Big Picture

Training:
PDS PLUS Sutures

ABDOMINAL WALL
ANATOMY & FASCIA
CLOSURE
Dr. Vikram Jaisinghani

Agenda
Skin: anatomy
Wound healing
Factors affecting wound healing

Complications of Wound healing

Anterior Abdominal Wall (AAW) Anatomy
AAW Complications & factors affecting healing
8 Strategies to reduce complications

 Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
Anterior Abdominal Wall (AAW) Anatomy

AAW Complications & factors affecting healing

8 Strategies to reduce complications

Skin

Skin
Epidermis: provides waterproofing and serves as a barrier to infection,
no blood vessels
Dermis: location for the appendages of skin
Connective tissue
Basement membrane (anchors dermis)
Nerve endings (touch/heat)
Sweat glands
Sebaceous glands
Apocrine glands
Hair follicles
Lymphatic vessels
Blood vessels

Basic Anatomy of Skin and Fascia

Epidermis

Dermis
Subcutaneous
tissue (fat)

Fascia/Muscle

Skin and Fascia

1
2

1 = skin and subcutaneous tissue; 2 = fascia

 Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
Anterior Abdominal Wall (AAW) Anatomy

AAW Complications & factors affecting healing

8 Strategies to reduce complications

Wound healing
Classification of wounds
Types of wound healing

Phases of wound healing

Factors that influence wound healing

10

Classification of Acute Skin Wounds

Abrasions
Bites
Burns

Traumatic

Lacerations

Punctures
Incisions

Strecker-McGraw et al. Emerg Med Clin North Am. 2007;25:1-22.

Surgical

Traumatic Wounds and Lacerations

Traumatic wounds are common and bear extensive

medical costs
US >26 million/year = $35 billion1,2
EU >42 million/year = 15 billion3

Physical exam should be careful and meticulous4

Time and mechanism of injury
Potential for infection
Hemostasis

Foreign bodies

Tendon, vascular, and joint injuries

Neurovascular exam
Patient history

Timeframe for closure: maximum of 24 hours from

the time of injury5

1.
2.
3.
4.

National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary.
CDC NEISS All Injury Program 2005 Results.
EU Injury Database Report 2009.
Lammers. Principles of wound management. In: Roberts and Hedges. Clinical Procedures in Emergency Medicine. 5th ed.
Saunders Press; 2010.
5. Pfaff and Moore. Emerg Med Clin North Am. 2007;25:189.

Classification of wounds
Bacterial presence:
Contamination: Bacteria are present, but not proliferating
Colonization: Bacteria proliferating without host reaction
Infected tissue: Deposition and proliferation of microorganisms in the organism, with consequent host reaction

13

Defining Wound Healing

A healed wound is one where1
Connective tissues have been repaired and
Wound has been completely epithelialized by regeneration

that has returned to its normal anatomic structure and

function without the need for continued drainage or
dressing
Some wounds fail to heal properly - chronic, non-

healing wounds- need continued management2

Aberrations in certain phases of healing -result in
excessive healing (hypertrophic scars, keloids)2
1. Enoch SE and Leaper DJ. Surgery. 2008;26:31-37.
2. Ethridge RT, Leong M and Phillips LG. Wound Healing. In: Townsend CM, Beauchamp RD, Evers BM and Mattox KL, eds.
Sabiston Textbook of Surgery. 18th ed. Saunders, 2007:191-216.

Types of Wound healing

Wounds or incisions can heal in different ways:
Primary healing
- direct wound healing without complications (wound is closed
with sutures)
- Secondary healing
- indirect wound healing with complications; wound edges are
not approached with sutures
- Spaces between the wound edges are filled by granulation
Tissue
Tertiary healing
- wound is filled by granulation tissue & is infection free
(wound edges are approximated with sutures)

Three Major Types of Wound Healing

Primary healing/healing by primary

intention
Wound is closed within 12-24 hours
Examples: clean surgical incision,

clean laceration
Result: optimal cosmetic outcome

Clean incision

Delayed primary healing

Delineated wound that is closed after a few days having been left open to prevent infection
Examples: bites, abdominal wounds after peritoneal soiling
May result in scarring
Secondary healing (healing by secondary intention)
Wound with extensive loss of soft tissue
Examples: trauma, severe burns, open abdomen
May result in scarring

Ethridge et al. Wound healing. In: Townsend et al, eds. Sabiston Textbook of Surgery. 18th ed. Saunders; 2007.

Stages of Primary Wound healing

Exudative /Inflammatory phase Proliferative phase

0-5 days
suture material is the
sole factor in holding
together the wound
Suture high tensile
strength

5- 14 Days
stabilization of
the wound
closure is
gradually taken
over by
collagen
Suture- highest
tensile strength

Remodeling phase

7-14 days to a
year
suture material
becomes
irrelevant
Foreign
material- side
effects

Phases of Primary wound healing

1. Exudative/Inflammatory phase: 0 - 5 days
Suture Material is responsible for the adaptation of the wound

hours

Phases of Primary wound healing

2. Proliferative phase: 5-14 days
Collagen grows in and increases the stability of the wound

4-6 days

Phases of Primary wound healing

3. Reparative phase: 21 days 1 year
Any foreign material can cause side effects

weeks

III Proliferative phase

II Inflammatory phase
IV Remodelling and scar formation

Alterations in one or more of these

phases could result in chronic wounds
Abnormalities in these phases result
in hypertrophic scars and keloids
Macrophages
Cytokines and growth factors
Lymphocytes
Phagocytosis

Neutrophils

0.1

0.3

ECM formation
Angiogenesis and
granulation tissue
formation
Re-epithelialization
3

10

Further synthesis
of ECM
MMP and TIMP activity

30

100

Days after wounding (log scale)

ECM = extracellular matrix; MMP = metalloproteinases; TIMP = tissue inhibitors of metalloproteinases.

Enoch S and Leaper DJ. Surgery. 2008;26:31-37.

V Scar maturation

Coagulation
Platelet activation
I Hemostasis

Maximum response

The Phases of Wound Healing

300

Stages of Secondary Wound healing

Exudative (inflammatory) phase

Days

Proliferative phase

Weeks

Remodeling Phase

Months

Tenets of Halsted Continue to Guide Surgeons

Gentle handling of tissue
Aseptic technique
Sharp anatomic dissection of tissue
Careful hemostasis, using fine, nonirritating suture

material in minimal amounts

Obliteration of dead space in the wound
Avoidance of tension

Foy HM, Evans SRT. Teaching technical skills-Errors in the process. In: Grand SRT. Surgical Pitfalls: Prevention and
Management. Saunders; 2009:11-22.

 Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
Anterior Abdominal Wall (AAW) Anatomy

AAW Complications & factors affecting healing

8 Strategies to reduce complications

Factors Influencing Wound Healing

Operative/
Surgeon
Factors

Wound
Healing
Tissue
Factors

Patient
Factors

Classification of Factors That May Impede

Wound Healing
Systemic

Local

Advanced age

Presence of foreign body and

Metabolic factors

foreign body reactions

Increased skin tension
Blood supply
Continued presence of microorganisms
Infection

Immunosuppression/

persisting disease
Deficiency syndromes
Shock of any cause
Infection

Leaper. Basic surgical skills and anastomoses. In: Bailey and Loves Short Practice of Surgery. 25th ed.
Edward Arnold Ltd; 2008.

Factors Leading to Risk of Compromised Healing

Advanced age (>70 years old)

Obesity
Smoking
Poor glucose control or hyperglycemia
Diabetes (type 1/2)
Nutritional or immunologic impairment
Low serum albumin concentration

A patient with even ONE of these risk factors is at greater risk

of developing a surgical site infection (SSI)
1.Mangram AJ et al. Am J Infect Control Hosp Epidemiol. 1999;27:97-134.
2.NICE Clinical Guideline. October 2008.
3.World Health Organization. WHO Guidelines for Safe Surgery 2009. 2009.

Some Wounds Are More Likely to be Infected

Wounds are generally classified into 4 categories1:
Class 1 = Clean
Class 2 = Clean contaminated
Class 3 = Contaminated
Class 4 = Dirty infected
Contaminated or dirty/infected wound classifications

are independently associated with increased risk of

SSI1

1.Mangram et al. Infect Control Hosp Epidemiol. 1999;20:247-277.

Classification of wounds based on infection

Class

Definition

I Sterile
(Clean)

No trauma effect
No inflammation
No breach of sterility
Tracheobronchial system, GI tract and urogenital
tract intact

II Mildly
contaminated
(Cleancontaminated)

Opening of the GI tract

Appendectomy
Opening of the oropharynx
Opening of the vagina
Opening of the urinary tract collecting system for
sterile urine
Opening of the bile system with sterile bile
minimal breach of sterility
29

Classification of wounds based on infection

Class

Definition

III Strongly
Contaminated
(Contaminated)

Opening of the lower GI tract

Traumatic wounds
Opening of the collecting system with infected urine
Opening of bile ducts with infected bile
Breach of sterility

IV Infected
(Dirty)

Bacterial infection in OP area

Draining of abscesses
Traumatic wounds with necrosis, foreign bodies and
exit of faeces
Old wounds
Bite wounds or similar
30

Suture Contamination Can Increase Risk of Infection

Biofilms: every suture acts as a medical implant,

increasing the risk of infection via bacterial colonization1

A

1. Mangram et al. Infect Control Hosp Epidemiol. 1999;20:247-277.

2. Suzuki T et al. J Clin Microbiol. 2007;45:3833-3836.

SSI Video

Local Tissue Trauma Can Impede Healing

Tissue trauma can result from:
Devices used for closure
Handling of tissue

Proper Suturing Technique: Critical Components

of Wound Healing
Wound edges should be left slightly gaping to allow

swelling
Edges should be everted
The knot should be placed to one side of the wound
Knots must be secure, with the ends long enough to
grasp if the suture is to be removed
Use no touch technique whenever possible
Use appropriate needle holders

Leaper D. Basic surgical skills and anastomoses. In: Bailey and Loves Short Practice of Surgery. 25th ed.
Edward Arnold Ltd; 2008.

Tissue Specific Healing Time Guides the Choice of

Tissue Repair Material

5-7 days
5-7 days
7-14 days
7-14 days
14-28 days
8-12 weeks

Weeks

*Minimum

healing times shown here are for healthy individuals without medical complications.

 Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
Anterior Abdominal Wall (AAW) Anatomy

AAW Complications & factors affecting healing

8 Strategies to reduce complications

Examples of Wound Healing Complications

Scarring

Images courtesy of David Leaper, MD.

Dehiscence

Infection

Wound Healing Complications: Scar Formation

Typical scar characteristics
Flat surface
Narrow
Matches skin color

Complicated scars
Elevated

Depressed

Hypertrophic

Harahap (ed). Surgical Techniques for Cutaneous Scar Revision. Marcel Dekker; 2000:81-106.
Tot. Wound Repair Regen. 2002;10:93-97.

Keloids

Wound Healing Complications: Dehiscence

Mechanism may be an underlying

wound healing problem or surgical

technique

Surgical site infection (SSI) is a

major risk factor for dehiscence

Images courtesy of David Leaper, MD

Lammers. Principles of Wound Management. In Roberts Clinical Procedures in Emergency Medicine. Saunders Press. 2010.

Wound Healing Summary

Healing of acute wounds: a complex, dynamic series of

events
Optimal wound healing by primary intention; not possible

in all cases
Many factors delay or impede wound healing: long-term

complications-steps can be taken to ensure best outcomes

SSI prevention is a critical factor in achieving optimal

acute and long-term wound healing

 Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
Anterior Abdominal Wall (AAW) Anatomy

AAW Complications & factors affecting healing

8 Strategies to reduce complications

Anterior Abdominal Wall

&
Fascia Anatomy

Basic Anatomy of Skin and Fascia

Epidermis

Dermis
Subcutaneous
tissue (fat)

Fascia/Muscle

Skin and Fascia

1
2

1 = skin and subcutaneous tissue; 2 = fascia

Anterior Abdominal Wall Anatomy

General Characteristics:
Three large flat sheets of muscle connecting rib
cage to hip bone (pelvis).
Muscular posteriorly and laterally.
Aponeurotic anteriorly and medially.
Muscle layers:
o External oblique.
o Internal oblique.
o Transversus abdominus.
o Rectus abdominus.

Anterior Abdominal Wall

Abdominal Wall: Muscles (I)

Consists of Three broad thin sheets that are

aponeurotic in front
From exterior to interior they are:

External oblique
Internal oblique
Transverse abdominus

A wide vertical muscle lies on either side of the

midline anteriorly:
- Rectus abdominis muscle

Abdominal Wall: Muscles (II)

As the aponeurosis of three sheets pass forward, they

enclose the rectus abdominis to form the rectus

sheath
The cremaster muscle which is derived from the lower

fibers of internal oblique, passes inferiorly as a

covering of the spermatic cord and enters scrotum

Abdominal Wall: Muscles (III)

External Oblique Muscle:

Is a broad, thin, muscular sheet

Origin: Lower 8 ribs
Insertion: Xiphoid process, linea alba, pubic tubercle, iliac crest
Action: Supports abdominal contents, assist in forced expiration,
micturition (passing urine), defecation, parturition, vomiting

Internal Oblique Muscle:

Origin: Lumbar fascia, iliac crest, lateral two-thirds of inguinal

ligament
Insertion: Lower three ribs and costal cartilages, xiphoid process,
linea alba, symphysis pubis
Action: Supports abdominal contents, assist in forced expiration,
micturition, defecation, parturition, vomiting

External Oblique Muscle

Xiphoid process
Costal margin (lower
margin of the rib cage)

Anterior Superior
Iliac Spine
Pubic symphysis &
tubercle
(middle part of the
pelvic or hip bone)

Abdominal Wall: Muscles (IV)

Transversus Abdominus muscle:

Origin: Lower six costal cartilages, lumbar fascia, iliac crest,

lateral third of inguinal ligament
Insertion: Xiphoid process, linea alba, symphysis pubis
Action: Compresses abdominal contents

Rectus Abdominus muscle:

Origin: Symphysis pubis and pubic crest

Insertion: 5th, 6th and 7th costal cartilages and xiphoid process
Action: Compresses abdominal contents, flexes vertebral
column, accessory muscle of expiration

Internal Obliques & Rectus Abdominus

Xiphoid process

Costal margin
(lower margin of
the rib cage)

Pubic symphysis &

tubercle
(middle part of the
pelvic or hip bone)

Anterior Abdominal Wall: Cross Section

54

Tissue layers of the abdominal wall

1.
2.
3.
4.
5.

Skin
Subcutaneous
Fascia
Muscles
Peritoneum

:
:
:
:
:

Epidermis
Fat layer underneath skin
Connective tissue layer covering
muscle
Fibrous tissue strand
Serous membrane that forms the lining of abdominal cavity

Rectus Sheath
Is a long fibrous sheath

Encloses the rectus abdominis

Formed mainly by aponeurosis of three lateral abdominal muscles
Between the costal margin and the level of the anterosuperior iliac

spine, the aponeurosis of the internal oblique splits to enclose the

rectus muscle
The external oblique aponeurosis is directed in front of the muscle
Transversus aponeurosis is directed behind the muscle
The posterior wall of the rectus sheath is not attached to the rectus
abdominis muscle
The anterior wall is firmly attached to it by the muscles tendinous
intersections

Linea Alba

The rectus sheath is separated from its fellow on

the opposite side by a fibrous band called the linea
alba

Extends from the xiphoid process to the symphysis

pubis

Anterior Abdominal Wall: Cross Section

58

FASCIA (I): Anatomy

Fascia means band in Latin
Fascia is connective tissue (see

next slide)
Fascia can be found in every

part of the body.

It is located between

subcutaneous layer of the skin

and the muscles
Non-vascularized - so it heals

very slowly

FASCIA (II): Layers

Fascia is divided into 3 key layers.

1. Superficial fascia
is attached to the bottom part of the dermis (the
recticular dermis) and contains variable amounts
of fat. It can stretch in any direction and adjusts
quickly to tension, almost like a rubber band.

2. Deep fascia
is thin and denser than the superficial fascia. It is
also smooth and slippery, which allows the
surrounding body parts to glide and slide over
each other. This is the type of fascia that is found
around muscles, bones, nerves, and vessels.

3. Visceral fascia
is the thin, tough membrane that surrounds the
viscera or internal organs and keeps them in place.

FASCIA (III): Functions

Fascia seperates tissue layers

and provides a sliding/gliding

environment for surfaces that
need to move or slide along
each other.
Fascia keeps things in place.

For example: keeping

suspending organs in correct
orientation
Fascia provides support for

blood vessels and nerves

through and between muscles

FASCIA (IV): Abdominal Wall

Strongest tissue in the abdominal

wall
Anterior and posterior fascia layer.
When discussing midline incisions,
fascia usually refers to the anterior
rectus fascia, the fascia above the
rectus muscles. This fascia holds the
abdominen together and is the most
important layer of closure.
The fascia can extend beyond the

muscles and bind to other fascia.

An extension of the fascia is called an
aponeurosis.

Midline Abdominal Wall Incision

Midline incisions are made in the
midline of the rectus abdominis
muscle. The rectus abdominis is
actually 2 muscles united by the
aponeurosis, which is called the linea
alba or white line.
Advantages of midline incisions:
1. Safe, as no major vessels nor
nerves in the area
2. Faster than transverse incisions
3. Very good access to abdomen

FASCIA: Most Important layer in Closure

The fascia is considered the most important layer in

closure of an abdominal surgical wound because it

must bear the maximum stress on the incision.
Because of the slow healing time of fascia,

immediate and extended wound support is a

primary concern.

stress

stress

suture in fascia holding

maximum stress on the
incision

Anterior Abdominal Wall Wound

complications
&
Factors affecting healing

Goals of fascia closure

Optimal fascial closure prevent Early and Late Cx
EARLY Cx: Most concern for all Surgeons

- Infection
- Dehiscence
LATE Cx:

- Incisional Hernia
- Suture Sinus
- Wound Pain

Most common complications

Surgical Site Infection
Wound dehiscence
Incisional hernias

Infection

1. Seiler Ann Surg 2009;249:576-82

2. Bloemen Br J Surg 2011

123

19 %
4 %
16-23 %

Dehiscence

Incisional Hernia

67

Recent publications show this might be achievable

today

Surgical Site Infection

Wound dehiscence
Incisional hernias

19 %

<5 %

4 %

< 0,5 %

16-23 %

< 10 %

Reference:
Millbourn Arch Surg 2009, RCT 737 patients

1. Seiler Ann Surg 2009;249:576-82

2. Bloemen Br J Surg 2011
3. Millbourn Arch Surg 2009, RCT 737 patients

68

Strong correlation between complications

Short
term

SSI is an independent risk

factor for both dehiscence and
incisional hernia (1)

SSI

Incisional
hernia
Long
term

44% of dehiscenced patient

suffer from subsequent
incisional hernia (2)

Wound
dehiscence

48% - 88% of patients with

incisional hernia had previously
had an SSI (3)

1. Israelsson Eur J Surg 1996, van Ramshorst World J Surg 2010

2. vant Riet Am Surg 2004
3. Bucknall TE Br Med J (Clin Res Ed.) 1982, Fischer JD, Turner FW. Can J Surg 1974

Surgical Site infection (I)

Rate: as high as 10-19% reported

Can extend hosp. stay by 2-11 days

Pathogens : E Coli, Staph. A, Enterococcus
Route of contamination: GI flora, skin flora

Wound infection: independent risk factor for both dehiscence and

incisional hernia
Surgical technique :
- normal technique 30-50% of infected patients end up with IH
- small bites- no correlation
- More tissue necrosis with large bites

SSI (II)
Incidence up to 19% in midline closure, typically > 10% (1)

Risk factors influenced by wound status

Wound status

Clean

847

41%

Clean contaminated

598

29%

Contaminated

470

23%

Dirty

172

8%

Total

2.087

100%

Example of wound status in 2087 laparotomies in German general surgery department (2)

1. Seiler Ann Surg 2009, Justinger Surg 2009, Millbourn Arch Surg 2009
2. Justinger 2009

High impact on patients life and health

economics
High cost of prolonged hospitalisation,
medication & additional surgery. 600-8.100
in case of SSI after abdominal surgery1.

Surgical Site Infection A European Perspective of Incidence and Economic Burden David J Leaper, Harry van Goor,
Jacqueline Reilly, Nicola Petrosillo, Heinrich K Geiss, Antonio J Torres, Anne Berger. Int Wound J 2004;1:247273

Dehiscence (I)
Rate:0.4% - 3.5 %
Longer stay and mortality
Mean: post-op day 9 (Douglas: 0-5 days no strength)

Risk factors (Niggebrugge 1995, van Ramshorst 2010)

Systemic factors: Old age, male gender, malignancy etc.
Local factors:
Layered closure (p<0.001)
post-operative wound infection (p<0.001)
pulmonary complications (p<0.001)
Emergency surgery

Dehiscence (II)

Dehiscence (III)
Local/mechanical factors (more important than

systemic factors )
o wound infections
o abdominal distension
o pulmonary complications
(Poole GV Jr. Mechanical factors in abdominal wound closure: the prevention of fascial
dehiscence. Surgery 1985 Jun;97(6):631-40.)

44% of patients develop incisional hernia after

dehiscence
(vant RM et al. Incisional hernia after repair of wound dehiscence: incidence and risk factors. Am
Surg 2004 Apr;70(4):281-6)

Adequate tissue breaking strength is necessary to

provide support for sutures!

Dehiscence (IV)
IMPLICATIONS:
Prolonged hospital stays
Burst abdomen, exposure of abdominal contents - requires

immediate treatment
Incisional hernia
Re-operations
Increased risk of morbidity and mortality

Dehiscence: Reported causes(1) (V)

Tissue related:
Suture cutting
through the tissue

Suture related:
Broken suture
Slipping knots

Tissue necrosis
SSI

NOTE
Can we reduce the risk of cut-through by modifying the suture technique? (2)

1. Poole GV Jr,1985 Jun; 97(6):631-40.) Van Ramshorst et al. Abdominal wound dehiscence in adults. World J
Surg 2010 Jan;34(1):20-7.
2. Poole GV Jr, Surgery 1985 Jun; 97(6):631-40.)

Dehiscence : Role of Sutures (VI)

Fascia depends on wound closure device

for support during healing!

Patient Movement (bending, jumping,
lifting) increased intra-abd. Pressure >
strain on wound and suture
Suture cutting through fascia ( patient
factors)
Suture comes UNTIED
Suture Choice: Immediate & extended
support

wound edges together

+
Prevent Infection

Incisional hernias (I)

Most common long-time complication after midline

incision
Rate 9% - 20%
(Seiler CM et al. Interrupted or continuous slowly absorbable sutures for closure of primary elective midline
abdominal incisions. Ann Surg 2009 Apr;249(4):576-582.)

Mechanism
oWound edges separate > 12 mm after 4 weeks

oIncisional hernia develops within weeks after

surgery
Playforth MJ et al. The prediction of incisional hernias by radio-opaque markers. Ann R Coll Surg Engl 1986;68:824. PMID: 3954314
Burger JW et al. Incisional hernia: early complication of abdominal surgery. World J Surg. 2005 Dec;29(12):160813. PMID: 16311846

Incisional hernias (II): Clinical Studies

Article: The prediction of incisional hernias by radio-opaque markers
Journal: Ann R Coll Surg Engl. 1986 Mar;68(2):82-4
Authors: Playforth MJ, Sauven PD, Evans M, Pollock AV
Abstract: On the hypothesis that incisional defects occur soon after operation but the resulting
hernia may not be diagnosed until months or years later, we attached three to five pairs of stainless
steel haemostatic clips to the cut edges of the anterior aponeurosis during the closure of 59 major
laparotomy incisions and X-rayed the abdomen one month later. Three patients were withdrawn
and the remaining 56 were examined with special reference to incisional herniation at their sixmonth follow-up visit. The senior author subsequently arranged a series of extra clinics for surviving
patients up to three years later (median 30 months after operation). He had no knowledge of the
results of the abdominal X-rays when assessing whether or not the patient had a hernia. Six patients
were found to have incisional hernias, and correlation with the measurements on the one-month Xrays showed separation of pairs of clips ranging from 12-70 mm (median 40). Three of the six hernias
were discovered within seven months, the remaining three at 13, 28 and 29 months. In contrast
none of the 50 patients without incisional hernias had more than 9 mm of separation of any pair of
clips on the one-month X-ray. We conclude that the origins of incisional hernias can be traced back
to events during the first month after operation and that they are not the result of later weakening
of a well-healed laparotomy wound.

Incisional hernias (III): Clinical Studies

Article: Incisional hernia: early complication of abdominal surgery
Journal: World J Surg. 2005 Dec;29(12):1608-13
Authors: Burger JW, Lange JF, Halm JA, Kleinrensink GJ, Jeekel H
Abstract: It has been suggested that early development of the incisional hernia is caused by
perioperative factors, such as surgical technique and wound infection. Late development may
implicate other factors, such as connective tissue disorders. Our objective was to establish whether
incisional hernia develops early after abdominal surgery (i.e., during the first postoperative month).
Patients who underwent a midline laparotomy between 1995 and 2001 and had had a computed
tomography (CT) scan of the abdomen during the first postoperative month were identified
retrospectively. The distance between the two rectus abdominis muscles was measured on these CT
scans, after which several parameters were calculated to predict incisional hernia development.
Hernia development was established clinically through chart review or, if the chart review was
inconclusive, by an outpatient clinic visit. The average and maximum distances between the left and
right rectus abdominis muscles were significantly larger in patients with subsequent incisional hernia
development than in those without an incisional hernia (P < 0.0001). Altogether, 92% (23/25) of
incisional hernia patients had a maximum distance of more than 25 mm compared to only 18%
(5/28) of patients without an incisional hernia (P < 0.0001). Incisional hernia occurrence can thus be
predicted by measuring the distance between the rectus abdominis muscles on a postoperative CT
scan. Although an incisional hernia develops within weeks of surgery, its clinical manifestation may
take years. Our results indicate perioperative factors as the main cause of incisional hernias.
Therefore, incisional hernia prevention should focus on perioperative factors.

Incisional hernia (IV): Most common long-term

complication
IH

Worrying facts:

IH can start developing after 4

weeks after closing!

Incidence 9 to 25%, even higher for high risk patients

Risk of obstruction (10%), strangulation (2%)

Never resolve spontaneously
Recurrence 24% 58%

Diener Ann Surg 2010 Bloemen Br J Surg 2011, Vant Riet M, Jeekel J. Br J Surg 2002, 89, 1350-1356
Dubay DA, Franz MG. Surg Clin N Am 83 (2003) 463-481

Incisional hernia (V): Factors

Patient factors
are important.
But technique
above all!

Surgical Technique ( x 3 )
Wound Infection ( x 2 )

Overweight

Age

Israelsson Eur J Surg 1997;163:175-80 Murray et al. Am J Surg 2011

Abdominal Wall Complications & Risk factors

summary
Complications

SSI

Factors contributing to outcomes:

A.

Patient factors
Chronic disease, age, overweight etc

B.

Tissue factors
Tissue cutting through, necrosis

C.

Surgeon factors
Broken suture, loose knot

Patient
factors

Tissue
factors

Surgeon
factors

Wound
dehiscence

Incisional
hernia

Factors contributing to outcomes

Patient
factors

Patient factors influence wound healing

process
Age

Gender
Malnutrition
Systemic Infection
Immunosuppression / Corticosteroids
Underlying disease

Co-morbidities, e.g. diabetes

Hypotension
Overweight
Lifestyle, e.g. smoking
Justinger Surgery 2009

Factors contributing to outcomes

Tissue
factors
Tissue
factors

Healing of the abdominal wall FASCIA

Aponeurosis/Fascia: Function is purely mechanical-

high proportion of fibres with comparatively little

cellularity
Density of blood vessels: most poorly vascularized

tissues
Aponeurosis wound repair process: requires

considerably more
Rath AM, Chevrel JP. The healing of laparotomies: review of the literature. Hernia 1998;2:145-149

Healing of the abdominal wall FASCIA

In an investigation of the healing of lumbodorsal aponeurotic

incisions in rabbits, Douglas5 noted that the strength of any of the

wounds could not be detected until the sixth day after wounding.
All wounds showed measurable strength by the eighth day, and
thereafter, a rapid increase until about the end of the second
month, when the curve of healing began to flatten out.
Subsequently, a slow increase in strength was detectable, which
continued throughout the duration of the study (one year). At the
end of two weeks, the wound approached 20% of that of
unwounded tissue; at the end of one month, 50%; at two months,
60% to 80%; and one-year values, up to 90%

(Douglas DM. The healing of aponeurotic incisions. Br J Surg 1952; 40: 79-84.)

Fascial healing is slow and unpredictable

At 14-28 days, the fascia is

self-supportive but still weak

Even at 2 months, it still has

less than half its original
strength

Rath AM, Chevrel JP. The healing of laparotomies: review of the literature. Part 1. Physiologic and pathologic
aspects. Hernia. 1998;2:145149.

Fascia Healing: Initial type III collagen is weaker than

the definite scar type I
Extensive inflammation due to i.e. infection leads to
increased break-down of mature collagen and lower
tensile strength of the wound

Tensile Strength

Type I

Type III

Scar formation regenerative phase

Initial phase of wound healing

Type III (weak) collagen (80%)
Low tissue tensile strength

Definite scar
Type I (strong) collagen (80%)
High tissue tensile strength

J.J. Hoer etl.al Hernia (2002) 6: 9398. Dubay and Franz. Surg Clin N Am 83 (2003) 463481. Hawley PR et al. The
aetiology of colonic anastomosis leaks. Proc R Soc Med. 1970; 63(Suppl 1): 2830

Load

Initial wound is totally dependent on suture for

strength (I)

Suture strength
needed

Build up of type 1 collagen

Dubay and Franz. Surg Clin N Am 83 (2003) 463481

Time

Initial wound is totally dependent on suture for

strength (II)
Load

Suture strength
needed

Build up of type 1 collagen

Dubay and Franz. Surg Clin N Am 83 (2003) 463481

Time

The wound is at its weakest at post-op day 3

Total collagen

Synthesis
Lysis

Greenfields Surgery, Scientific Principles&Practice, 2001: Chapter 3; Wound Healing: LIPPINCOTT

WILLIAMS&WILKINS

Factors contributing to outcomes

Surgeon
factors

Factors under surgeons influence

Antibiotics

1.

Continuous vs. interrupted

Wound preparation

2.

Knotting technique

Incision location: midline vs.

3.

Transverse
Suture technique Postop
management: Drainage &
compression

4.

5.

Suture length / wound length

ratio
Bite size
Mass closure vs.
Aponeurosis only

6.

Tension

7.

Suture material

8.

Anti-SSI measures

9
6

Midline v/s other incisions

Advantages
Easy
no major vessels/nerves in the
area
Faster
Excellent access to abdomen
Disadvantages
More pain than transverse or
paramedian incisions
Higher rate of incisional hernia

Burger JWA et al. SJS 2002

8 Strategies
to
reduce complications

No consensus* on technique
12 centers to report closure tactics for primary,

elective laparotomies(1)
Elective
primary
laparotomies

Continuous
suture 65%

Midline
incision 54%

Transverse
incisions 35%

Interrupted
19%

Combination
15%

* >75% of surgeons acting similarly

1. Rahbari et al BMC Surgery 2009

Other
incisions 11%

No consensus* on material
12 centers to report closure tactics for primary, elective
laparotomies(1)

Suture
material

Nonabsorbable 5%

Medium
term abs
39%

Suture
type

Slowly
absorbable
55%

Monofilament

60%

Braided suture
40%

* >75% of surgeons acting similarly 1. Rahbari et al BMC Surgery 2009

Suture technique
Continuous or interrupted

Interrupted vs. Continuous technique

Continuous is Easy, faster (half time)
& less suture material
Continuous is faster
Accomodates wound lengthening

due to distension
Bursting strength of wound signif.
higher
Minimizes number of knotsequivalent or lower incidence of
incisional hernia
Disadv (theorotical): Wound security
depends on singls strand of suture
and limited number of knots

Continuous suturing technique

A continuous suture provides:
More collagen type1
Higher wound strength
A significantly lower incisional hernia rate (p=0.001)

Markus K. Diener et al. Elective Midline Laparotomy Closure,

Annals of Surgery (2010) vol251, nr 5

Continuous suturing technique

Markus K. Diener et al. Elective Midline Laparotomy Closure,

Annals of Surgery (2010) vol251, nr 5

Continuous suture: Greater tensile strength

Her et al. Langenbecks Arch Surg (2001) 386:218223

Potential problem: full dehiscence

Continuous suture increases the risk of single point

of failure
This can lead to dehiscence (1)

1. Gupta Asian J Surg 2008

Knotting technique
Use self-locking knot

Good knotting technique

SELF LOCKING KNOT
High knot security
High knot efficiency
Minimal volume

Self-locking knot
Does not slip

Minimal effect on suture strength

Small in volume

Israelsson Eur J Surg 1994;160:323-7

1
0

Knot efficiency (1)

Knot tensile strength : Straight tensile strength (USP 1 polydioxanone)

1. Israelsson Eur J Surg 1994

Tensile strength

Straight suture

100%

Conventional knot

58%

Self-locking knot

94%

Suture length / Wound length ratio

SL:WL ratio 4

What is the suture length to wound length ratio?

Jenkins Br J Surg 1976

SL:WL 4 reduces the rate of incisional hernia (1)

SL:WL ratio

Incisional Hernia rate (%)

< 4.0

21%

4.0

10%

N: 808

1. Israelsson Eur J Surg 1996;162:605-9

SL:WL 4 greater tensile strength

and increases the quality and
amount of collagen

Her et al. Langenbecks Arch Surg (2001) 386:218223

J.J. Her K. Junge A. Schachtrupp U. Klinge V. Schumpelick Hernia (2002) 6: 9398
Cengiz Eur J Surg 2000;166:647-9

SL:WL 4 compensates for wound extension

Abdominal distension may lengthen the wound up to 30%!

Jenkins TPN Br J Surg 1976

SL:WL 4 compensate for wound extension

SL:WL < 4

SL:WL > 4

SL:WL<4 may cause necrosis

SL:WL < 4

SL:WL > 4

Bite size
5-8 mm from wound edges

SL:WL>4 should be accomplished with small bites

SL:WL 4
Small bites
5-8 mm preferable

Higher wound
strength(1),
lower
complication
rate(2)

1) Cengiz Arch Surg 2001;136:272-5

Harlaar JJ et al. Small stitches with small suture distances increase laparotomy closure strength. Am J Surg 2009
Sep;198(3):392-5
2) Millbourn Arch Surg 2009

Smaller bites: lower complication rate

Correct placement approximately 5-8 mm

from wound edges (1)

Millbourn Arch Surg 2009

Closure technique
Mass closure or aponeurosis only?

Mass closure v/s layered closure

Mass closure:
- Incorporate all layers of abd. Wall (except skin) as 1
structure
- Statistically significant hernia & dehiscence
Layered:
- Peritoneum, musculo-aponeurotic layer, skin
- incidence adhesions, surgery time, compromises
adequacy of subsequent layer closure

Bucknall (1982) Prospective study, 1129 abd. Surgeries:

significantly higher dehiscence in layered (3.81%) v/s
mass closure (0.76%)

Mass closure stitch

suboptimal
approximation of
the aponeurosis
leads to suture
cutting through
fat and muscle.

Cengiz Eur J Surg 2001;167:60-3

Suture cutting through weak tissue

Large bites (>10mm from
wound edge), porcine
abdominal wall:

1. Harlaar Am J Surg 2009

2. Rath, Chevrel Hernia 1998

Small bites:
No separation of wound
edges observed(1)

Suture cutting through weak tissue

Large bites (>10mm from
wound edge), porcine
abdominal wall

Small bites:
No separation of wound
edges observed(1)

1. Harlaar Am J Surg 2009

2. Rath, Chevrel Hernia 1998

Sutures first cut through

the relatively weak tissue
lateral to aponeurosis,
causing wound edges to
separate (1)
This may lead to
developing of an incisional
hernia (2)

Aponeurosis only: Recommended technique

Good approximation

of the edges of
aponeurosis
No separation of
wound edges
No soft tissue
necrosis

Tension

High tension less collagen content lower tensile

strength

Rule of thumb:
The stitches in
aponeurosis
should at least be
visible

J.J. Her K. Junge A. Schachtrupp U. Klinge V. Schumpelick Hernia (2002) 6: 9398

Her et al. Langenbecks Arch Surg (2001) 386:218223

Choice of suture material

Absorbable or non-absorbable

Choice of suture material (I)

Suture material

NonAbsorbable

Braided
(Polyester)

Absorbable

Monofilament
(Polypropylene,
Nylon)

Medium term

Long term

Wound support

Wound support

3-4 weeks

6 weeks or more

Braided
(Polyglactin 910,
Polyglicolid acid)

Monofilament
(Polyglecaprone,
Glycomer 631)

Monofilament

(Polydioxanone,
Polyglyconate

Choice of suture material (II)

Suture material

+ Long term strength

NonAbsorbable

Braided
(Polyester)

Absorbable
- Risk of sinus

Monofilament
(Polypropylene,
Nylon)

- Patient discomfort and

pain on longer term Long term
Medium term
Wound support

Wound support

3-4 weeks

6 weeks or more

Braided
(Polyglactin 910,
Polyglicolid acid)

Monofilament
(Polyglecaprone,
Glycomer 631)

Monofilament

(Polydioxanone,
Polyglyconate

Choice of suture material (III)

Suture material

NonAbsorbable

Braided
(Polyester)

Absorbable

Monofilament
(Polypropylene,
Nylon)

Medium term

Long term

Wound support

Wound support

3-4 weeks

6 weeks or more

Braided
(Polyglactin 910,
Polyglicolid acid)

Monofilament
(Polyglecaprone,
Glycomer 631)

Monofilament
(Polydioxanone,
Polyglyconate)

Choice of suture material (IV)

Suture material

- Long term strength

Non- Higher risk
of Incisional
Absorbable
Hernia

Braided
(Polyester)

Monofilament
(Polypropylene,
Nylon)

Absorbable

Medium term

Long term

Wound support

Wound support

3-4 weeks

6 weeks or more

Braided
(Polyglactin 910,
Polyglicolid acid)

Monofilament
(Polyglecaprone,
Glycomer 631)

Monofilament
(Polydioxanone,
Polyglyconate)

Choice of suture material (V)

Suture material

NonAbsorbable

Braided
(Polyester)

Absorbable

Monofilament
(Polypropylene,
Nylon)

Medium term

Long term

Wound support

Wound support

3-4 weeks

6 weeks or more

Braided
(Polyglactin 910,
Polyglicolid acid)

Monofilament
(Polyglecaprone,
Glycomer 631)

Monofilament
(Polydioxanone,
Polyglyconate)

Choice of suture material (VI)

Suture material

NonAbsorbable

Braided
(Polyester)

Absorbable

+ Long term strength

+ No patient discomfort
Medium term or pain on long
Longterm
term
Monofilament
Wound support
Wound support
+(Polypropylene,
Incisional
Hernia
risk
similar
to
non-absorbing
Nylon)
3-4 weeks
6 weeks or more
sutures
Braided
(Polyglactin 910,
Polyglicolid acid)

Monofilament
(Polyglecaprone,
Glycomer 631)

Monofilament
(Polydioxanone,
Polyglyconate)

Evidence: Choice of suture material

Absorbable vs. Non-absorbable
Non-absorbable sutures associated to more pain and suture
sinuses (1,2)
Equally good results with slowly absorbable sutures
Slowly absorbing vs. Fast absorbing suture
Fast absorbing sutures related to higher rate of incisional

hernias (1,3)

Refs: see next page

Evidence: Choice of suture material

Polydioxanone vs. Non-absorbable sutures
Incisional hernia rate after closure with polydioxanone
similar to non-absorbable sutures (4,5,6,7)

1. Wissing J et al. Fascia closure after midline laparotomy: results of a randomized trial. Br J Surg 1987 Aug;74(8):738-41. PMID: 3307992
2. vant Riet M et al. Meta-analysis of techniques for closure of midline abdominal incisions. Br J Surg 2002;89:1350-6. PMID: 12390373
3. Hodgson NC et al. The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg 2000; Mar;231(3):436-42
4. Israelsson LA, Jonsson T. Closure of midline laparotomy incisions with polydioxanone and nylon: the importance of suture technique.
Br J Surg 1994;81(11):1606-8. PMID: 7827883
5. Docobo-Durantez F et al. [Randomized clinical study of polydioxanone and nylon sutures for laparotomy clousure in high-risk patients].
Cir Esp. 2006 May;79(5):305-9. PMID: 16753121

6. Hodgson NC et al. The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg 2000; Mar;231(3):436-42
7. Bloemen 2011

Wound support times of different suture

materials

Polydioxanone (10wk)

Polyglyconate (6wk)

Polyglactin 910 (4wk)

Polyglycolic acid (3wk)

Wound support times of different suture

materials
Impaired wound

Polydioxanone (10wk)

Polyglyconate (6wk)

Polyglactin 910 (4wk)

Polyglycolic acid (3wk)

Anti-bacterial (PLUS) Sutures to prevent SSI

Multicenter RCT
Hygiene measures according to guidelines, correct antibiotic prophylaxis, Monofilament suture

Despite taking measures, 19% infection rate persists

Is there a need for additional measures?

Prevention of suture bacterial colonization

Presence of suture

material may increase

the risk of infection (1)
Bacterial growth on
suture material
appeared to have the
characteristics of biofilm
formation(2)
Contamination
Easy to prevend

1. Mangram Infect Control Hosp Epidemiol 1999

2. Henry-Stanley et al. Surgical Infections 2010
3. Edmiston et al. J Am Coll Surg 2006

Colonization

Biofilm formation
Difficult to treat

Prevention of suture bacterial colonization

Suture with

antiseptic provides
an effective strategy
in reducing
perioperative
surgical morbidity(3)

1. Mangram Infect Control Hosp Epidemiol 1999

2. Henry-Stanley et al. Surgical Infections 2010
3. Edmiston et al. J Am Coll Surg 2006

Antibacterial sutures are associated with reduced

number of infections in abdominal wall closure
All publications on antibacterial sutures in abdominal wall closure:
Justinger
C et al.

Surgery

2009

Prospective

Midline
incision

Significant reduction of wound infections, from

10,8% to 4,9% (2088 patients) (p<0.001)

Ming
malairak

J Med Assoc Thai

2009

Randomized

Appendectomy

No difference in
appendectomies (100 patients)

Justinger
C et al.

Langenbecks Arch
Surg

2011

Prospective

Transverse
incision

Significant reduction of wound infections, from 9,2%

to 4,3% (839 patients) (p<0.005)

Rasic Z
et al.

Collegium
Antropologicum

2011

Randomized

Midline
incision

Significant reduction in the wound infection rate

(p=.035) and the dehiscence rate (p=.027)

Galal I, ElHindawy K

Am J Surg

2011

Randomized

General
surgery

Significant reduction in the

wound infection rate (p=.011)

Conclusions (I)
To reduce the complication rates in abdominal

midline closure:
(1) Use correct suture technique
Continuous suture with self-locking knot(s)
SL:WL ratio > 4

Small stitches at close intervals

Aponeurosis only

Minimal tension
Monofilament, slowly absorbable suture

Conclusions (II)
(2) Prevent wound infections
Correct suture technique
Attention to hygiene measures

Additional measures, e.g. antibacterial sutures

THANK YOU!