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COMMENTARY |
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Year : 2012 | Volume
: 5
| Issue : 1 | Page : 26-27 |
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A comparison between mass closure and layered closure of midline abdominal incisions
Subhash Chawla
Command Hospital, Lucknow, UP, India
Date of Web Publication | 20-Jun-2012 |
Correspondence Address: Subhash Chawla Command Hospital, Lucknow, UP India
Source of Support: None, Conflict of Interest: None | Check |
How to cite this article: Chawla S. A comparison between mass closure and layered closure of midline abdominal incisions. Med J DY Patil Univ 2012;5:26-7 |
Techniques for closure of the midline abdominal incision have varied over time with better understanding of the physiology and engineering of closure of the abdominal wall and improvement in materials of surgical suture. The ideal wound closure provides strength and barrier to infection. To achieve that goal closure should be fast, efficient, performed without tension/ischaemia, comfortable to the patient, technically easier to surgeon and aesthetic. Hence, one should follow the principles of wound closure.
Engineering sciences applied to wound healing have shown that the interrupted sutures have a weaker suture line than do running sutures. The weakest point in any suture line is the knot. Therefore more knots equal a weaker suture line, and fewer knots equal a stronger suture line. Wounds have less than 5% of normal tissue strength during the first postoperative week, thus the wound security is dependent solely upon the suture closure technique. Hence, choice of suture material and type of closure is most critical element of effective wound closure. With the advent of synthetic non-absorbable sutures, especially monofilament sutures, an entire abdominal midline incision from xiphoid to symphysis can be closed with the mass closure technique using only one knot.
The physiology and engineering of this suture lies on the give and take of a suture line or cable line in any situation where total fixation of a suture through tissue with movement results in a "giggly saw" technique of tearing the tissue. Mass closure with the one-knot loop suture technique allows give of the suture with coughing, respiration, and movement. It basically holds the wound together and allows the properties of wound healing, the strongest of all wound-healing techniques, to take place without necrosis and closure by second intention. Monofilament suture should be used. Most wounds can be completely closed with monofilament synthetic suture. There is a place for monofilament synthetic permanent suture such as nylon or Prolene. [1] The loop suture eliminates all the knots except one. Care must be taken to allow a 3-cm margin, wider than a man's finger, and to place the sutures 2 1/2 -3 cm apart. These characteristics of the length and width of the mass closure are necessary to conform to engineering principles.
Mass closure technique reduces the time required for closure of the incision, incidence of wound dehiscence and the incidence of incisional hernia. [2] Incisional hernia occurs due to wound complications such as seroma, wound infection and faulty closure technique. [3] The absence of tension on the suture line is must. Tension impedes microcirculation, decreases local tissue oxygenation and interferes with proper hydroxylation of prolene and lysine. Incidence of incisional hernia can be further reduced by aseptic meticulous technique, perfect haemostasis, sharp dissection, mass closure by use of nonabsorbable monofilament suture material, weight reduction and control of diabetes.
References | | |
1. | Bloemen A, van Dooren P, Huizinga BF, Hoofwijk AG. Randomized clinical trial comparing polypropylene or polydioxanone for midline abdominal wall closure. Br J Surg 2011;98:633-9. |
2. | Diener MK, Voss S, Jensen K, Büchler MW, Seiler CM. Elective midline laparotomy closure: The INLINE systematic review and meta-analysis. Ann Surg 2010;251:843-56. |
3. | Chawla S, Singh G. Incisional Hernia through nonvertical incisions. MJAFI 2000;54:316-9. |
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