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The Incision and Wound Closure in Blunt Abdominal Trauma
Symposium on Nonpenetrating Thoracoabdominal Injuries
The Incision and Wound Closure in Blunt Abdominal Trauma
Paul A. Kennedy, M.D., F.A.C.S.,* and Gordon F. Madding, M.D., M.S. (Surg.)**
Routine exploration of the abdomen for a known disease is planned in such a manner not only to allow satisfactory exposure for the procedure to be done but also to insure a strong wound closure. Blunt trauma, on the other hand, frequently leaves considerable doubt as to the extent and location of the organ or organs injured. This unknown quality makes necessary the use of an incision that will allow for a complete exploration of the abdominal cavity and which will give adequate exposure for carrying out any surgical procedure indicated. Vertical incisions, either paramedian or midline, satisfy these requirements since they may be extended from the symphysis pubis to the xiphoid and, when necessary, may be carried across the costal margin for the care of extensive liver or diaphragmatic injuries. Although they allow for easy access to all quadrants of the abdomen, they are attended by a higher incidence of wound complications. Transverse and subcostal incisions lend themselves to stronger repaiJ:09 and are attended by fewer complications, but they do limit the exposure necessary in many cases of blunt trauma and, therefore, are used less often. In any abdominal operation, emergency or otherwise, the incision which exposes the peritoneal cavity, as well as its closure, deserves as much thought as does the intraperitoneal procedure. Failure to give sufficient attention to either the incision or the wound closure may lead to complications that will result in increased morbidity and mortality.
FACTORS INFLUENCING WOUND REPAIR Although first consideration in making an incision for exploration of the abdomen that has received blunt trauma is satisfactory exposure, it is ':'Assistant Clinical Professor of Surgery, Stanford University School of Medicine, Stanford California *"Associate Clinical Professor of Surgery, University of California School of Medicine; Associate in Surgery, Stanford University School of Medicine, Stanford, California
Surgical Clinics of North America - Vol. 52, No.3, June 1972
761
762
PAUL
A.
KENNEDY AND GORDON
F.
MADDING
important to consider early those factors which will have some influence, either positive or negative, on wound healing. Consideration must be given during the making of the wound to wound repair. Systemic conditions such as hypoproteinemia and anemia may have an important bearing on wound healing, and if these deficits are present, steps to correct them should be taken immediately and continued into the postoperative period. When little time is available to adequately correct such defects, certain technical measures must be incorporated to strengthen the support of the wound. Where there has been contamination by perforation of the gastrointestinal tract, every effort must be made to protect the full thickness of the wound as much as is possible. Wound towels are immediately placed when the skin and subcutaneous tissue is opened, and as soon as the peritoneum is incised, double-thickness moist laparotomy packs are used to cover the wound edges. We have had no experience with the newer plastics designed for such purposes, but they may prove to be worthwhile. CrandelF uses a specially prepared impermeable pad which he sutures to the peritoneum to assure that its protective position will be maintained during the entire procedure, thus protecting the wound from intraperitoneal contamination. It is advisable, when contamination is heavy, to use special drapes to isolate the instruments used. When this portion of the procedure is completed gowns, gloves, towels, and instruments are changed. When contamination of the wound is recognized, thorough irrigation with saline may obviate some wound complications. Since infection is frequently mentioned as a causative factor in wound dehiscence,s systemic efforts at control are started during the operative procedure. Cephalothin (Kellin), 2 gm. to 1000 mI., is begun as an intravenous infusion and is continued in the postoperative period. At the completion of the operation, 2 gm. of cephalothin are placed in the peritoneal cavity in those instances in which contamination has occurred. Lehman et al. 4 found infection to be a major cause of wound separation in the cases they studied. They noted that although the incidence of wound complications has been reduced by improved aseptic techniques and antibiotics, this has not been reflected in a similar reduction in wound separation. Gross infection is present in apparently 25 per cent of wounds which disrupt, but more important perhaps is the more frequent subclinical infection that exists. In one report pathogenic organisms were found in 88 per cent of wound disruptions. 2 Although nutrition, age of the patient,!l and the type and length of the wound may all be incriminated as possible causative factors in the failure of the wound to heal, more significant perhaps is the stress placed on the wound from the time of the immediate repair until wound healing has taken place. It is a fact that some wound separations begin on the operating table as the patient is being extubated, or in the immediate postoperative period which may be associated with violent retching or vomiting. We believe it is important that the abdominal wall be kept relaxed until the wound is completely repaired and the retention sutures have been tied. This is certainly true when a long vertical incision has been used.
INCISION AND WOUND CLOSURE
763
A chronic cough places great stress upon a recent incision, particularly on vertical incisions, and precipitates wound separation early or late. In some cases it clearly initiates disruption, but in all probability a pre-existing weakness existed in the wound closure. Since the triad of distention, vomiting, and coughing have the common effect of increasing intraabdominal pressure, efforts should be directed at their control.4 A large nasogastric tube is kept in place for at least 3 to 4 days or longer, until it is demonstrated that the gastrointestinal tract is functioning normally. We feel that having the patient sit up with the legs over the side of the bed for scheduled coughing exercises asks less of the wound than continuous ineffective coughing.
TYPES OF INCISION AND WOUND PREPARATION We have routinely used either a midline or a paramedian incision in all cases of blunt abdominal trauma, but more recently we have used the midline approach exclusively. Exploration can be more thorough, and by extending the incision the operator can readily carry out any repair necessary. Once the incision is made and wound towels are placed, the full thickness of the wound is protected by moist laparotomy packs. Particular care is made to obtain complete hemostasis. Using a cautery for this purpose may leave a lesser amount of devitalized tissue than when ligatures are used exclusively. In either event, effort should be made to coagulate as little tissue as possible and care should be taken to avoid mass ligatures. The preparation of the wound undoubtedly has a significant influence on wound healing. If drainage is indicated, separate incisions should be used. They should be of adequate size so as to allow for adequate drainage. Drains preferably should not be brought out through the laparotomy incision, and if bowel is to be exteriorized this too should be done through a separate convenient incision, avoiding the initial exploratory wound. Numerous studies have been made in an effort to explain why one wound separates while another heals kindly. The answer is not readily apparent. How the wound is made and closed, whether or not hemostasis was perfect as it could have been, the type of suture material used - these are but a few of the questions that can be asked.
WOUND REPAIR (RETENTION SUTURE) Some form of retention sutures are indicated in closing such wounds since most of the factors that lead to wound complications are present.6 It is generally agreed that retention sutures properly placed can and do reduce the incidence of wound separation. A shorter incision in a younger individual in whom the gastrointestinal tract is not involved may permit a routine closure, omitting retention sutures. This, however, will be the exception.
764
PAUL
A.
KENNEDY AND GORDON
F.
MADDING
The many and varied descriptions of retention suturing are testimony to the fact that no one ideal method has been found to be completely satisfactory, and each operator must decide on a method which in his hands gives the best results. As Norris stated: "The elimination of wound dehiscence is within the province of the operating surgeon, yet the occurrence of this surgical catastrophe remains constant in the layer type closure regardless of the suture material used."7 This is true today and emphasizes the need for some form of retention sutures. It has been pointed out by Childs! that wound eviscerations affect the prognosis adversely to approximately the same degree as does the involvement of each additional organ in the multiplicity factor scale. Dehiscence with some degree of evisceration adds to the morbidity and mortality and gives weight to the argument for the use of retention sutures. The type of retention sutures adopted by us during World War II have proved to be satisfactory and we have continued to use them to the present time where indicated (Fig. 1). We routinely use this method in all trauma cases where the abdomen has been explored through a vertical type incision and we have not experienced wound separation where it has been employed. A heavy mersilene No.5 double-armed suture* is passed through all layers of the abdominal wall, including the peritoneum. The point at which the needle is introduced through the skin will vary depending upon the thickness of the abdominal wall; the thicker the abdominal wall, the further away from the wound edge. The needle is passed across the midline and brought out the opposite side. Tension is then maintained on the sutures so that they remain taut in the wound. It is essential to have the abdominal wall completely relaxed during the closure, and this combined with holding the retention sutures taut will avoid including a loop of small bowel during the closure. The retention sutures are placed at 2 to 3 cm. intervals. With the retention sutures held taut, the peritoneum and posterior fascia are closed with a running No. 0 chromic catgut suture. At intervals during the closure, the peritoneal aspect of the wound is examined with the index finger to be certain the retention suture is flush against the peritoneum. In long wounds the peritoneal suture is interrupted once or twice. The anterior fascia is then closed with interrupted No. 00 tichron sutures.':":' In some contaminated wounds this anterior fascial layer is closed with interrupted No. 0 catgut. When there is a large amount of subcutaneous fat this is approximated with triple 0 plain catgut and the skin is then approximated with 4-0 interrupted silk. In older patients and in some contaminated wounds and in situations in which time is most important, we use a single layer closure. No.5 mersilene retention suture is passed through all layers the only change being that the sutures are placed somewhat closer together. The sutures are held taut and tied, care being taken to avoid including small bowel in the closure. Apposition of the skin edges is then made if necessary with interrupted silk sutures. Whether a layered closure with retention su':'Ethicon ":'Davis and Geck
765
INCISION AND WOUND CLOSURE
Wire s·uture
a Subcutaneus tissue
itoneum
c
Rubber bolster
sion line
Wire s
Figure 1. Wound closure using retention sutures to augment layer closure: a, placement of retention sutures of wire or synthetic material; b, layer closure; c, retention sutures tied after layer closure is completed. (Modified from Crandell, W. B.: Abdominal disruption. In Madding, G. F., and Kennedy, P. A., eds.: Surgical Techniques. San Francisco, Bancroft Whitney Co., 1970, Vol. 3.)
tures or a simple one-layer closure is used, the retention sutures are left in place for 12 to 17 days. Heimberger et aP used simple "through-and-through" wound closure in 231 consecutive exploratory laparotomies performed on Vietnamese civilians with two disruptions. Their routine included placing the sutures 1 cm. apart and 2 to 3 cm. from the wound edge. Postoperatively the dressings were changed frequently. The untoward appearance of the wound was not indication for them to remove sutures prematurely and they were allowed to remain in place 21 days. In less than 5 days after removal all suppuration cleared. Simple mass closure makes for an unattractive wound and frequently is attended by pain and discomfort, but when properly used it makes for a satisfactory closure with a low incidence of complications. In
766
PAUL
A.
KENNEDY AND GORDON
F.
MADDING
its favor also is the fact that it is the method most commonly used to repair wound dehiscence when it occurs.
OTHER METHODS OF RETENTION SUTURING A number of retention sutures have been described and each has something to offer. An alternate method used by Lehman et al. 4 employs a figure of eight in which the needle is passed through all layers of the abdominal wall, including the peritoneum, and is passed through the posterior fascia and peritoneum of the opposite side and back over to include only the peritoneum and posterior fascia of the first side. It is then passed through the full thickness of the opposite side. The wound is closed in layers. Lord et al. 5 described a retention suture which included the skin and anterior rectus fascia in a far-near near-far figure of eight fashion. The peritoneum and posterior abdominal wall fascia is first closed with a continuous single strand of No.1 chromic catgut. After all retention sutures have been placed they are pulled taut by the surgeon who exerts tension on the uncrossed ends in the opposite direction. Sufficient tension is applied to approximate the fascial layer carefully. An interrupted double o silk for closure of the anterior fascial sheath about 1 cm. apart is then used. In contaminated wounds No.1 chromic catgut is used instead of silk. Using this method they reported a dehiscence rate of less than 1 per cent in 1129 vertically placed incisions. Another form of retention used by some is that in which all but the skin and subcutaneous tissue are included. Spencer et al. tO reported a method in which No. 28 steel wire is used in a figure of eight fashion. The wire suture is passed through the anterior rectus sheath, the rectus muscle, the posterior rectus sheath, and the peritoneum. Emphasis is placed on including at least 3 cm. of tissue in each suture, placing the individual sutures about a cm. apart and tying the wire with just enough tension to approximate the tissues. Subcutaneous tissue and skin are then closed separately with silk or catgut. Wound evisceration occurred in 1 patient.
DISCUSSION AND SUMMARY Abdominal trauma may occur as a result of any number of accidents and frequently involves all ages, the young and the old, the well and the infirm. It is important, therefore, for the surgeon to keep in mind that one or several untoward forces may be at work in addition to the immediate injury and that early efforts should be made at their control. Recognition of such factors and their correction may playa large part in minimizing wound complications. The midline incision is readily made and gives excellent exposure f;or any quadrant of the abdomen and may be extended into the chest where necessary. The use of a more anatomic incision may restrict the surgeon
767
INCISION AND WOUND CLOSURE
considerably and place him at a disadvantage. The incision should be well protected in some fashion during the operation, since gross contamination will be frequent. Using extra towels and drapes, and changing gowns and gloves when necessary, will all help to reduce the degree of wound contamination. When the procedure has been completed, careful peritoneal toilet and irrigation of the wound with normal saline will also reduce the likelihood of infection. Although prophylactic use of antibiotics locally and systemically cannot be supported clearly, a case can be made for their use. Considerable care must be given to the making and repair of the wound since several factors which mitigate against primary wound healing may be at work in every case of blunt trauma to the abdomen. The general principles of careful handling of tissue, protection of the wound, and leaving a minimal amount of foreign material in the wound are all important. It is essential in such wounds to use some form of retention suturing that will lend adequate support until wound healing takes place. The postoperative course must not only include full support of the patient but it must also include attention to such things as cough, intestinal distention, anemia, and other factors which unfavorably influence wound healing.
REFERENCES 1. Childs, S. B.: Surgery in World War II. Vol. II, Traumatic Evisceration (312 Casualties). Washington, D.C., Office of The Surgeon General, Department of the Army, 1955, chap. 10, p. 173. 2. Crandell, W. B.: Abdominal wound disruption. In Madding, G. F., and Kennedy, P. A., eds.: Surgical Techniques. San Francisco, Bancroft Whitney Co., 1970, vol. 3, pp. 42-55. 3. Heimberger, R. A., and Campbell, D. C., Jr.: Can Tho, South Vietnam: Simple abdominal wall closure in Vietnamese civilian war casualties. Surgery 61 :858-863, 1967. 4. Lehman, J. A., Jr., Cross, F. S., and Parkington, P. F.: Prevention of abdominal wound disruption. Surg. Gynec. Obstet. 126:1235-1241, 1968. 5. Lord, J. W., Jr., Pfeffer, R. B., and Golomb, F. M.: Elimination of disruption of abdominal incisions. Surg. Gynec. Obstet., 129: 758-760, 1969. 6. McCallum, G. T., and Link, R. F.: The effect of closure techniques on abdominal disruption. Surg. Gynec. Obstet., 119:75-80, 1964. 7. Norris, J. D.: A review of wound healing and the mechanics of dehiscence. Surgery, 5: 75, 1939. 8. Shires, G. T.: Care of the Trauma Patient. New York, McGraw-Hill Book Co., 1966, p. 35. 9. Singleton, A. 0., and Blocker, T. G.: The problem of disruption of abdominal wounds in postoperative hernia J.A.M.A., 112:122,1939. 10. Spencer, F. C., Sharp, E. H., and Jude, J. R.: Experiences with wire closure of abdominal incisions in 292 selective patients. Surg. Gynec. Obstet., 117:235, 1963. 11. Wolfe, W. I.: Disruption of abdominal wounds. Ann. Surg., 131 :534,1950.
The Incision and Wound Closure in Blunt Abdominal Trauma
Paul A. Kennedy, M.D., F.A.C.S.,* and Gordon F. Madding, M.D., M.S. (Surg.)**
Routine exploration of the abdomen for a known disease is planned in such a manner not only to allow satisfactory exposure for the procedure to be done but also to insure a strong wound closure. Blunt trauma, on the other hand, frequently leaves considerable doubt as to the extent and location of the organ or organs injured. This unknown quality makes necessary the use of an incision that will allow for a complete exploration of the abdominal cavity and which will give adequate exposure for carrying out any surgical procedure indicated. Vertical incisions, either paramedian or midline, satisfy these requirements since they may be extended from the symphysis pubis to the xiphoid and, when necessary, may be carried across the costal margin for the care of extensive liver or diaphragmatic injuries. Although they allow for easy access to all quadrants of the abdomen, they are attended by a higher incidence of wound complications. Transverse and subcostal incisions lend themselves to stronger repaiJ:09 and are attended by fewer complications, but they do limit the exposure necessary in many cases of blunt trauma and, therefore, are used less often. In any abdominal operation, emergency or otherwise, the incision which exposes the peritoneal cavity, as well as its closure, deserves as much thought as does the intraperitoneal procedure. Failure to give sufficient attention to either the incision or the wound closure may lead to complications that will result in increased morbidity and mortality.
FACTORS INFLUENCING WOUND REPAIR Although first consideration in making an incision for exploration of the abdomen that has received blunt trauma is satisfactory exposure, it is ':'Assistant Clinical Professor of Surgery, Stanford University School of Medicine, Stanford California *"Associate Clinical Professor of Surgery, University of California School of Medicine; Associate in Surgery, Stanford University School of Medicine, Stanford, California
Surgical Clinics of North America - Vol. 52, No.3, June 1972
761
762
PAUL
A.
KENNEDY AND GORDON
F.
MADDING
important to consider early those factors which will have some influence, either positive or negative, on wound healing. Consideration must be given during the making of the wound to wound repair. Systemic conditions such as hypoproteinemia and anemia may have an important bearing on wound healing, and if these deficits are present, steps to correct them should be taken immediately and continued into the postoperative period. When little time is available to adequately correct such defects, certain technical measures must be incorporated to strengthen the support of the wound. Where there has been contamination by perforation of the gastrointestinal tract, every effort must be made to protect the full thickness of the wound as much as is possible. Wound towels are immediately placed when the skin and subcutaneous tissue is opened, and as soon as the peritoneum is incised, double-thickness moist laparotomy packs are used to cover the wound edges. We have had no experience with the newer plastics designed for such purposes, but they may prove to be worthwhile. CrandelF uses a specially prepared impermeable pad which he sutures to the peritoneum to assure that its protective position will be maintained during the entire procedure, thus protecting the wound from intraperitoneal contamination. It is advisable, when contamination is heavy, to use special drapes to isolate the instruments used. When this portion of the procedure is completed gowns, gloves, towels, and instruments are changed. When contamination of the wound is recognized, thorough irrigation with saline may obviate some wound complications. Since infection is frequently mentioned as a causative factor in wound dehiscence,s systemic efforts at control are started during the operative procedure. Cephalothin (Kellin), 2 gm. to 1000 mI., is begun as an intravenous infusion and is continued in the postoperative period. At the completion of the operation, 2 gm. of cephalothin are placed in the peritoneal cavity in those instances in which contamination has occurred. Lehman et al. 4 found infection to be a major cause of wound separation in the cases they studied. They noted that although the incidence of wound complications has been reduced by improved aseptic techniques and antibiotics, this has not been reflected in a similar reduction in wound separation. Gross infection is present in apparently 25 per cent of wounds which disrupt, but more important perhaps is the more frequent subclinical infection that exists. In one report pathogenic organisms were found in 88 per cent of wound disruptions. 2 Although nutrition, age of the patient,!l and the type and length of the wound may all be incriminated as possible causative factors in the failure of the wound to heal, more significant perhaps is the stress placed on the wound from the time of the immediate repair until wound healing has taken place. It is a fact that some wound separations begin on the operating table as the patient is being extubated, or in the immediate postoperative period which may be associated with violent retching or vomiting. We believe it is important that the abdominal wall be kept relaxed until the wound is completely repaired and the retention sutures have been tied. This is certainly true when a long vertical incision has been used.
INCISION AND WOUND CLOSURE
763
A chronic cough places great stress upon a recent incision, particularly on vertical incisions, and precipitates wound separation early or late. In some cases it clearly initiates disruption, but in all probability a pre-existing weakness existed in the wound closure. Since the triad of distention, vomiting, and coughing have the common effect of increasing intraabdominal pressure, efforts should be directed at their control.4 A large nasogastric tube is kept in place for at least 3 to 4 days or longer, until it is demonstrated that the gastrointestinal tract is functioning normally. We feel that having the patient sit up with the legs over the side of the bed for scheduled coughing exercises asks less of the wound than continuous ineffective coughing.
TYPES OF INCISION AND WOUND PREPARATION We have routinely used either a midline or a paramedian incision in all cases of blunt abdominal trauma, but more recently we have used the midline approach exclusively. Exploration can be more thorough, and by extending the incision the operator can readily carry out any repair necessary. Once the incision is made and wound towels are placed, the full thickness of the wound is protected by moist laparotomy packs. Particular care is made to obtain complete hemostasis. Using a cautery for this purpose may leave a lesser amount of devitalized tissue than when ligatures are used exclusively. In either event, effort should be made to coagulate as little tissue as possible and care should be taken to avoid mass ligatures. The preparation of the wound undoubtedly has a significant influence on wound healing. If drainage is indicated, separate incisions should be used. They should be of adequate size so as to allow for adequate drainage. Drains preferably should not be brought out through the laparotomy incision, and if bowel is to be exteriorized this too should be done through a separate convenient incision, avoiding the initial exploratory wound. Numerous studies have been made in an effort to explain why one wound separates while another heals kindly. The answer is not readily apparent. How the wound is made and closed, whether or not hemostasis was perfect as it could have been, the type of suture material used - these are but a few of the questions that can be asked.
WOUND REPAIR (RETENTION SUTURE) Some form of retention sutures are indicated in closing such wounds since most of the factors that lead to wound complications are present.6 It is generally agreed that retention sutures properly placed can and do reduce the incidence of wound separation. A shorter incision in a younger individual in whom the gastrointestinal tract is not involved may permit a routine closure, omitting retention sutures. This, however, will be the exception.
764
PAUL
A.
KENNEDY AND GORDON
F.
MADDING
The many and varied descriptions of retention suturing are testimony to the fact that no one ideal method has been found to be completely satisfactory, and each operator must decide on a method which in his hands gives the best results. As Norris stated: "The elimination of wound dehiscence is within the province of the operating surgeon, yet the occurrence of this surgical catastrophe remains constant in the layer type closure regardless of the suture material used."7 This is true today and emphasizes the need for some form of retention sutures. It has been pointed out by Childs! that wound eviscerations affect the prognosis adversely to approximately the same degree as does the involvement of each additional organ in the multiplicity factor scale. Dehiscence with some degree of evisceration adds to the morbidity and mortality and gives weight to the argument for the use of retention sutures. The type of retention sutures adopted by us during World War II have proved to be satisfactory and we have continued to use them to the present time where indicated (Fig. 1). We routinely use this method in all trauma cases where the abdomen has been explored through a vertical type incision and we have not experienced wound separation where it has been employed. A heavy mersilene No.5 double-armed suture* is passed through all layers of the abdominal wall, including the peritoneum. The point at which the needle is introduced through the skin will vary depending upon the thickness of the abdominal wall; the thicker the abdominal wall, the further away from the wound edge. The needle is passed across the midline and brought out the opposite side. Tension is then maintained on the sutures so that they remain taut in the wound. It is essential to have the abdominal wall completely relaxed during the closure, and this combined with holding the retention sutures taut will avoid including a loop of small bowel during the closure. The retention sutures are placed at 2 to 3 cm. intervals. With the retention sutures held taut, the peritoneum and posterior fascia are closed with a running No. 0 chromic catgut suture. At intervals during the closure, the peritoneal aspect of the wound is examined with the index finger to be certain the retention suture is flush against the peritoneum. In long wounds the peritoneal suture is interrupted once or twice. The anterior fascia is then closed with interrupted No. 00 tichron sutures.':":' In some contaminated wounds this anterior fascial layer is closed with interrupted No. 0 catgut. When there is a large amount of subcutaneous fat this is approximated with triple 0 plain catgut and the skin is then approximated with 4-0 interrupted silk. In older patients and in some contaminated wounds and in situations in which time is most important, we use a single layer closure. No.5 mersilene retention suture is passed through all layers the only change being that the sutures are placed somewhat closer together. The sutures are held taut and tied, care being taken to avoid including small bowel in the closure. Apposition of the skin edges is then made if necessary with interrupted silk sutures. Whether a layered closure with retention su':'Ethicon ":'Davis and Geck
765
INCISION AND WOUND CLOSURE
Wire s·uture
a Subcutaneus tissue
itoneum
c
Rubber bolster
sion line
Wire s
Figure 1. Wound closure using retention sutures to augment layer closure: a, placement of retention sutures of wire or synthetic material; b, layer closure; c, retention sutures tied after layer closure is completed. (Modified from Crandell, W. B.: Abdominal disruption. In Madding, G. F., and Kennedy, P. A., eds.: Surgical Techniques. San Francisco, Bancroft Whitney Co., 1970, Vol. 3.)
tures or a simple one-layer closure is used, the retention sutures are left in place for 12 to 17 days. Heimberger et aP used simple "through-and-through" wound closure in 231 consecutive exploratory laparotomies performed on Vietnamese civilians with two disruptions. Their routine included placing the sutures 1 cm. apart and 2 to 3 cm. from the wound edge. Postoperatively the dressings were changed frequently. The untoward appearance of the wound was not indication for them to remove sutures prematurely and they were allowed to remain in place 21 days. In less than 5 days after removal all suppuration cleared. Simple mass closure makes for an unattractive wound and frequently is attended by pain and discomfort, but when properly used it makes for a satisfactory closure with a low incidence of complications. In
766
PAUL
A.
KENNEDY AND GORDON
F.
MADDING
its favor also is the fact that it is the method most commonly used to repair wound dehiscence when it occurs.
OTHER METHODS OF RETENTION SUTURING A number of retention sutures have been described and each has something to offer. An alternate method used by Lehman et al. 4 employs a figure of eight in which the needle is passed through all layers of the abdominal wall, including the peritoneum, and is passed through the posterior fascia and peritoneum of the opposite side and back over to include only the peritoneum and posterior fascia of the first side. It is then passed through the full thickness of the opposite side. The wound is closed in layers. Lord et al. 5 described a retention suture which included the skin and anterior rectus fascia in a far-near near-far figure of eight fashion. The peritoneum and posterior abdominal wall fascia is first closed with a continuous single strand of No.1 chromic catgut. After all retention sutures have been placed they are pulled taut by the surgeon who exerts tension on the uncrossed ends in the opposite direction. Sufficient tension is applied to approximate the fascial layer carefully. An interrupted double o silk for closure of the anterior fascial sheath about 1 cm. apart is then used. In contaminated wounds No.1 chromic catgut is used instead of silk. Using this method they reported a dehiscence rate of less than 1 per cent in 1129 vertically placed incisions. Another form of retention used by some is that in which all but the skin and subcutaneous tissue are included. Spencer et al. tO reported a method in which No. 28 steel wire is used in a figure of eight fashion. The wire suture is passed through the anterior rectus sheath, the rectus muscle, the posterior rectus sheath, and the peritoneum. Emphasis is placed on including at least 3 cm. of tissue in each suture, placing the individual sutures about a cm. apart and tying the wire with just enough tension to approximate the tissues. Subcutaneous tissue and skin are then closed separately with silk or catgut. Wound evisceration occurred in 1 patient.
DISCUSSION AND SUMMARY Abdominal trauma may occur as a result of any number of accidents and frequently involves all ages, the young and the old, the well and the infirm. It is important, therefore, for the surgeon to keep in mind that one or several untoward forces may be at work in addition to the immediate injury and that early efforts should be made at their control. Recognition of such factors and their correction may playa large part in minimizing wound complications. The midline incision is readily made and gives excellent exposure f;or any quadrant of the abdomen and may be extended into the chest where necessary. The use of a more anatomic incision may restrict the surgeon
767
INCISION AND WOUND CLOSURE
considerably and place him at a disadvantage. The incision should be well protected in some fashion during the operation, since gross contamination will be frequent. Using extra towels and drapes, and changing gowns and gloves when necessary, will all help to reduce the degree of wound contamination. When the procedure has been completed, careful peritoneal toilet and irrigation of the wound with normal saline will also reduce the likelihood of infection. Although prophylactic use of antibiotics locally and systemically cannot be supported clearly, a case can be made for their use. Considerable care must be given to the making and repair of the wound since several factors which mitigate against primary wound healing may be at work in every case of blunt trauma to the abdomen. The general principles of careful handling of tissue, protection of the wound, and leaving a minimal amount of foreign material in the wound are all important. It is essential in such wounds to use some form of retention suturing that will lend adequate support until wound healing takes place. The postoperative course must not only include full support of the patient but it must also include attention to such things as cough, intestinal distention, anemia, and other factors which unfavorably influence wound healing.
REFERENCES 1. Childs, S. B.: Surgery in World War II. Vol. II, Traumatic Evisceration (312 Casualties). Washington, D.C., Office of The Surgeon General, Department of the Army, 1955, chap. 10, p. 173. 2. Crandell, W. B.: Abdominal wound disruption. In Madding, G. F., and Kennedy, P. A., eds.: Surgical Techniques. San Francisco, Bancroft Whitney Co., 1970, vol. 3, pp. 42-55. 3. Heimberger, R. A., and Campbell, D. C., Jr.: Can Tho, South Vietnam: Simple abdominal wall closure in Vietnamese civilian war casualties. Surgery 61 :858-863, 1967. 4. Lehman, J. A., Jr., Cross, F. S., and Parkington, P. F.: Prevention of abdominal wound disruption. Surg. Gynec. Obstet. 126:1235-1241, 1968. 5. Lord, J. W., Jr., Pfeffer, R. B., and Golomb, F. M.: Elimination of disruption of abdominal incisions. Surg. Gynec. Obstet., 129: 758-760, 1969. 6. McCallum, G. T., and Link, R. F.: The effect of closure techniques on abdominal disruption. Surg. Gynec. Obstet., 119:75-80, 1964. 7. Norris, J. D.: A review of wound healing and the mechanics of dehiscence. Surgery, 5: 75, 1939. 8. Shires, G. T.: Care of the Trauma Patient. New York, McGraw-Hill Book Co., 1966, p. 35. 9. Singleton, A. 0., and Blocker, T. G.: The problem of disruption of abdominal wounds in postoperative hernia J.A.M.A., 112:122,1939. 10. Spencer, F. C., Sharp, E. H., and Jude, J. R.: Experiences with wire closure of abdominal incisions in 292 selective patients. Surg. Gynec. Obstet., 117:235, 1963. 11. Wolfe, W. I.: Disruption of abdominal wounds. Ann. Surg., 131 :534,1950.