224
The scientific basis of the management of injury, wounds, and ulcers
variations are attributable to the minutiae of anastomotic technique. Anastomotic safety depends on the integration of many factors, of which sound judgment, meticulous preparation, sound technique, of which the single-layer serosubmucosal method using braided polyamide is an example, antibiotic lavage, and avoidance of anastomotic drains and of neostigmine form a personal creed. Although these are some of the more tangible aspects of safety in repair after resection they are not only elusive of study but may also be individually less important. Together they make a 'package deal' that might possibly lend itself to evaluation and to adoption.
References I Fielding, L P (1978) Personal communication. 2 Goligher, J C, Graham, N G, and De Dombal, F T (1970) British Journal of Surgery, 57, I09. 3 Rosenberg, I L, Graham, N G, De Dombal, F T, and Goligher, J C (I97I) British Journal of Surgery, 58, 266. 4 Hawley, P R (1970) Proceedings of the Royal Society of Medicine, 63, 752. 5 Debas, H T, and Thomson, F B Surgery, Gynecology and Obstetrics, I35, 747. 6 Adamsons, R J, Musco, F, and Enquist, I F (I965) Surgery, Gynecology and Obstretics, 12I, 1028.
7 Jenkins, T P N (1976) British Journal of Surgery, 63, 873. 8 Stewart, D J, and Matheson, N A (1978) British Journal of Surgery, 65, 54. 9 Stewart, D J, and Matheson, N A (1978) British Journal of Surgery, 65, 57. io Schrock, T R, Deveney, C W, and Dunphy, J E (I973) Annals of Surgery, I77, 5I3. ii Bell, C M A, and Lewis, C B (I968) British Medical Journal, 3, 587. I2 Matheson, N A, and Irving, A D (I975) British Journal of Surgery, 62, 239. I3 Halsted, W S (I887) American Journal of the Medical Sciences, 94, 436. I4 Hamilton, J E (I967) Annals of Surgery, i65, 917. I5 Letwin, E, Williams, H T G, and Harrison, R C (I967) Journal of the Royal College of Surgeons of Edinburgh, 12, I 2I. i6 Orr, N W M (I969) British Journal of Surgery, 56, 771. I7 McAdams, A J, Meikle, A G, and Taylor, J 0 (I970) American Journal of Surgery, I20, 546. i8 Everett, W G (I975) British Journal of Surgery, 62, 135.
I9 Goligher, J C, Lee, P W G, Simpkins, K C, and Lintott, D J (1977) British Journal of Surgery, 64, 609. 20 Matheson, N A, and Irving, A D (1976) Surgery, Gynecology and Obstetrics, 143, 619. 2I Gilmour, D G, Aitkenhead, A R, Hothersall, A P, and Ledingham, I McA British Journal of Surgery. In press.
CLOSURE OF THE ABDOMINAL WOUND Thomas T Irvin PhD chM FRcSEd Consultant Surgeon, Royal Devon and Exeter Hospital (Wonford), Exeter. Formerly Reader in Surgery, University Surgical Unit, Royal Infirmary, Sheffield
Introduction Almost every general surgeon who is practised in the art of abdominal wound suture might reasonably regard himself as an expert on the subject of abdominal wound healing. Yet the undeniable fact is that abdominal wound dehiscence and incisional hernia are familiar complications in modem surgical practice. Wound dehiscence or burst abdomen occurs in 1-3% of patients undergoing laparotomy through vertical incisions13 and incisional hernias occur in 4-I0% of cases35. These are serious complications and are not confined to cachectic patients or patients with advanced malignancy. In a recent study3 they occurred most frequently after elective operations for
peptic ulcer or gallstones and in another study' almost 50% of the patients who burst their abdominal wounds failed to survive this complication. It is understandable, therefore, that much research has been carried out on abdominal wound healing. It has been shown7 that various local and systemic factors may adversely affect the process of wound repair, but Dudley8 and Jenkins9 have suggested that abdominal wound disruption is essentially a mechanical problem. The abdominal wound is subjected to considerable mechanical forces. Coughing or any other factor which results, in abdominal distension will exert a lateral pull on the wound which may cause the suture material to cut
The scientific basis of the management of injury, wounds, and ulcers
225
Method
The conventional method of abdominal wound closure in layers, and the 'mass closure' technique.
through the wound edges. Distension also increases the length of the abdominal wound9 and this is a further factor which will tend to cause sutures to cut through when the wound is closed with a continuous suture. Most surgeons use a layered technique of closure of laparotomy wounds: a precise anatomical apposition of the peritoneal and fascial layers is achieved with two layers of sutures placed close to the cut edges (see figure). Jenkins9 has shown that there is really a rather narrow margin of safety in this technique of closure and it has been suggested8' 9 that a greater degree of safety is provided by the 'mass closure' technique (see figure), in which the sutures are placed at some distance from the wound edges through all layers of abdominal wall except skin. In theory this technique results in less tension at the suture-wound interface and less risk of the sutures cutting through. Current opinion'0 is therefore that closure in layers should be abandoned in favour of mass closure or that if layered closure is used this should be protected by the addition of through-and-through retention sutures. Several reports9' 11, 12 have suggested that the use of these techniques may largely avoid the problems of postoperative wound dehiscence and incisional hernia. In the Surgical Unit in Sheffield we have recently assessed the relative merits of mass closure and layered closure with retention sutures in a randomised prospective clinical trial.
The two methods of closure were randomly allocated in a consecutive series of 200 patients undergoing laparotomy through vertical median or paramedian wounds in the Professorial Surgical Unit at the Sheffield Royal Infirmary. All the senior and junior members of the surgical team (2 consultants and 3 registrars) participated in the trial. In Method I (ioo patients) a layered closure was performed with two layers of continuous 3 metric gauge polypropylene (Prolene) supported by interrupted braided polyester retention sutures (Ethibond) inserted through all layers of the abdominal wall. In Method II (Ioo patients) a single-layer mass closure was performed using interrupted figure-of-eight sutures of3 metric gauge monofilament stainless steel wire inserted through all layers of the abdominal wall except skin. The wire sutures were knotted by hand and the cut ends were carefully buried beneath the abdominal fascia. In both methods the skin was closed with interrupted silk sutures. The incidence of wound dehiscence, wound infection, and incisional hemia was recorded and the patients were followed up for 6 months after surgery. The x2 test was used in the statistical analysis of the results.
Results Nine patients (5 Method I and 4 Method II)
were excluded from the study, 6 dying before a reasonable assessment of wound healing could be made and 3 requiring a further laparotomy in the early postoperative period. The two groups were well matched for age and sex, types of surgery performed, types of wounds, incidence of palliative and emergency operations, and surgeons closing the wounds. WOUND DEHISCENCE AND INCISIONAL HERNIA
There was I case of wound dehiscence (burst abdomen) after each method of closure. In addition, incisional hernias occurred in 4 patients treated by Method I and in 5 by Method II. The total incidence of wound failure (dehiscence plus hernia), therefore, was 5.3% with Method I and 6.3% with Method II. WOUND INFECTION This complication was recorded only when pus discharged from the abdominal wound and occurred in 15 patients treated by Method I (I 5.8 %) and I 3 by Method II (I 3.5 o%). It occurred after akl types of gastrointestinal surgery but most commonly after colorectal surgery. VARIABLES AFFECTING WOUND HEALING Wound
dehiscence and incsional hernia were not significantly related to the type of surgery
226
The scientific basis of the management of injury, wounds, and ulcers
performed, emergency operations, the type of wound (median or paramedian), or the surge(on performing the wound closure. However, wound infection was a highly significant factor in the pathogenesis of these complications. Dehiscence or herniation occurred in 4 (25Co) of I63 clean wounds and in 7 (25%) of 28 infected wounds (X2=I8.43, P
The scientific basis of the management of injury, wounds, and ulcers
variations are attributable to the minutiae of anastomotic technique. Anastomotic safety depends on the integration of many factors, of which sound judgment, meticulous preparation, sound technique, of which the single-layer serosubmucosal method using braided polyamide is an example, antibiotic lavage, and avoidance of anastomotic drains and of neostigmine form a personal creed. Although these are some of the more tangible aspects of safety in repair after resection they are not only elusive of study but may also be individually less important. Together they make a 'package deal' that might possibly lend itself to evaluation and to adoption.
References I Fielding, L P (1978) Personal communication. 2 Goligher, J C, Graham, N G, and De Dombal, F T (1970) British Journal of Surgery, 57, I09. 3 Rosenberg, I L, Graham, N G, De Dombal, F T, and Goligher, J C (I97I) British Journal of Surgery, 58, 266. 4 Hawley, P R (1970) Proceedings of the Royal Society of Medicine, 63, 752. 5 Debas, H T, and Thomson, F B Surgery, Gynecology and Obstetrics, I35, 747. 6 Adamsons, R J, Musco, F, and Enquist, I F (I965) Surgery, Gynecology and Obstretics, 12I, 1028.
7 Jenkins, T P N (1976) British Journal of Surgery, 63, 873. 8 Stewart, D J, and Matheson, N A (1978) British Journal of Surgery, 65, 54. 9 Stewart, D J, and Matheson, N A (1978) British Journal of Surgery, 65, 57. io Schrock, T R, Deveney, C W, and Dunphy, J E (I973) Annals of Surgery, I77, 5I3. ii Bell, C M A, and Lewis, C B (I968) British Medical Journal, 3, 587. I2 Matheson, N A, and Irving, A D (I975) British Journal of Surgery, 62, 239. I3 Halsted, W S (I887) American Journal of the Medical Sciences, 94, 436. I4 Hamilton, J E (I967) Annals of Surgery, i65, 917. I5 Letwin, E, Williams, H T G, and Harrison, R C (I967) Journal of the Royal College of Surgeons of Edinburgh, 12, I 2I. i6 Orr, N W M (I969) British Journal of Surgery, 56, 771. I7 McAdams, A J, Meikle, A G, and Taylor, J 0 (I970) American Journal of Surgery, I20, 546. i8 Everett, W G (I975) British Journal of Surgery, 62, 135.
I9 Goligher, J C, Lee, P W G, Simpkins, K C, and Lintott, D J (1977) British Journal of Surgery, 64, 609. 20 Matheson, N A, and Irving, A D (1976) Surgery, Gynecology and Obstetrics, 143, 619. 2I Gilmour, D G, Aitkenhead, A R, Hothersall, A P, and Ledingham, I McA British Journal of Surgery. In press.
CLOSURE OF THE ABDOMINAL WOUND Thomas T Irvin PhD chM FRcSEd Consultant Surgeon, Royal Devon and Exeter Hospital (Wonford), Exeter. Formerly Reader in Surgery, University Surgical Unit, Royal Infirmary, Sheffield
Introduction Almost every general surgeon who is practised in the art of abdominal wound suture might reasonably regard himself as an expert on the subject of abdominal wound healing. Yet the undeniable fact is that abdominal wound dehiscence and incisional hernia are familiar complications in modem surgical practice. Wound dehiscence or burst abdomen occurs in 1-3% of patients undergoing laparotomy through vertical incisions13 and incisional hernias occur in 4-I0% of cases35. These are serious complications and are not confined to cachectic patients or patients with advanced malignancy. In a recent study3 they occurred most frequently after elective operations for
peptic ulcer or gallstones and in another study' almost 50% of the patients who burst their abdominal wounds failed to survive this complication. It is understandable, therefore, that much research has been carried out on abdominal wound healing. It has been shown7 that various local and systemic factors may adversely affect the process of wound repair, but Dudley8 and Jenkins9 have suggested that abdominal wound disruption is essentially a mechanical problem. The abdominal wound is subjected to considerable mechanical forces. Coughing or any other factor which results, in abdominal distension will exert a lateral pull on the wound which may cause the suture material to cut
The scientific basis of the management of injury, wounds, and ulcers
225
Method
The conventional method of abdominal wound closure in layers, and the 'mass closure' technique.
through the wound edges. Distension also increases the length of the abdominal wound9 and this is a further factor which will tend to cause sutures to cut through when the wound is closed with a continuous suture. Most surgeons use a layered technique of closure of laparotomy wounds: a precise anatomical apposition of the peritoneal and fascial layers is achieved with two layers of sutures placed close to the cut edges (see figure). Jenkins9 has shown that there is really a rather narrow margin of safety in this technique of closure and it has been suggested8' 9 that a greater degree of safety is provided by the 'mass closure' technique (see figure), in which the sutures are placed at some distance from the wound edges through all layers of abdominal wall except skin. In theory this technique results in less tension at the suture-wound interface and less risk of the sutures cutting through. Current opinion'0 is therefore that closure in layers should be abandoned in favour of mass closure or that if layered closure is used this should be protected by the addition of through-and-through retention sutures. Several reports9' 11, 12 have suggested that the use of these techniques may largely avoid the problems of postoperative wound dehiscence and incisional hernia. In the Surgical Unit in Sheffield we have recently assessed the relative merits of mass closure and layered closure with retention sutures in a randomised prospective clinical trial.
The two methods of closure were randomly allocated in a consecutive series of 200 patients undergoing laparotomy through vertical median or paramedian wounds in the Professorial Surgical Unit at the Sheffield Royal Infirmary. All the senior and junior members of the surgical team (2 consultants and 3 registrars) participated in the trial. In Method I (ioo patients) a layered closure was performed with two layers of continuous 3 metric gauge polypropylene (Prolene) supported by interrupted braided polyester retention sutures (Ethibond) inserted through all layers of the abdominal wall. In Method II (Ioo patients) a single-layer mass closure was performed using interrupted figure-of-eight sutures of3 metric gauge monofilament stainless steel wire inserted through all layers of the abdominal wall except skin. The wire sutures were knotted by hand and the cut ends were carefully buried beneath the abdominal fascia. In both methods the skin was closed with interrupted silk sutures. The incidence of wound dehiscence, wound infection, and incisional hemia was recorded and the patients were followed up for 6 months after surgery. The x2 test was used in the statistical analysis of the results.
Results Nine patients (5 Method I and 4 Method II)
were excluded from the study, 6 dying before a reasonable assessment of wound healing could be made and 3 requiring a further laparotomy in the early postoperative period. The two groups were well matched for age and sex, types of surgery performed, types of wounds, incidence of palliative and emergency operations, and surgeons closing the wounds. WOUND DEHISCENCE AND INCISIONAL HERNIA
There was I case of wound dehiscence (burst abdomen) after each method of closure. In addition, incisional hernias occurred in 4 patients treated by Method I and in 5 by Method II. The total incidence of wound failure (dehiscence plus hernia), therefore, was 5.3% with Method I and 6.3% with Method II. WOUND INFECTION This complication was recorded only when pus discharged from the abdominal wound and occurred in 15 patients treated by Method I (I 5.8 %) and I 3 by Method II (I 3.5 o%). It occurred after akl types of gastrointestinal surgery but most commonly after colorectal surgery. VARIABLES AFFECTING WOUND HEALING Wound
dehiscence and incsional hernia were not significantly related to the type of surgery
226
The scientific basis of the management of injury, wounds, and ulcers
performed, emergency operations, the type of wound (median or paramedian), or the surge(on performing the wound closure. However, wound infection was a highly significant factor in the pathogenesis of these complications. Dehiscence or herniation occurred in 4 (25Co) of I63 clean wounds and in 7 (25%) of 28 infected wounds (X2=I8.43, P
