Specialists Without Borders
Seminar in Surgery
Rwanda, September 2010
Closing the Abdomen
Mary Theophilus
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Outline
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Factors influencing type of abdominal closure
Post-operative wound dehiscence
Principles of abdominal closure
Abdominal Compartment Syndrome
Laparostomy = temporary closure
Closure post-laparostomy
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What type of closure?
Factors influencing type of abdominal closure
• Patient factors
– diabetes, steroids, obesity, malnutrition etc…
• Operative factors
– Risk of wound infection…contamination?
– Unable to close abdomen
– Weak or frayed fascia
• Planned re-operation(s)?
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Post-operative Wound Dehiscence
• Signs
– Excessive serous discharge from wound
– Palpable defect in fascia
– Bowel on view !
• A full thickness wound dehiscence involving
bowel requires urgent closure
– herniated bowel will develop an overlying layer of
granulation tissue (peritonealised) making future
hernia repair impossible.
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Post-operative Wound Dehiscence
2 weeks post-laparotomy for perforated appendicitis
Small bowel in the base of the wound has been covered by
granulation tissue, making primary closure of the wound
impossible. The wound was treated with dressings.
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Principles of Abdominal Closure
• No tension !
• Single layer closure
– Incorporating fascia and no muscle
• Jenkins’ Rule of 4
– 2cm by 2cm
• Continuous vs Interrupted
– If high risk of wound infection - use interrupted
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Tension Sutures
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If it will not close!
• Back to first principles – NO TENSION
• Abdominal Compartment Syndrome
• = Laparostomy with later primary or mesh
closure
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Abdominal Compartment Syndrome
• Organ dysfunction caused by intraabdominal
hypertension
• Normal pressure – 5-7mmHg , Hypertension >12mmHg
• Respiratory, renal and GI tract impairment
• Intravesical pressure measurement
• NG tube, empty gut, diuretics
• = Laparostomy with later primary or mesh
closure
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Laparostomy - Temporary Closure
Advantages
• Protects small bowel from fascial adhesions
• Avoids fascial retraction and loss of domain
• Allows tissue oedema to settle and the
abdomen to close without tension
• Useful if further planned re-operation
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Laparostomy - Temporary Closure
Disadvantages
• Fraying of the fascia (if sutured) compromising
subsequent definitive closure
• Long term laparostomy can lead to shortening
of the rectus abdominis muscles
– Especially in the obese
– Makes definitive closure difficult
– Relaxation incisions maybe required
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Good technique
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Rapid closure
Protects intra-abdominal organs
Prevents peritoneal contamination
Addresses peritoneal fluid
Allows reoperation with minimal tissue
damage
• Allows timely and easy closure with low rate
of ensuing wound complications
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Laparostomy Techniques
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Bogota bag
Towel clip closure
Zip closure
Mesh (absorbable, non-absorbable,
composite)
• Vac dressing
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Laparostomy Techniques
• Bogota bag
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Laparostomy Techniques
• Towel clip closure
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Laparostomy Techniques
• Vac Dressing
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Laparostomy Techniques
• Suction dressing
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Primary closure post laparostomy
• Ideal
• May be closed serially
• May require other techniques to facilitate :
Relaxing incisions in the fascia
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Component Separation Technique
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Mesh closure post Laparostomy
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Non absorbable
Absorbable
Composite
Bilayer
Organic
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Close skin if possible, else
vac dressings, skin
grafting, tissue flaps
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Conclusions
Primary closure best but only if NO TENSION
Abdominal compartment syndrome should be
avoided and treated with laparostomy
Good laparostomy techniques enable early
secondary closure and help avoid late wound
complications
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References
• Finding the best Abdominal Closure: An
evidence based review of the Literature, Ceydeli
A, Rucinsk J, Wise L; Current Surgery 2005 vol 62:2, 220-225
• Temporary abdominal closure with the
Vacuum pack technique, Ozguc H, Paksoy E,Ozturk E; Acta
Chir Belg 2008, 108 (414-419)
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Thank You!