Closing Midline Incisions

Clinical Case

Incisional hernia remains a common complication after abdominal surgery, frequently requiring reoperation for its definitive treatment. The decisions that have to be made when closing an abdominal incision are crucial. Some examples are the continuous or interrupted suturing technique, the suture length to wound length ratio and the size of the stitch.

In this lecture, Dr Leif Israelsson focuses on these aspects. In 1997, he demonstrated that a suture length to wound length ratio < 4 was associated with an almost four times higher risk of an incisional hernia, even more than in those patients with overweight or who had previously developed wound infections. The importance of this suture length to wound length ratio lies in the fact of diminishing the separation of the wound edges in the postoperative period.

The classical stitch includes the entire thickness of the tissue, from the peritoneum to the subcuticular fat. This might cause necrosis, leading first to wound infections and lately to incisional hernias. Nowadays, there is enough evidence to recommend suturing only the aponeurosis with “small” stitches (3 mm between the stitch and the aponeurotic edge). A randomised trial comparing the “small” and “large” stitch techniques concluded that wound infections and incisional hernias were more common when “large” stitches were used (5% vs 10% and 5% vs 18%, respectively and with statistical significance).

Based on the current literature, Dr Leif Israelsson provides an update on the importance of these concepts when closing an abdominal incision, manoeuvre that every general surgeon should master. Incisional hernia remains a common complication after abdominal surgery, frequently requiring reoperation for its definitive treatment. The decisions that have to be made when closing an abdominal incision are crucial. Some examples are the continuous or interrupted suturing technique, the suture length to wound length ratio and the size of the stitch.