Reinforced tension line suture closure after midline laparotomy in emergency surgery

Abstract

Midline laparotomy is an emergency surgical operation frequently performed in cases of intra-abdominal pathology. Closure of the incision is usually done by continuous suturing by mass closure. In an emergency operation the intra-abdominal milieu is usually contaminated leading to gut oedema and, hence, an increase in postoperative intra-abdominal pressure. It is complicated by wound dehiscence, burst abdomen, etc. The cause of this complication is an increase in horizontal tensile forces on the site of the insertion of sutures which cuts the sheath. In this technique of reinforced tension line suture peak tensile forces are distributed from the suture base to the surrounding tissue through a horizontal suture, thereby preventing the suture from cutting through the tissue. From July 2007 to June 2009 patients requiring laparotomy were randomly divided into test and control groups by a 'closed envelope' technique. Their postoperative intra-abdominal pressure was recorded by urinary bladder catheter manometry. The result of this technique was compared with the incidence of burst abdomen in cases where it was closed by continuous suture. A total of 190 patients underwent laparotomy. In 90 the abdomen was closed by reinforced tension line (RTL) and in 100 patients by continuous suturing. None of the RTL group had a burst abdomen. Thirteen who had closure by continuous suture had a burst abdomen. The analysis of the results was done using the chi-square test. On comparing the incidence of burst abdomen in cases operated by continuous suture technique and by RTL, the P value was found to be 0.0026 which is highly significant. On analysis of the incidence of burst abdomen in cases having a grade II intra-abdominal pressure the P value was found to be 0.0009 which is highly significant. Closure of midline incision by RTL reduces the incidence of burst abdomen. Registration No. PROVCTRI/2008/091/000269 (http://www.ctri.in).

Determining risk factors for surgical wound dehiscence: a literature review

“…In 77% of the non‐reinforced sites, sutures tore away from the tissues at a median load of 60·7 N, which was a much lower force than tolerated by the reinforced sides. Similarly, Agarwal who used the RTL continuous technique in patients who underwent emergency midline laparotomies found that this technique resulted in no burst sutures. Furthermore, in 100 patients who were closed using a non‐RTL continuous suture wounds resulted in SWD ( P = 0·009).…”

European Hernia Society guidelines on the closure of abdominal wall incisions

“…The PRISMA flow diagram of our additional search is shown in Addendum 3 (Key Question M). Eight records were screened by full text [78][79][80][81][82][83][84][85]. Three RCTs on the prevention of burst abdomen using either retention sutures or a reinforced tension line suture in patients with increased risk for wound dehiscence and burst abdomen were identified [78][79][80].…”

“…The Summary of Findings is listed in Table 4. Two studies showed favourable results [78,79], but one study reported a high number of adverse events when using retention sutures [80]. Hernia (2015) 19:1-24 11…”

Vacuum-assisted wound closure and mesh-mediated fascial traction for open abdomen therapy — a systematic review

“…If the risk of burst abdomen or postoperative large incisional hernia is considered to be high at abdominal closure, a longitudinal suture parallel to the fascial margin as a reinforced tension line may be used in combination with the standard continuous primary fascial closure suture along the fascia, in order to reduce the incidence of burst abdomen [36,37]. There is seldom a need to leave the patient with a giant planned ventral hernia, a condition associated with great morbidity and need for later advanced abdominal wall reconstruction.…”