference
between the two groups with p=0.688.
Graph 4
Contam-
inated
86.8% Contam-
inated
89.3% Clean
10.7%
Clean
13.2%
Single layer
Conventional layer
Type of wound:
Classified as
 Clean wounds
 Contaminated wounds
99
In single layered closure
There were 53 patients in this Group (Group I) who had either clean or
contaminated wounds.
Clean wounds
7 patients with clean wounds were operated. No patient had wound infection,
wound dehiscence and had incisional hernia.
Contaminated wounds
Among 46 patients who had contaminated wounds and were operated, 6 patients
had wound infection, 1 had wound dehiscence and 1 patients had incisional hernia.
In conventional layered closure
There were 56 patients in this group (Group II) who had either clean or
contaminated wounds.
Clean wounds
Among 6 patients with clean wounds who were operated. No one had wound
infection, wound dehiscence and incisional hernia.
Contaminated wounds
Among 50 patients who had contaminated wounds operated 12 patients had
wound infection, 4 had wound dehiscence, 2 developed incisional hernia.
100
Table 6
Time taken for closure

Time in layered
minutes
15-20 38 71.7 - - 38 34.9
21-25 10 18.9 5 8.9 15 13.8
26-30 4 7.5 11 20.8 15 13.8
31-35 1 1.9 36 67.9 37 33.9
36-40 - - 4 7.5 4 3.7
Total 53 100.0 56 100.0 109 100.0
Significant proportion of cases in single layered have taken less

Inference
time to closure (p<0.001).
Graph 5

80
70
60
50
Percentages
40
30
20
10
0
15-20 21-25 26-30 31-35 36-40
Time (min) taken to closure
101
Particular attention was paid to the duration of time consumed for abdominal wall
closure. The mean time consumed was
 In single layered closure (Group I) 20.18 min
 In conventional layered closure (Group II) 33.42 min
Thus, the time consumed in single layered closure (Group I) was about
13 minutes lesser than in Conventional layered closure (Group II).
102
Table 7
Factors affecting wound healing

Factors layered
affecting
wound Number % Number % Number %
healing
(n=53) (n=56) (n=109)
Anemia 12 22.6 10 17.9 22 20.2
Uremia 6 11.3 5 8.9 11 10.1
Jaundice 4 7.5 5 8.9 9 8.3
DM 3 5.7 2 3.6 5 4.6
Malnutrition 20 37.7 18 32.1 38 34.9
Factors affecting the wound healing are equally distributed in

Inference
both the groups (p>0.05)l
Graph 6

40
35
30
25
Percentages
20
15
10
0
Anemia Uremia Jaundice DM Malnutrition
Factors affecting wound healing
103
Incidence of various factors affecting wound healing are as follows:
Anaemia, uremia, jaundice, diabetes, malnutrition, pulmonary disease.
Positive criteria for different factors
1. Anaemia < 10 gm%
2. Uremia: Serum Urea > 40mg/dl, Serum creatinine > 1.5 mg/dl
3. Jaundice: Bilirubin > 2 mg/dl
4. Diabetes: FBS > 120 mg/dl
PPBS> 160 mg/dl
5. Obesity: BMI > 30
6. Malnutrition: BMI < 20.
7. Pulmonary disease: cough, expectoration and fever
104
Wound infection
Wound infection is defined as emergence of pus from wound, irrespective of
subsequent culture.
Classified as:
 Superficial infection – When skin and sub cutaneous tissue involved
 Deep infection – when infection was reaching upto the muscles.
All patients with purulent or sero purulent discharge were subjected to culture and
sensitivity.
In single layered closure (Group I)
Among 53 patients undergoing single layered closure with whom 40 patients who
had undergone emergency surgery 4 developed wound infection. In 13 patients who had
undergone elective surgery, 2 developed wound infection during postoperative period.
In conventional layered closure (Group II)
Among 56 patients undergoing conventional layered closure, with whom
51 patients who had undergone emergency surgery 12 developed wound infection, in
5 patients who had undergone elective surgery no one developed wound infection during
postoperative period.
105
Wound dehiscence
It is defined for our study purpose as “wound separation of all layers including
peritoneum with or without protrusion of viscera out of the wound.
In single layered group (Group I)
Out of 53 patients who underwent surgery, which were, followed 1 patient
developed wound dehiscence. An incidence of 1.88%.
In conventional layered group (Group II)
Out of 56 patients who underwent surgery which were followed, 4 patients
developed wound dehiscence. An incidence of 7.14%.
106
Table 8
Duration of follow up
Conventional
Single layered Total
Duration of follow up layered
Number Number Number
% % %
(n=53) (n=56) (n=109)
Up to 3 months 42 79.2 44 78.6 86 78.9
4-6 months 31 58.5 28 50.0 59 54.1
7-9 months 16 30.2 17 30.4 33 30.3
10-12 months 6 11.3 4 7.1 10 9.2
Duration of follow up is statistically similar between the groups
Inference
(p>0.05).
Graph 7

80
70
60
50
Percentages
40
30
20
10
0
Up to 3 months 4-6 months 7-9 months 10-12 months
Duration of follow up
After the patients were discharged from hospital, regular monthly follow-ups was
done for first three months, once in three months for next one year. During the follow up,
patients were examined in the first visit specially for wound infection or wound
dehiscence and during subsequent visits attention was paid to wound pain, suture sinus
formation, incisional hernia and scar complications.
107
Table 9
Postoperative complications
Single layered Conventional layered

Postoperative
complications
Emergency Elective Total Emergency Elective Total
6 12
1.Wound infection 4 2 12 -
(11.3%) (21.4%)
2. Wound
1 - 1 (1.9%) 4 - 4 (7.1%)
Dehiscence
3. Incisional hernia 1 - 1 (1.9%) 2 - 2 (3.6%)
4. Suture sinus 2 - 2 (3.8%) 1 1 2 (3.6%)
5. Pain over the scar 3 2 5 (9.4%) 4 3 7 (12.5%)
Wound infection and wound dehiscence are more in conventional layered

Inference
group with p=0.200 and p=0.363.
Graph 8

25
20
Percentages
15
10
0
Wound infection Wound dehiscence Incisional hernia Suture sinus Pain over scar
Postoperative complications
108
Table 10
Postoperative complications and follow-up status
Follow up status
Single layered Conventional layered

Postoperative
complications During Up to During Up to
Up to 3 Up to 6 Up to 3 Up to 6
Hospital 12 Hospital 12
months months months months
stay months stay months
1.Wound
5 1 - - 10 2 - -
Infection
2. Wound
1 - - - 3 1 - -
Dehiscence
3. Incisional
- - 1 - - - 1 1
Hernia
4. Suture sinus 1 1 - - 1 1 - -
5. Pain over
- 2 3 - - 4 3 -
the scar
Suture sinus formation
It was diagnosed to exist when a micro abscess or chronic granulation infection
had resulted in a fistulous tract.
In single layered closure (Group I) – Suture sinus formation was observed in
2 patients, out of 53 patients undergoing single layered closure.
In conventional layered group (Group II) – Suture sinus formation was observed
in 2 patients. Out of 56 patients undergoing conventional layered group, which was due
to chromic catgut suture material reaction and which healed after removing it.
109
Incisional hernia
Is defined as a protruding swelling palpable in the wound during the examination
of the patient in supine position, due to failure of facial layer closure of abdominal wall
postoperative.
In single layered closure, out of 53 patients undergoing surgery 1 had incisional
hernia.
In conventional layered closure, out of 56 patients undergoing surgery 2 patients
had incisional hernia 12 months after surgery.
Scar complication
These were in form of:
 Pain over the scar
 Hypertrophy of the scar
In single layered closure out of 53 patients, 5 patients developed pain over the
scar and no incidence of hypertrophy of the scar.
In conventional layered closure, out of 56 patients, 7 patients developed pain over
the scar and none had incidence of hypertrophy of the scar.
110
Table 11
Type of closure
Conventional
Single layered Total
Type of layered
closure
Midline 48 90.6 7 12.5 55 50.5
Paramedian 5 9.4 49 87.5 54 49.5
Total 53 100.0 56 100.0 109 100.0
Midline closures are significantly more in single layered and

Inference paramedian closures are significantly more in Conventional
layered with p<0.001.
Graph 9
Para
median
9.4%
Midline
Midline Para
12.5%
90.6% median
87.5%
Single layer
Conventional layer
111
Table 12
Mean pattern of Hospital stay in days
Hospital stay in Conventional

Single layered Overall
days layered
Range 2-39 1-49 1-49
Mean  SD 16.346.96 18.188.62 17.287.87
Duration of hospital stay after surgery is higher for

Significance
the group with conventional layered with p=0.225.
Graph 10
30
25
Duration of HS in days
20
15
10
0
112
DISCUSSION
Any contribution to the study and knowledge of wound closure is important to
surgical speciality and this is a valuable contribution. Closure of abdominal incision has
been greatly simplified by realization that all incisions heal by forming a block of fibrous
tissue.35
The strength of abdominal wall depends on linea alba and anterior rectus sheath.
The technique of laparotomy wound closure is an important factor in preventing the
postoperative wound complications like wound infection, wound dehiscence, suture sinus
formation, incisional hernia and scar complications.
However, there are many systemic and local factors responsible for delay in
wound healing.
Systemic factors include – obesity, jaundice, diabetes, emaciation, deficiency of
protein, iron and vitamin, old age, Cachexia, toxaemia, uremia, alcoholism, malignancy,
treatment with steroids and immuno suppressants and other disease status.
Local factors include – infection, haematoma formation, foreign body reaction
and the lack of rest. Mechanical factors such as postoperative vomiting, hiccough,
explosive coughing and chest infection, gross gaseous distension, ascites, straining during
micturition and constipation.36
The time taken for closure in single layered closure (Group I) was 20.18 mins as
compared to conventional layered closure (Group II) was 33.42 mins. Thus the time
113
consumed for single layered closure was about 13 mins lesser than conventional layered
closure. Thus it is proved in our study that the time consumed for closure is reduced by
single layered closure as compared to conventional layered closure.
The current study has shown that the mass closure technique for abdominal
wounds results in lower incidence of wound infection, burst abdomen and incisional
hernia than in layered technique.
114
Table showing incidence of postoperative complications
Author and Years Wound infection Wound Dehiscence Incisional hernia Suture sinus
Wound infection=% WI Wound dehiscence = % WD Incisional Hernia = % IH Suture sinus = % SS
Total cases of study Total cases of study Total cases of study Total cases of study
SLC CLC SLC CLC SLC CLC SLC CLC
Jones et al (1941)15 1/116=0.85% 32/140=22.8% 0/116 = 0% 3/140 = 3.9% - - - -
Mc Callum et al 20/1389= 38/1660=2.28% - - - -

(1964)80 1.43%
Tagart et al (1967)32 17/96=18% 29% 1/115 = 0.87% 3.4% - 3% - -
Higgins et al 9/1224=0.7% 43/1153=3.7% - -

(1969) 33
Goligher (1976)10 11/108=10.18% 10/107=9.34% 1/108=0.92% 11/107=10.2% 0/108=0% 4/107=3.73% 1/108=0.92% 7/107=6.54%
Leaper (1977) 12 56/241=23.23% 23/116=19.82% 1/241=0.41% 1/116=0.9% 6/241=2.48% 4/110=4.2%
A Singh (1981)35 2/30=6.6% 5/30=16.6% 0/30=0% 3/30=10% 0/30=0% 2/30=6.6%
Shukla (1981)38 10/100=10% 17/100=17% 2/100=2% 15/100=15% 0/100=0% 3/100=3%
Bucknall (1982)13 6/788=0.8% 13/341=3.8% 61/788=7.7% 23/341=6.7% 8/300=2.6% 8/300=2.6%
Mathur (1989)36 37/300= 12.33% 1/300=0.33% 3/300=1% -
Chowdhury (1994)37 18/80=22.5% 38/80=47.5% 0/80=0% 3/80=3.75% 0/80=0% - 2/80=2.5% 20/80=25%
Present study (2006) 6/53=11.32% 12/56=21.42% 1/53=1.88% 4/56=7.14% 1/53=1.89% 2/56=3.57% 2/53=3.8% 2/56=3.57%
115
Wound infection
The part played by wound sepsis is important, as this is the major avoidable cause
of wound failure. Inadequate treatment or immuno-compromised state may lead to
serious systemic complications like septicemia, shock and multi organ failure.
The incidence of wound infection is reduced by taking larger bites of tissues and
exerting less pressure taken in single layered closure there by maintaining adequate blood
supply, rather than exerting more pressure and taking lesser tissues in the conventional
layered closure, thus leading to ischaemia and necrosis which predisposes to infection.
The incidence of wound infection among various study groups also confirm this
observation.
In the comparative studies conducted Jones (1941), reported an infection rate of
0.85% with single layered closure as compared to 22.8% with conventional layered
closure.
Tagart (1967) had 18% wound infection with single layered closure as compared
to 29% with conventional layered closure.
Goligher (1976) had 10.18% wound infection with single layered closure as
compared to 9.34% with conventional layered closure.
Leaper (1977) had 23.33% wound infection with single layered closure as
116
A Singh (1981) had 6.6% wound infection with single layered closure as
Shukla (1984) had 10% wound infection – with single layered closure as
compared to 17% with conventional layered closure.
Chowdhury (1994) had 22.5% wound infection with single layered closure as
In our study, the incidence of wound infection with single layered closure was
11.32% as compared to conventional layered closure with 21.42%, which is comparable
with most of the above-mentioned studies.
Different authors used different suture materials for mass closure technique and
have reported wound infection rates, which are definitely less than those, observed in
conventional layered closure. In the presence study we have used polypropylene No. 1
only for single layered closure and for conventional layered closure we have used
polypropylene no 1 for linea alba or rectus sheath and chromic catgut no 1 for peritoneum
or posterior rectus sheath. The cause of sutured material for infection cannot be compared
with other studies.
Wound dehiscence
Wound dehiscence is a grave complication with poor prognosis. Faulty suture
technique is entirely responsible for early dehiscence but only partly responsible for late
incisional hernia, the other culprit being deep wound sepsis often associated with
117
intraperitoneal drainage. Wound dehiscence rates are higher with conventional layered
closure than single layered closure. The suture holding capacity of the anterior rectus
sheath alone was 2.25kg compared with 3.93 kgs after, full thickness
musculoaponeurosis. The structures found to have the greatest suture holding capacity
was the linea alba 7.93kgs as compared with 4.12kg for full thickness without linea alba
(Leaper).
A comparison of wound dehiscence between midline and paramedian incisions in
our study, there were 53 patients whose ventral abdominal incisions were closed with
singled layered closure technique. Among them 48 patients belonging to midline
incisions, 1 patient developed wound dehiscence. Among 5 patients belonging to para
median incisions, no one developed wound dehiscence. Since the wounds closed by mass
closure technique in para median incisions is less as compared to midline incisions, the
results could not be analyzed properly and comparable figures with the standard could
not be assessed.
Incidence of wound dehiscence in various study groups also confirms this
observation. Jones (1941) had no incidence of wound dehiscence with single layered
closure as compared to 3.93 with conventional layered closure.
Mc Callum (1964) had an incidence of 1.43% with single layered closure as
118
Tagart had an incidence of 0.87% with single layered closure as compared to
3.4% with conventional layered closure.
Higgins (1969) has an incidence of 0.7% with single layered closure as compared
to 3.7% with conventional layered closure.
Golligher (1976) has reported an incidence of 0.92% with single layered closure
as compared to 10.2% with conventional layered closure.
Leaper (1977) had an incidence of 0.41% with single layered closure compared to
0.9% with conventional layered closure. Singh A. (1981) had no cases of wound
dehiscence with single layered closure as compared to 10% wound dehiscence with
conventional layered closure.
Shukla (1981) had an incidence of 2% with single layered closure as compared to
1.5% wound dehiscence with conventional layered closure.
Bucknell (1982) had an incidence of 0.8% with single layered closure as
compared to 3.8% wound dehiscence with conventional layered closure.
Chowdhury (1994) had no wound dehiscence cases with single layered closure as
compared to 3.75% wound dehiscence with conventional layered closure.
In our study, we had 1.88% wound dehiscence with single layered closure (Group
I) as compared to 7.14% wound dehiscence with conventional layered closure (Group II).
119
This study has found that single layered closure reduced the incidence of
dehiscence as compared to conventional layered closure.
In our study, the incidence of wound dehiscence is higher in both the study groups
as compared to the studies by various authors. This is because in our study, we had a
large number of patients who were elderly, had intraabdominal sepsis and presented late.
Most of these patients were anemic, uremic, malnourished and most of them were
operated on emergency basis and also had higher incidence of post operative wound
infections. These predisposing factors were responsible for delayed wound healing and
subsequent dehiscence as compared to the western countries where the incidence is less.
Incisional hernia
It develops from the scar of a surgical incision, when a patient is examined by
making him lie flat on the bed and is asked to lift his legs or to cough, any bulges in the
scar is considered as Incisional hernia. Incisional hernias are mainly due to faulty incision
and faulty technique of closure, other important determinants are sex (males more
predisposed) and age (elderly more predisposed) of the patients, chest infection and
wound infection. As age advances, breakdown of collagen fibres takes place weakening
the old-healed scars, predisposing for hernia, thus indicating the need to use non-
absorbable suture material to support it, using chromic catgut in conventional layered
closure proved to be a draw back in causing incisional hernia and thus proving the
advantages of using polypropylene in preventing incisional hernia by holding more tissue
with little tension for a long period of time after the wound heals.
120
Various study groups confirm that incidence of incisional hernia is reduced by
single layered closure with polypropylene as compared to conventional layered closure
with chromic catgut and polypropylene. Golligher (1976) had no incidence of incisional
hernia with single layered closure as compared to 3.73% with conventional layered
closure.
Leaper (1977) had 2.48% incisional hernia with single layered closure as
compared to 4.2% in conventional layered closure.
Singh A (1981) had no cases of incisional hernia with single layered closure as
Shukla (1981) had no cases of incisional hernia with single layered closure as
In our study, the incidence of incisional hernia was 1.89% with single layered
(group I) as compared to 3.757% with conventional layered closure (Group II).
Suture Sinus Formation
It is defined as a chronic granulating infection or micro abscess that results in a
persistent fistulous tract. The incidence of suture sinus formation is predisposed by the
use of multi filament suture material. Due to lodgment of infective foci in the crevices of
suture material. The incidence of suture sinus formation is various study groups are as
follows:
121
In a comparative study conducted by Goligher (1976) had 0.92% suture sinus
formation with single layered closure as compared to 6.54% with conventional layered
closure.
Bucknall (1982) had 2.6% suture sinus formation with single layered closure as
Chowdhry (1994) had 2.5% suture sinus formation with single layered closure as
The incidence of suture sinus formation is lesser in singled layered closure as
compared to conventional layered closure by various authors.
In our study the incidence of suture sinus formation in single layered closure was
3.8% as compared to 3.6% in conventional layered closure. In our study we have used
only mono filament sutures in both the study groups so the incidence of suture sinus
formation is similar and inconclusive.
122
CONCLUSION
Finally, the observations tabulated from our comparative study proved to be
similar to other studies conducted by various authors thus proving that single layered
technique had the following advantages in:
 Reduces the time consumed for closure. Closure is even more secure in cachectic
patients and this allows early mobilization.
 Reduces the incidence of wound infection, thus decreasing the hospital stay and
morbidity.
 Reduces the incidence of wound dehiscence.
 Reduces the incidence of incisional hernia.
 Reduces the incidence of suture sinus formation and scar complications by using
monofilament suture material.
Thus, this method holds the promise for a safe technique of closure with minimal
complication.
123
SUMMARY
Large clinical experience and experimental findings seems to prove the
superiority of single layered closure over conventional layered closure of abdominal
incisions. Ideally, the technique of closure should be so simple that results should be
good in the hands of trainee as in those of the master surgeon it should be free from the
complications of wound infection, wound dehiscence, incisional hernia and persistent
sinuses, it should be comfortable to the patient and should leave a reasonably aesthetic
scar.
In conventional layered closure of abdominal wounds, the time consumed is
relatively more, the tissue reaction is more, more pressure is exerted to hold the facial
planes leading to avascularity and pressure necrosis which further leads to wound
infection and wound dehiscence and therefore produces – weak scar, which results in
increased incidence of incisional hernia.
Advantages of single layered closure
Less time is consumed for closure of abdominal wounds.
Prevents strangulation of tissues and maintains adequate blood supply by taking
larger bites and less force to hold the tissues. This results in a healthy and strong scar,
decreased incidence of wound dehiscence and incisional hernia.
124
The use of non-absorbable monofilament polypropylene, which has less tissue
reaction and does not harbour organisms on its surface and thus decreases the incidence
of postoperative wound infection.
Hence, it can be concluded that less time consumption, minimum complications,
reduced hospital stay and leaving a reasonably aesthetic scar. Justify the use of single
layered closure technique in place of conventional layered closures technique in ventral
abdominal incisions.
125
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134
PROFORMA
Patient particulars
Name: IP No.:
Age: Sex: OT No.:
Address:
DOA: DOS: DOD:
 Complaints with duration:
 History of presenting illness:
 Past history:
 Personal history:
 Family history:
GENERAL PHYSICAL EXAMINATION
Vital data
BMI = Weight (kg)/Height (m)2
Pulse: Blood pressure:
Respiratory rate: Temperature:
Pallor: Icterus: Cyanosis:
Clubbing: Lymphadenopathy: Pedal edema:
135
EXAMINATION OF ABDOMEN
 Inspection:
 Palpation:
 Percussion:
 Auscultation:
 PR Examination:
SYSTEMIC EXAMINATION
 Respiratory system:
 Cardiovascular system:
 Central nervous system:
INVESTIGATIONS
Hb%: Blood urea:
TC: Serum creatinine:
DC: Urine routine:
ESR: Albumin:
BT: Sugar:
CT: Microscopy:
FBS: LFTs:
PPBS: ECG:
CXR:
Supine and erect X-ray abdomen:
USG abdomen
CT scan:
Others:
136
Preoperative diagnosis:
Surgical treatment:
 Emergency:
 Elective:
Postoperative diagnosis:
OPERATIVE NOTES
Incision used
 Midline:
 Paramedian
Types of closure
 Mass closure:
 Conventional layered closure:
SUTURE MATERIAL
 No. 1 Prolene:
 Chromic catgut:
 Others:
Anaesthesia: General / Spinal / Caudal / Epidural
Time of operation (in minutes):
137
POSTOPERATIVE PERIOD
 Wound infection:
 Wound dehiscence:
 Drain removal and suture removal:
FOLLOW-UP
 Scar complications
 Suture sinus formation
 Scar pain
 Incisional hernia
Extras:
138
PATIENT’S CONSENT FORM
Principal Investigation:
Investigation:
This study has been explained to me in my own language and I understood:
1. What the study involves?
2. That the refusal to participate will not affect my treatment in any way.
3. That I may withdraw to take parting this study.
Signature of the subject: ________________________________________
Full Name: __________________________________________________
Date: ________________
Address: ____________________________________________________
Witness (should be a person not connected with the study)
I have been present while the procedure to be performed has been explained to the
subject and I have witnessed his/her consent to take part.
Signature of witness with date: __________________________________
Full Name: __________________________________________________
Address: ____________________________________________________
____________________________________________________________
Consent was taken from all the patients.
139
Sl. No. Name of the patient Age Sex DOA DOS DOD I.P. NO. Complaints with duration
1 Gangadarappa 50 M 17/01/2004 19/01/2004 09/02/2004 22 886 Pain abdomen - 1 month;
Constipation - 1 week; Vomiting - 6
days
2 Vimalan 45 M 05/02/2004 05/02/2004 17/02/2004 13 1815 Pain abdomen- 2 days; Vomiting -

2 days
3 Rajappa 45 M 17/01/2004 09/02/2004 04/03/2004 24 869 Pain abdomen - 8 days; Vomiting -

3 days
4 Imaam Sab 57 M 28/02/2004 08/03/2004 20/03/2004 13 3157 Pain abdomen - 6 months; Mass P/A -
6 months
5 Antony Raj 38 M 24/03/2004 05/04/2004 20/04/2004 16 4548 Pain abdomen - 2 months; Distension
- 1 week; and decreased frequency
passing stools - 1 week
6 CS Nilofer Sulthan 20 F 07/04/2004 12/04/2004 18/04/2004 7 5302 Pain abdomen - 3 months
7 Mohamed Masthin 55 M 14/04/2004 19/04/2004 04/05/2004 16 5717 Pain abdomen - 2 months; stools
once in 3-4 days
8 Mehaboob Shariff 25 M 22/04/2004 22/04/2004 03/05/2004 12 6132 Assault at 11.00 pm with knife -
21/4/04
9 Nagarathnamma 60 F 02/06/2004 03/06/2004 20/06/2004 18 8672 Pain abdomen - 1 day
10 Palani 37 M 12/06/2004 19/06/2004 01/07/2004 13 9272 Pain abdomen; distension; vomiting,

constipation - 3 days
11 Indramma 64 F 16/06/2004 19/06/2004 21/06/2004 3 9277 Loose stools - 8 days; distension - 6

days; pain abdomen - 6 days
12 Nagaraju 26 M 23/06/2004 05/07/2004 21/07/2004 18 9888 Pain abdomen - 1 month; mass P/A -
1 month
13 Shafi 30 M 30/06/2004 05/07/2004 15/07/2004 11 10335 Pain abdomen; vomiting - 3 months
14 Chinnappa 45 M 28/07/2004 29/07/2004 10/08/2004 13 11956 Pain abdomen - 2 days
15 Nanjappa 70 M 15/08/2004 15/08/2004 01/09/2004 18 12895 Pain abdomen - 3 days
16 Basavapujari 55 M 15/08/2004 22/08/2004 10/09/2004 19 12883 Pain abdomen - 9 months
17 Muniswamappa 67 M 25/08/2004 30/08/2004 21/09/2004 23 13469 Bleding P/R - 6 months
18 Murthy 23 M 02/09/2004 03/09/2004 26/09/2004 24 13895 Pain abdomen - 2 days; Vomiting -
2 episodes
19 Keshava Padma 19 F 03/09/2004 20/09/2004 05/10/2004 16 13940 Pain abdomen; Vomiting; Loose
stools - 3 months
20 Sangeetha 21 F 23/09/2004 23/09/2004 07/10/2004 15 15038 Gun shot - 6.30 pm - 22/9/04;

abdomen (Rt Side)
21 Kamarunissa 42 F 13/10/2004 14/10/2004 26/10/2004 13 16139 Pain abdomen; distension; 45 days
22 Ravi Kumar 21 M 14/10/2004 14/10/2004 14/11/2004 31 16168 Pain abdomen - 3 days; fever - 10
days
23 Kempamma 42 M 30/10/2004 02/11/2004 19/11/2004 18 17118 Pain abdomen - 6 days; vomiting - 6

days; not psd stools - 6 days; H/o
surgery 9 months back- Bull Gore
Injury
24 Raju 24 M 28/11/2004 28/11/2004 09/12/2004 12 18625 Pain abdomen - 2 days; Vomiting - 2
days; Fever, headache - 1 week
25 Saraswathamma 20 F 06/12/2004 06/12/2004 18/12/2004 13 18993 Pain abdomen - 5 days; Distension -

5 days; Vomiting - 2 days
26 Jeeva Reddy 53 M 09/12/2004 09/12/2004 19/12/2004 11 19182 Paid abdomen - 7 days; nausea/
Vomiting - 1 week
27 Munikadiramma 65 M 11/12/2004 14/12/2004 06/01/2005 23 19302 Pain abdomen - 8 days; distension -
8 days; vomiting - 2 days
28 Deepa 11 F 27/12/2004 29/12/2004 05/01/2005 8 20005 Pain abdomen - 20 days
29 Lakshmi Reddy 40 M 29/12/2004 30/12/2004 10/01/2004 12 20158 Distension - 4 days; constipation - 2

days; pain - 2 days; vomiting - 2 days
30 Mujahid Pasha 24 M 26/12/2004 01/01/2005 15/01/2005 15 20005 Pain abdomen - 3 days; Distension -
2 days
31 Somasundar 75 M 08/01/2004 10/01/2005 14/01/2005 5 366 Distension abdomen - 7 days; Pain -

5 days; Constipation and vomiting -
5 days
32 Stella 26 M 19/01/2005 20/01/2005 02/02/2005 13 909 Pain abdomen - 18 days; Vomiting -

1 day; Fever - 1 day
33 Ansar 48 M 22/01/2005 22/01/2005 02/02/2005 11 1009 Pain - 10 days; Distension - 2 days
34 Malleshwari 30 F 23/01/2005 24/01/2005 12/02/2005 20 1040 Pain abdomen and distension - 3

days; Vomiting and fever - 1 day
35 Hansa 28 F 02/02/2005 02/02/2005 21/02/2005 20 1542 Pain abdomen - 3 days; Fever - 8

days; Contipation - 2 days
36 Nagaraja 60 M 06/02/2005 06/02/2005 16/02/2005 11 1700 Pain abdomen - 7 hours; Distension -
7 hours
37 Tabrez Khan 22 M 09/02/2005 09/02/2005 21/02/2005 12 1917 Stab injury - 8.00 pm on 9.2.05;
Brought to hospital at 1.30 p.m. and
surgery at 12.10 pm on 10.2.05
38 Nagesh 25 M 16/02/2005 17/02/2005 04/03/2005 16 2282 Pain abdomen - 2 days; Fever - 1 1/2
months
39 Rama 26 M 23/03/2005 23/03/2005 44/05 13 4064 Pain abdomen - 3 days
40 Venkatesh 35 M 27/03/2005 29/03/2005 16/04/2005 19 4260 Fever - 7 days; Pain - 5 days;

Distension - 5 days
41 Ankappa Reddy 35 M 20/04/2005 23/04/2005 07/05/2005 15 5509 Pain abdomen - 7 days; Distension -
4 days
42 Ganesh 20 M 30/04/2005 30/04/2005 19/05/2005 20 6040 (R) Inguino scrotal swelling with
pain, irreducible from - 7 days;
Vomiting and constipation - 2 days
43 Shamachari 50 M 11/05/2005 21/05/2005 29/05/2005 39 6553 Pain abdomen - 15 days; Vomiting -

7 days; Constipation - 2 days
44 Basavaraj 38 M 25/05/2005 26/05/2005 15/06/2005 20 7847 Fever - 10 days; Pain abdomen and
constipation - 1 day
45 Clarwin 14 M 27/05/2005 27/05/2005 20/06/2005 23 7908 Pain abdomen, fever and vomiting -
2 days
46 Muniyappa 30 M 28/05/2005 28/05/2005 23/06/2005 26 8839 Pain abdomen : 3 days; Distension -

3 days; VomitinG - constipation - 2
days
47 Nanjamma 62 F 26/06/2005 27/06/2005 11/07/2005 15 8983 Fever - 12 days; distension abdomen,

pain, vomiting - 3 days
48 Babu 24 M 20/07/2005 20/07/2005 06/08/2005 18 10628 Pain abdomen - 1 week; distension -

3 days; vomiting and constipation - 2
days
49 Venkatagiriappa 48 M 27/07/2005 28/07/2005 03/08/2005 7 10958 Pain abdomen - 2 days; Constipation -

1 day
50 Noorjahan 40 F 17/08/2005 27/08/2005 18/09/2005 23 11949 Bleeding P/R - 2 months altrd bowel
habits - 6 months
51 Hanumakka 65 F 10/10/2005 16/10/2005 11/11/2005 32 13966 Bleeding P/R - 1 week; altered bowel
habits - 6 months; loss of weight-
20% - 6 months
52 Ahmed Sharief 64 M 09/10/2005 09/10/2005 10/10/2005 2 14564 Left inguino scrotal swelling -
10 years; Pain with discolouration
from 1 week
53 Saleem 35 M 13/11/2005 13/11/2005 29/11/2005 16 16284 Pain abdomen- 2 days; Vomiting - 2

days
Type of Type of
Diagnosis Type of Investigations incision wound
Pyogenic liver abscess with septicaemic shock LFTs T. Pro- 6.4; Alb - 2.0; Bil - 0.9; Cong Bil - 0.3 mg%; SGOT - 70; SGPT - 40, AIP - 192; Midline Contmd
GGT - 69 mg%; PT - 18; INR - 1.36; USG abdomen, CPKMB - 31; Na - 131 mg, K-4.1, Cl - supraumbilical
100 mg%
Gangerenous caecum and ascending colon PT - I7; Electro : Na - 133, K-4; Cl - 92 mg/l Midline -do-
SMA emboli - Ileo caecal branch supraumbilical
Pseudo pancreatic cyst U/s Pseudo pancr cyst; electro Na- 127; K-4.1; Cl-90; HCo-24 mg/l Midline -do-
supraumbilical
Pyloric stenosis with hydatid cyst - liver Gastrojejunostomy procedure U/s. Hydated cyst; Echo - mild MR, EF - 64%; LFT's T-Pro - Midline Clean
6.6; Alb - 4.2; G/O - 2.4; Bil - 1.2, DB - 0.6; INB - 0.6, SGOT - 64; SGPT - 40, ALP - 190 supraumbilical
Pseudo pancreatic cyst U/s. Pseudopancr cyst Midline -do-

supraumbilical
Ac. Appendicitis with bilateral ovarian cyst U/s Appendicitis with ovarian cyst - haemorrhagic Hb- 8.5mg% Midline infra Midline
umb infra umb
Ca colon descending Lt colon Colonoscopy;papillary - adeno ca - Grd II; U/s diffuse thickening of colon CEA - 2.6 mg/ml; Midline Contmd
LFTs TPFO - 6.7, GIO - 3.1; A/g - 1.15:1, ALP - 82.6, Alb - 3.6, a1 - 0.3, a2-0.8; b - 0.8,
Electro Na - 139, K-4.2, Cl - 105, HCO - 24 mg%/l
Stab injury - abdomen (Lt iliac region) jejunal Plaing xray abdomen - erect gas under diaphragm; PCV 4.4 mg/dl Midline -do-
perforation / laceration
Intususception Rt Colon, growth in caecum, Plain x-ray abdomen - erect ,gas under diaphragm Midline -do-
asc colon with caecal intususception
Peritonitis sec to DU perforation sealed off U/s Ascitis, hepatomagely, perisplenic collection; Electro - Na - 138; K- 3.1, Cl -105, HCO3 - Midline -do-
23
Small bowel obstution - gangrenous small Electro Na- 135, K- 2.8, Cl - 108, HCO 3 - 25, B/U - 97, S/c - 1.8; Echo - RBBB, LBBB Midline -do-
bowel due to ischaemic colitis
Pseudo pancreatic cyst Ch - NNA; U/s pseudopancr cyst, LFTs - TB - 1.1, DB - 0.6, T.Pro - 5.6; Alb - 3.2; GIO - 2.4, Midline Clean
SGOT - 41, SGPT - 13, ALP - 53 ; Electro Na - 13.3, K - 4.0, Cl - 97, HCO 3 - 24
GOO Secondary to chronic DU USG abdomen (N) Study; EGD - Bulbar deformity, Deuodenal ulcer, incompt LES; Electro: Midline Clean
Na - 140, K-3.6, Cl - 104, HCO3 - 25 mg/l supraumbilical
Peritonitis sec to DU perforation ; Per Op Erect x-ray abdomen; gas under diaphragm B/U - 87 - 89-31.5; S/C - 3.1-2.4-1.1; BUN - 41 Midline Contmd
Meckel's diverticulum mg%; Electro Na- 129, K-5.5, Cl - 90, HCO - 24 mg/l supraumbilical
Peritonitis sec to DU perforation with hydatid Erect x-ray abdomen; gas under diaphragm; U/s free fluid peritoneum;Lt lobe, pleural effusion Midline -do-
cyst Lt lobe liver supraumbilical
Ca Colon transverse and hepatic flexure CEA 15.88 ng/ml; U/s Irregular bowel mass RIF? Ca colon; LFT's DB - 0.26, InDB - 0.87; TB Midline -do-
- 1.13 mg%; GGT - 23.6; SGOT - 32, SGPT - 14; ALP - 87 IU/L, A/G - 1.07, Alb - 3.2, T Pro -supraumbilical
6.2; Electro - Na - 139, K-3.8, Cl-110, HCO3 -24
Ca Rectum CEA 2.51 mg/ml; U/s Rt Pleural effsn; G III peforation; B/L cortical cyst; LFT's T-0.6, DB - Midline -do-
0.3 mg%; T. Pro - 6.8, Alb - 3.8, SGOT - 173 U/L; Electro Na- 139, K-3.8, Cl - 110, HCO3 - supraumbilical
24
Peritonitis sec to DU perforation; Pre op - Eerect x-ray abdomen; gas under diaphragm Midline -do-
sealed DU perforation supraumbilical
Sub acute intestinal obstruction Ileocaecal TB LFTs GGT - 8 IU/l; T Pro - 4.8; Alp - 56.7; Glob - 2.0; Alb - 2.8; Tb - 0.3, DB - 0.1; IB - 0.1; Midline Clean
Per op - Ileal stricture crohns disease SGOT - 36; SGPT - 41, PCV - 38.9%; Plt - 4.38lakhs Colonoscopy -crohns; U/s. Distal small
intestinal obstn; Electro Na-139, K-3.6 mg/l; Cl-94 mg/l
Gun shot abdomen; pelvis, Rt thigh; Rt Plain x-ray abdomen; gas under diaphragm; Electro; Na - 137; K-3.7, Cl - 95, HCO3-22.3; U/s Midline Contmd
forearm; Per op; multiple small bowel injuries Peritoneal and pelvic collection? HVP cause
with G.B perforation
Acute Intestinal obstruciton; Perop; ac. S. Amylase - 49 IU/L, Lipase - 34.4 IU/L Ca- I - 4.2; T - 6.6; U/s Mild hepatomegaly fatty Midline Contmd
Haemorrhage pancreatitis liver, ascitis; electro Na-128; K-4.7; Cl - 9.8 mg/l
Peritonitis sec to ileal perforation Erect X-ray abdomen - gas under diaphragm U/s - (N) Study, Electro Na-137; K- 4.6, Cl - 9.9; Midline -do-
HCO3 - 18 mg/l
SAI obstren sec to post op adhesions Plain x-ray abdomen; multiple air fluid levels; PCV - 36; Plt - 2.01lakhs Electro - Na- 132; Cl- Midline -do-
95; K-3.7; HCO3 - 21.2 mg
Peritonitis sec to DU perforation Erect x-ray; abdomen gas under diaphragm; U/s peritoneal collctns; paralytic illeus ? HVP, Midline Contmd
Electro: Na- 124, K- 5.3, Cl - 105 mg/l
Ac Intestinal obstruction; gangrenous jejunal Erect x-ray abdomen; gas under diaphragm; montoux test - -ve; Electro: Na - 143, K- 4.0, Cl Midline -do-
segment 96
Peritonitis sec to DU perforation Erect x-ray abdomen; gas under diaphragm; Electra Na - 139, K-4.2, cl - 93 Paramedian -do-
Sub acute intestinal obstruction due to LFTs TB - 2.8, DB - 2.2, IB - 0.6; T. Pro - 4.5; Alb - 2.3; G/O - 2.2; AIP - 75; SGOT - 15; Midline -do-
gangrenous small bowel segmental with SGPT - 6; U/sascitis and splenomegaly; Electro: Na - 131, K- 4.6, Cl - 95 mg/l
splenomegaly? Cause
Intususception, Per op Ileo colic - U/s intususception ileocolic rgn; Widal - -ve; Electro: Na - 133; K-2.9, Cl - 97, HCO3 - 24 Midline -do-
intusuception with polyp with mesentric mg/l
lymphadenitis (Meckels diverticulum+)
SAI obstruction sec to adhesions Erect x-ray abdomen; Multiple air fluid levels (4-5); PLT - 3.58 lakhs Electro: Na- 140, K-4.6, Midline -do-
Cl - 9.5, HCO3 - 22 mg/l
AIO due to band between Meckels Electro: Na- 133; K-2.9; Cl - 97 mg/l; Widal -ve;TC - 12,000; N80, L19, E1, B0, Eerect x-ray Midline Contmd
diverticulum and ileum FSO - AIO supraumbilical
Peritonitis sec to appendicular perforation Hb 9.0 gms; TC-24,000; Eerect x-ray; FSO peritonitis with air fluid levels Midline -do-
supraumbilical
AIO due to intususceptoin (Jejuno - jejunal) Hb% - 9 gms%; RBS - 185 mg%; Amylase - 2820 IU/L; USG abdomen - Asym bowel Midline -do-
thickness; firm splenic flexure; Electro Na - 140; K-3.4, Cl-70; UGI endo - (N) Study
AIO due to intususceptoin - Ileo colic with Electro Na- 134, K-3.2, Cl - 97, X-ray FSO - AIO Right lower -do-
multiple colonic perforation para median
AIO due to gastrtic volvulus with necrosis of Electro Na- 137, K-4.0, Cl - 99; Hb - 9.8 gm%, Erect x-ray, FSO AIO, LFT: TB 0.8, DB - 0.6, Midline -do-
part of antr stomach walls T Pro - 4.9, Alb- 3.1; Alp - 5.6, SGOT - 35, SGPT - 41
Peritonitis sec to ileal perforation Electro Na - 136, K-3.5, Cl - 90, Erect x-ray gas under diaphragm Midline -do-
Peritonitis sec to DU perforation Electro Na - 139, K-2.8, Cl - 68, Erect x-ray gas under diaphragm Midline -do-
Liver laceration over superior part; Rt lobe Hb 10.6 gm% Parathesia Clean
Peritonitis sec to ileal perforation Electro: Na- 133, K-3.9, Cl - 97; LFT's - TB - 4.4, IB - 3.8, T.Pro - 7.5, Alb - 3.6, Alp - 5.7, Midline Contmd
SGOT -111, SGPT -147
Peritonitis sec to DU perforation Erect X-ray; gas under diaphragm Midline -do-
Peritonitis sec to DU perforation sealed off Erect x-ray FSO AIO, USG abdomen; free fluid in pelvis, Rt Para colic gutter Paramedian -do-
Peritonitis sec to ruptured splenic abscess USG abdomen : IA abscess sec to splenic abscess; Erect x-ray FSO AIO Midline -do-
(Rt) Strangulated inguinal hernia; gangrenous Electro Na-136, K-3.3, Cl 94 mg/l; Erect x-ray - FSO AIO Midline -do-
omentum with distal ileum
GOO due to pyloric stenosis Electro : Na- 139, K-3.6, Cl - 101, HCO3-24, Echo - (N), OGD:PS, LFT TB-0.5,DB -0.1, T. Paramedian Clean
Pro - 5.2, Alb - 4.0, Alp - 61, SGOT 12, SGPT - 7
Peritonitis sec to ileal perforation Electro Na-136, K-5.2, Cl 94 mg/l; Erect x-ray - gas under diaphragm Midline Contmd
AIO due post - appendicectomy adhesions and Erect x-ray - AIO Midline -do-
bands
Peritonitis sec to ileal perforation with Electro Na- 132, K-2.9; Cl-91 mg% Midline Contmd
haemorrhagic pancreatitis
Peritonitis sec to DU perforation Electro Na - 139, K-4.9, Cl -105 mg% Midline -do-
Peritonitis sec to appendicular perforation - Eiectro Na- 129,K-3.8, Cl-92mg Midline -do-
reoperation for leak post appendectomy
Peritonitis sec to DU perforation Electro Na- 133, K-3.6, Cl 94 mg% Midline -do-
Ca Rectum CT scan; Ca - rectum with perirectal Lymph nodes no metastatis, CEA - 12.5 IU/L Electro: Midline Clean
WNL
Ca Rectum Electro Na-141, K-3.9, Cl-90 mg Midline -do-
Left obstructed inguinal hernia Electro Na-131, K-2.6, Cl - 86 mg/l Midline -do-
Peritonitis sec to DU perforation Electro Na-148, K-5.6, Cl - 92 Mg/l, Erect X-ray, gas under diaphragm Midline -do-
Time
Technique consumed
Surgery done Material for closure for closure (mins) Postoperative phase Follow up
Emergency laparatomy and drainage, Hb-9.2; Altrd LFT; Polypropelene No - 1 Continuous 20 Uneventful 2m
lavage and placement of drains Smoking mass closure
emergency
Rt. Hemicolectomy with Ileocolie - Smoker -do- -do- 15 -do- 3m

anastomosis emergency
Cystoexostomy elective Smoker - 3 year; Alcoholic - -do- -do- 20 -do- 6m

10 year
Gastrojejunostomy procedure elective Smoker - Hb - 9.4 mg% -do- -do- 15 -do-
Cystogastrostomy elective Smoker - 10 mg%,Urea- -do- -do- 25 WI (+) Klebsiella; ® to most 11m
58,Cr-1.9 antibiotics
Interval appendicectomy with bilateral Hb-8.5% -do- -do- 20 Uneventful 7m

ovarian cyst elective
Lt. Hemicolectomy with end to end Ca Colon; A/G:1.15:1; Alb -Polypropelene No - 1 Continuous 25 WI (+) Klebsiella to Ciproflox 2m
anastomasis - elective 3.6; GIO - 3.1 mass closure Nor for Amikacin
Resection of a segment of jejunum and -do- -do- 20 Uneventful 7m

end to end anastomosis
Resection of intususcepted segment and Hb - 8.4 gm%; B/U - 60 -do- -do- 30 WI (+) E. Coli Amikacin 12m
Ileo transverse anastomosis; emergency mg%; Cotrimazole
Laparatomy with peritoneal toileting -do- -do- 15 Uneventful

placement of brains - elective
Resection of small bowel with end to Age - Hb - 8.4 gm%, RBS - -do- -do- 25 PCO3 - Pt expired
end ileostomy - emergency 215; Electro Na - 135, k-
2.8, Cl - 108; HCO3 - 25;
B/U - 97, B/l - 1.8
Cystogastrostomy elective Altd LFT Hb - 9.6 gm% -do- -do- 20 Uneventful 6m
GJ with TV elective Smoker - 10 gm Polypropelene No - 1 Continuous 15 Uneventful 7m

mass closure
Closure of perforation with Smoker and alcoholic; B/U --do- -do- 20 -do-
omentoplasty and peritoneal toileting - 87-89; S/C - 2.4; Electro
emergency Na-128, K-5.5, Cl - 90 mg/l
Closure of perforation with peritoneal PPBS - 171 mg%; B/U - 50 -do- -do- 20 Dysphagia; ENT U/L Vocal cord 9m
toileting - emergency mg %; Hb - 8.7 gm% palsy
Radical Rt hemicolectomy - elective DM-10 years; Altd LFTs -do- -do- 15 Uneventful 3m
Ca. Colon
APR - procto sigmoidectomy with Ca (Rectum) Age -do- -do- 15 -do- 11m
colostomy - elective
Laparatomy with peritoneal toileting -do- -do- 20 -do-
emergency
Rt. Hemicolectomy with resection of abdomen - 7.8; Altrd LFTs Polypropelene No - 1 Continuous 25 Uneventful 6m
stricture ilecum and end to end (CH) altrd TC- 4000; DC - mass closure
anastomasis (ICA) elective A45, L49, E5, M1
Cholecystectomy and seromuscular -do- -do- 15 -do-

closure of small bowel injuries -
emergency
Laparotomy and peritoneal - toileting - DM, Altered, Power -do- -do- 15 -do- 9m
emergency enzyme assay
Closure of perforation with peritoneal Hb - 9.8 mg%; RBS - 192 -do- -do- 25 WI (+) Klebsiella; 6m
toileting - emergency mg%; B/U - 45 mg%; S/c -
1.1 mg%
Laparotomy and release of adhesions Tobacco smoker -do- -do- 20 Uneventful 5m

with peritoneal toileting
Closure of DU perforation with RBS - 149 mg%; B/U - 223 Polypropelene No - 1 Continuous 15 Uneventful 10m
peritoneal toileting - emergency mg%; S/C - 9.7 mass closure
Juejunal segmental resection with E-E Hb-9.5 gm%; TC - 1600; -do- -do- 20 -do-
anastomosis - emergency ESR - 50 mm/hr
Closure of DU perforation with Alcoholic; Smoker; B/U - -do- -do- 15 -do- 8m

peritoneal toileting - emergency 50 mg%
Resection of small bower segment with TC - 20,500; DC - N89, -do- -do- 25 -do- 5m
E-E anastomosis - emergency L8; B/U - 60 Altrd LFT's
Reduction with Rt hemicolectomy with Hb - 9.5 gm% -do- -do- 20 -do- 6m

IT anastomosis - emergency
Reduction of adhesions under GA TC - 9200 B/U - 44 mg% -do- -do- 15 -do- 5m

emergency
Laparotomy and release of adhesions TC-12,000 Polypropelene No - 1 Mass closure 20 Uneventful 11m
Closure of perforation with peritoneal Hb- 9. 0 gm%; TC - -do- -do- 30 Death 14.1. 05 at 1.30 pm due to
toileting - emergency 24,000; Age-75 years cardiorespiratory arrest
Resection of a segment of jejunum and Hb% 9 ( gms%); RBS - -do- -do- 25 HPE - Angiolipoma, causing 9m
end to end anastomosis 185 mg% intusuception
Reduction of adhesions under GA -do- -do- 25 Death on 2.2.05 at 9.30 am due

emergency MI
Closure of perforation with peritoneal Hb - 9.8 gm%; Urea 56 mg -do- -do- 30 WI (+) E Coli; Amikacin; 5m
toileting - emergency Amikacin and Cortimazole
Closure of perforation with peritoneal -do- -do- 20 9m

toileting - emergency
Closure of perforation with peritoneal -do- -do- 15 8m
Emergency laparatomy and drainage, -do- -do- 20 Uneventful 12m

lavage and placement of drains
emergency
Closure of perforation with peritoneal LFT's increase Polypropelene No - 1 Mass closure 25 WI (+) process (8); WD (+) 6m
Closure of perforation with peritoneal -do- -do- 15 Uneventful 5m

Closure of perforation with peritoneal -do- -do- 20 Uneventful

Emergency laparatomy and drainage, -do- -do- 30 Omental biopsy, non-specific 8m

lavage and placement of drains changes
emergency
Reduction with Rt hemicolectomy with PPBS - 200 mg% -do- -do- 20 Uneventful 7m
IT anastomosis - emergency
GJ with TV elective -do- -do- 15 Uneventful 4m
Closure of perforation with peritoneal Hb-8 gm -do- -do- 35 Uneventful 5m

Laparotomy and release of adhesions -do- -do- 15 Uneventful 2m
Closure of perforation with peritoneal Polypropelene No - 1 Mass closure 15 Uneventful 3m

Closure of perforation with peritoneal Hb - 9.5 gm% -do- -do- 20 Uneventful 5m

Closure of perforation with peritoneal -do- -do- 20 Re admn: 15.8.05 3m


APR - procto sigmoidectomy with -do- -do- 15 Uneventful 3m

APR - procto sigmoidectomy with -do- -do- 20 Uneventful 2m

Laparotomy and release of adhesions Urea-66mg -do- -do- 25 Death on : 10.10.05


Complications
Uneventful
Uneventful
Pain over the Scar+
Uneventful
Suture Sinus
Formation+
Uneventful
Uneventful
Uneventful
Suture Sinus
Formation+
Uneventful
Pain over the Scar+
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Pain over the Scar+
Uneventful
Uneventful
Uneventful
Uneventful
Pain over the Scar+
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Pain over the Scar+
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
IH (+) 6 months after

surgery lower end
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
KEY TO MASTER CHART
AIO  Acute Intestinal Obstruction

Alb  Albumin
B/U  Blood Urea
BUN  Blood Urea Nitrogen
CEA  Chorio-embrionic Antigen
Cl  Chloride
DB  Direct Bilirubin
DM  Diabetes Mellitus
DOA  Date of Admission
DOD  Date of Discharge
DOS  Date of Surgery
DU  Duodenal Ulcer
DU  Duodenal Ulcer
ECHO  Echocardiography
E-EA  End-to-End Anastomosis
EF  Ejection Fraction
EGD  Esophagogastroduodenoscopy
ENT  Ear Nose Throat
F  Female
FSO  Features Suggestive of
GJ with TV  Gastrojejunostomy with Truncal vagotomy
GTT  Gamma Glutamate Transferase
HCo3  Bi-Carbonate
HS  Hospital Stay
IA Abscess  Intraabdominal Abscess
IB  Indirect Bilirubin
IH  Incisional Hernia
INR  International Normalization Ratio
146
IP NO  In-patient Number
ITA  Ileo Transverse Anastomosis
K  Potassium
LBBB  Left Bundle Branch Block
LES  Lower Esophageal Sphincter
M  Male
Na  Sodium
NNA Ch  Normocytic Normochromic Anemia Complete Hemogram
P  Pain
PCV  Packed Cell Volume
PO  Postoperative
PS  Pyloric Stenosis
PT  Prothrombin Time
RBBB  Right Bundle Branch Block
RBS  Random Blood Sugar
RIF  Right iliac fossa
S/C  Serum Creatinine
SAIO  Subacute Intestinal Obstruction
SGOT  Serum Glutamate Oxaloacetate Transferase
SGPT  Serum Glutamate Pyruvate Transferase
SJIC  Sri Jayadeva Institute of Cardiology
SMA  Superior Mesentric Artery
SS  Suture Sinus
TB  Total Bilirubin
U/L  Unilateral
USG  Ultrasonography
WD  Wound Dehiscence
WI  Wound Infection
WNL  Within Normal Limits
147

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A COMPARATIVE STUDY BETWEEN MASS CLOSURE VERSUS

CONVENTIONAL LAYERED CLOSURE OF ABDOMINAL

WOUNDS WITH MIDLINE AND PARAMEDIAN INCISIONS

Dr. M. KESHAVA MURTHY

A dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka

Bangalore, in partial fulfillment of the requirements for the degree of the

Under the guidance of

DEPARTMENT OF GENERAL SURGERY

BANGALORE MEDICAL COLLEGE

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “A COMPARATIVE STUDY

BETWEEN MASS CLOSURE VERSUS CONVENTIONAL LAYERED

CLOSURE OF ABDOMINAL WOUNDS WITH MIDLINE AND PARAMEDIAN

guidance of Dr. S. I. S. KHADRI M. S., Professor of Surgery, Bangalore Medical

Date: Signature of the Candidate

Place: Bangalore Name: Dr. M. KESHAVA MURTHY

This is to certify that this dissertation titled “A COMPARATIVE STUDY

BETWEEN MASS CLOSURE VERSUS CONVENTIONAL LAYERED

CLOSURE OF ABDOMINAL WOUNDS WITH MIDLINE AND PARAMEDIAN

INCISIONS” is a bonafide research work done by Dr. M. KESHAVA MURTHY in

partial fulfillment of the requirement for the degree of M. S. in General Surgery,

Bangalore Medical College.

Date: Signature of the Guide

This is to certify that this dissertation entitled “A COMPARATIVE STUDY

BETWEEN MASS CLOSURE VERSUS CONVENTIONAL LAYERED

CLOSURE OF ABDOMINAL WOUNDS WITH MIDLINE AND PARAMEDIAN

INCISIONS” is a bonafide research work done by Dr. M. KESHAVA MURTHY,

Postgraduate Student in General Surgery, under the guidance of Dr. S. I. S. KHADRI,

Professor, Department of General Surgery, Bangalore Medical College, Bangalore.

Dr. N. SRINIVASAN M. S., F. R. C. S. Dr. T. RAJESHWARI MS

DECLARATION BY THE CANDIDATE

electronic format for the academic/ research purpose.

Date: Signature of the Candidate

Place: Name: Dr. M. KESHAVA MURTHY

 Rajiv Gandhi University of Health Sciences, Karnataka

It gives me immense pleasure to express my heart-filled thanks to my Guide,

Dr. S. I. S. Khadri M. S., Professor, Department of General Surgery, Bangalore Medical

encouragement during my course of study.

I am extremely thankful to Dr. N. Srinivasan M. S., F. R. C. S., Professor and Head,

valuable advice and guidance in completing this dissertation.

I am extremely thankful to my Professors, Dr. Rajeeva Shetty, Dr. Nagraj,

support and help.

I thank all the postgraduates who have helped me to complete my dissertation.

Date: Signature of the Candidate

Place: Name: Dr. M. KESHAVAMURTHY

A/G ratio  Albumin/Globulin ratio

ACTH  Adenocortico Trophic Hormone

BMI  Body Mass Index

CDLC  Continuous Double Loop Closure

DNA  Deoxyribose Nucleic Acid

EDGF  Epidermal Cell Derived Growth Factor

EGF  Growth Factor

ESR  Erythrocyte Sedimentation Rate

FBS  Fasting Blood Sugar

GOO  Gastric Outlet Obstruction

Group I  Single Layered Closure

Group II  Conventional Layered Closure

HbSAg  Hepatitis-B S Antigens

HIV  Human Immuno Compromised Virus

IGF-I  Insulin like Growth Factor – I

LFTs  Liver Function Tests

NSAIDs  Non-steroidal anti -inflammatory Drugs

P  Pain over the Scar