CHAPTER XIII
Laparotomy Incisions and Closures, and Wound Dehiscences
Hugh F. Swingle, M. D., and Dominic S. Condie, M. D
In the 3,154 abdominal injuries treated by teams of the 2d Auxiliary SurgicalGroup, 2,258 records were sufficiently complete to permit an analysis of thetechnique of incision and closure, as well as an analysis of the 36 wounddehiscenses which occurred in these cases within the period of postoperativeobservation at forward hospitals (a usual range of 8 to 14 days).
INCISIONS
Of the abdominal incisions in these 2,258 cases, 2,072 (91.8percent) were vertical, and the remainder were transverse (table 25). The greatpreponderance of vertical incisions reflects the consensus of the surgeons ofthe group
TABLE 25.-Distribution of abdominalincisions and wound dehiscences in 2,258 abdominal injuries
Incision | Cases | Proportion | Dehiscence | Frequency |
|
| Percent | Number | Percent |
Vertical:1 |
|
|
|
|
| High midline | 150 | 7.2 | 3 | 2.0 |
| Low midline | 268 | 12.9 | --- | --- |
| High rectus | 1,176 | 56.8 | 25 | 2.1 |
| Low rectus | 140 | 6.8 | 3 | 2.1 |
| High paramedian | 303 | 14.6 | 3 | 1.0 |
| Low paramedian | 35 | 1.7 | --- | --- |
| 2,072 | 100.0 | 34 | --- |
Transverse: |
|
|
|
|
| Subcostal | 54 | 29.0 | 1 | 1.8 |
| Gridiron | 46 | 24.7 | --- | --- |
| Loin | 26 | 14.0 | --- | --- |
| Anterior2 | 60 | 32.3 | 1 | 1.7 |
| 186 | 100.0 | 2 | --- |
| 2,258 | --- | 36 | 1.6 |
1All midrectus, midline, andparamedian incisions are arbitrarily grouped with the appropriate highincisions.
2This was an upper abdominal incision used to connect wounds of entryand exit.
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that transverse incisions were of very limited value in war wounds of theabdomen. There were two principal reasons for this opinion:
1. Vertical incisions permitted the extensions which wereoften necessary to secure satisfactory access to injuries not diagnosed beforethe abdomen was open.
2. Vertical incisions left the lateral and medial portions ofthe abdominal wall free for separate incisions for colostomies. Exteriorizationof the colon was necessary in a great many of these cases and was bestaccomplished through another incision rather than through the surgical incision.
CLOSURES
Forty different methods of closure were used in the 2,258laparotomy wounds on which this chapter is based, the different techniquesrepresenting the individual choices of the various surgeons. In general, thesemethods fell into four large groups (table 26), with closure of the wound inlayers by means of catgut sutures supplemented by retention sutures comprisingmore than two-thirds of the cases. Mass closure, which was utilized in only 252cases, was usually accomplished by means of heavy braided silk, steel wire, ordoubled silkworm gut.
In some of the cases classified as layer closures, the peritoneum was closedwith a running suture of catgut, and the other layers were approximated withretention sutures which incorporated skin, fascia, and muscle, or merely skilland fascia. In some cases, interrupted sutures of silk or chromic catgut wereused in the anterior fascial layer, while the other layers were approximatedwith through-and-through sutures. In some cases, the peritoneum was closed bythe usual running catgut suture, while nonabsorbable sutures were used in theanterior fascial layer and retention sutures were placed by some one of theusual techniques. When retention sutures were omitted, interrupted cotton orsilk sutures were used for all layers, including the peritoneal layer.
Method | Cases | Proportion | Dehiscence | Frequency |
|
| Percent | Number | Percent |
Layer closure: |
|
|
|
|
| Catgut, retention sutures | 1,536 | 68.0 | 22 | 1.4 |
| Interrupted silk or cotton sutures in anterior fascia | 333 | 14.7 | 7 | 2.1 |
| No retention sutures | 1137 | 6.1 | 1 | .7 |
Mass closure, through-and-through sutures only | 252 | 11.2 | 6 | 2.4 |
| 2,258 | 100.0 | 36 | 1.6 |
1The majority of patients inthis category were submitted to exploration with negative findings or had onlyminimal lesions. For purposes of comparison, this group should therefore beexcluded.
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One variation in the technique of closure was the use of asmall gauze or rubber drain, placed just beneath the anterior fascia and usuallyremoved about the third day after operation. Gauze or rubber drains werefrequently placed in the subcutaneous tissue, to maintain separation of the skinedges for 2 or 3 days. Drainage of the incision was frequently carried out incontaminated wounds. Sometimes the skin was left open; sometimes it waspartially closed; and, in selected cases in which hollow viscera had not beenperforated, both subcutaneous and subfascial drainage were omitted, and it wassutured primarily.
In spite of the wide variety of techniques of closure which they employed, itwas the general feeling of the surgeons in the group that there was nosatisfactory substitute for accurate approximation of the various layers of theabdominal wall, combined with some method of retention suturing that wouldactually maintain wound closure. Mass closure, although it had a real place inthe management of patients in precarious condition, invariably meant thesacrifice of accurate layer approximation in the interest of saving time. As arule, therefore, it was resorted to only when the condition of the patient onthe operating table was so serious that prolongation of the procedure seemedlikely to deny him his best chance for recovery. Under these circumstances, massclosure was thought to be entirely justified and definitely indicated.
WOUND DEHISCENCES
The 36 wound dehiscences observed in the 2,258 abdominalinjuries on which this analysis is based (1.6 percent) all occurred in forwardhospitals in 1944 and 1945. If all the casualties could have been traced throughthe hospitals to which they were evacuated, the incidence might have beenconsiderably higher, as the following figures indicate: Of 250 patients wholived more than 7 days (out of 346 casualties with abdominal andthoracoabdominal injuries operated on by surgeons of the group in 1943), 30sustained wound dehiscences after they were evacuated to general hospitals.1
An analysis of these 36 cases reveals the following data:
The accidents happened from 1 to 19 days after operation, the average lapseof time being about 8 days. Exploration of the abdomen had been negative in onlyone instance; all the other patients had sustained some sort of intra-abdominalinjury. The small bowel was injured 21 times, the colon 17, the liver 9, thestomach 7, the kidney 4, the spleen twice, and the urinary bladder twice (thefigures are overlapping). The diaphragm was injured in 7 cases, andretroperitoneal hematomas were present in 4 cases. The order of frequency ofvisceral injuries thus coincided with the order of frequency in the entireseries of 3,154 cases (table 7, p. 92), which suggests that wounds to specificviscera cannot be regarded as predisposing to wound disruption.
1Report on the Surgery of Abdominal Wounds (unpublished data), submitted tothe commanding officer, 2d Auxiliary Surgical Group, 14 April 1944.
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The precise cause of the accident was not evident in any ofthese 36 cases, but the following conditions (multiple in 1 instance) probablycontributed to the disruptions: Distention, in 10 cases; wound sepsis, in 7cases; excessive coughing, in 4 cases; vomiting, spontaneous fistula of thesmall bowel, delirium, and clostridial myositis which required removal of theentire rectus muscle, in 3 cases each; severe nutritional deficiency in 2 cases;and spontaneous gastric fistula and the use of the laparotomy incision for thecolostomy, in 1 case each.
All the principal methods of closure failed at least once inthese 36 cases (table 26), and most of them failed in several. Layer closurewith nonabsorbable sutures of silk or cotton in the anterior fascia showed nosuperiority over closure with catgut sutures. In fact, on the basis of theavailable figures (table 26), the frequency was somewhat greater whennonabsorbable sutures were used. The incidence of disruption, as might have beenexpected, was higher for mass closure than for either of the two principalmethods of layer closure.
Retention sutures were used in the primary closure in 35 of the 36 cases. Inthe single case in which they were omitted, a running suture of plain catgut wasused in the peritoneal layer, the anterior fascia was closed with interruptedsutures of chromic catgut, and a Penrose drain was placed in the subfascialspace.
The figures concerning dehiscence in relation to the methodof employing retention sutures are of interest though of no statistical value(table 27). When they were placed through the skin and the fascia (either as aloop or a figure-of-eight), there were 2 wound disruptions in each 100 cases.When they included the skin, the fascia, and the muscle, there were 2.1disruptions in each 100 cases. When mass closure was employed, there were 2.4disruptions in each 100 cases. When, however, layer closure (closure of one ormore layers, with the skin usually left widely open) was combined withthrough-and-throughretention suturing, with all layers of the abdominal wall, including theperitoneum, incorporated in the retention sutures, there was only 1 disruptionin each 480 cases (0.2 percent).
Method | Cases | Proportion | Dehiscence1 | Frequency |
|
| Percent | Number | Percent |
Through skin and fascia | 813 | 38.3 | 16 | 2.0 |
Through skin, fascia, and muscle | 576 | 27.2 | 12 | 2.1 |
Through all layers of abdominal wall: |
|
|
|
|
| With layer closure | 480 | 22.6 | 1 | .2 |
| With mass closure | 252 | 11.9 | 6 | 2.4 |
| 2,121 | 100.0 | 35 | 1.6 |
1In 1 case of wound separation not included in this table, retention sutureswere not used.
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Catgut was used for the layer closure in the majority ofcases in which this combined technique was employed. The through-and-throughretention sutures were inserted in one of two ways: They were either pulled upand tied fairly snugly in the midline, or they were tied laterally over rubbertubes placed on each side of the incision. In only one instance in this seriesdid a possible mechanical intestinal obstruction result from the employment ofthis technique. The obstructive signs in this case disappeared when thethrough-and-through sutures were released on the fifth postoperative day, andrecovery thereafter was smooth.
The use of pulley sutures, either for mass closure or as a method ofretention suturing to supplement layer closure, produced almost uniformly poorresults in this series. Reports from general hospitals mentioned a number ofcases in which strangulation of the tissues was followed by massive sloughs andwhich usually required secondary wound closure.
Management
In 7 of these 36 instances of wound dehiscence, the wound wastaped and no surgery was done. In 28 cases, secondary suture was carried out.Silk through-and-through sutures were used in 16 cases, wire through-and throughsutures in 11 cases, and silk figure-of-eight sutures in 1 case. The remainingpatient died on the operating table before surgery could be started. Twopatients, one of whom had been treated conservatively and the other by secondarysuture, later presented small intestinal fistulas.
Causes of Death
There were 7 deaths in these 36 cases, 5 of which wereapparently caused by the wound dehiscence itself. One patient, as already noted,died on the operating table, partly from shock and partly from the anesthetic.In one case, fatal peritonitis followed retraction of a colostomy (which hadbeen exteriorized in the laparotomy wound) into the peritoneal cavity. In onecase, peritonitis resulted from two leaking areas in the small bowel caused bytrauma from the through-and-through wire sutures used in the secondary closure.In one case, death occurred 4 hours after secondary suture; aspiration ofvomitus during anesthesia was followed by fatal pulmonary and bronchial edema.In the remaining case, which was treated conservatively, death was the result ofacute mechanical intestinal obstruction.
Prophylaxis
The large number of wound dehiscences reported in 1943, to which referencehas already been made,2 provoked serious consideration among the surgeons ofthe 2d Auxiliary Surgical Group. The whole subject of wound closure was studied,and special attention was given to measures which might prevent futureaccidents. Analysis of the cases reported in 1943 revealed certain
2See footnote 1, p. 193.
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practices which could be considered as possibly causative.Thus it was not uncommon in the early experience in the North African theater toomit retention sutures in laparotomy wounds, even though the incisions wereusually closed in layers. It was also not uncommon to exteriorize a damagedsegment of colon in the laparotomy incision rather than in a separate smallincision. Finally, it was a rather common practice to evacuate patients withabdominal wounds prematurely (that is, before the optimal interval of 10 to 14days), even though evacuation necessitated long ambulance hauls over terrainthat was often rough. The policy of eliminating all of these practicesunquestionably played a part in reducing the incidence of wound dehiscence in1944 and 1945.
No policy, however, and no technique could entirely preventwound dehiscence, to which there existed a natural tendency in penetrating andperforating injuries of the abdomen. For this there were a number of reasons:
1. Massive soiling of the peritoneal cavity, as the result of perforation ofhollow viscera, produced peritonitis, either chemical or bacterial, in a largeproportion of cases and also resulted in heavy contamination of the laparotomyincision. Clinical sepsis, with its deleterious effects on sound wound healing,not infrequently followed.
2. Prolonged nasogastric suction was essential in these injuries at a timewhen nutritional reserves were likely to be critically low.
3. The rather high incidence of pulmonary complications, especially duringthe winter months, and the resulting severe and protracted cough often addedconsiderably to the strain on the abdominal incision.
4. The tactical situation was sometimes such that patients with abdominalinjuries had to be evacuated soon after operation, in spite of theundesirability of the practice. The combined effect of these variousuncontrollable factors explains why even in 1944 and 1945, when conscientiousefforts were made to prevent it, the incidence of wound dehiscence was farhigher among military casualties with abdominal injuries than it would be in aseries of nontraumatic abdominal operations in civilian life.
The measures employed to prevent wound disruption were multiple and, if theywere to be effective, had to be instituted as soon as the incision was made. Thetrauma of both incision and closure was kept to a minimum. Gross soiling andcontamination of the incision were avoided in every possible way. The Halstedianprinciples of tissue handling were sedulously employed to prevent woundreaction, the absence of which favored uncomplicated wound healing. Certainphysiologic and chemical principles were also borne in mind: The erythrocytecount was kept at 4 million per cubic millimeter, or higher, and the hemoglobinlevel was kept above 12 gm. percent. Plasma was given in amounts of 250 cc. onceor twice daily as long as Wangensteen decompression was required. Vitamin C wasgiven parenterally over the same period and was given orally as soon as feedingby mouth could be resumed. The patient was evacuated with the retention suturesstill in situ, and, during transit, additional abdominal support was provided bya binder, preferably of the scultetus type.
