Abdominal Wall Anatomy & Fascia Closure_sept

ABDOMINAL WALL ANATOMY & FASCIA

CLOSURE

Dr. Vikram Jaisinghani

Big Picture

Training:

PDS PLUS Sutures

Agenda

Skin: anatomy

Wound healing

Factors affecting wound healing

Complications of Wound healing

Anterior Abdominal Wall (AAW) Anatomy

AAW Complications & factors affecting healing

8 Strategies to reduce complications

Skin: anatomy

Wound healing

Epidermis: provides waterproofing and serves as a barrier to infection, no blood vessels

Dermis: location for the appendages of skin

Connective tissue

Basement membrane (anchors dermis)

Nerve endings (touch/heat)

Sweat glands

Sebaceous glands

Apocrine glands

Hair follicles

Lymphatic vessels

Blood vessels

Basic Anatomy of Skin and Fascia

Epidermis

Dermis

Subcutaneous

tissue (fat)

Fascia/Muscle

Skin and Fascia

1 = skin and subcutaneous tissue; 2 = fascia

Skin: anatomy

Wound healing

Classification of wounds

Types of wound healing

Phases of wound healing

Factors that influence wound healing

Abrasions

Lacerations

Punctures

Incisions

Classification of Acute Skin Wounds

Surgical

Strecker-McGraw et al. Emerg Med Clin North Am. 2007;25:1-22.

Traumatic

Traumatic Wounds and Lacerations

Traumatic wounds are common and bear extensive medical costs US >26 million/year = $35 billion1,2

EU >42 million/year = €15 billion3

Physical exam should be careful and meticulous4

Time and mechanism of injury

Potential for infection

Hemostasis

Foreign bodies

Timeframe for closure: maximum of 24 hours from the time of injury5

1. National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary.

2. CDC NEISS All Injury Program 2005 Results.

3. EU Injury Database Report 2009.

4. Lammers. Principles of wound management. In: Roberts and Hedges. Clinical Procedures in Emergency Medicine. 5th ed.

Saunders Press; 2010.

5. Pfaff and Moore. Emerg Med Clin North Am. 2007;25:189.

‒ Tendon, vascular, and joint injuries

‒ Neurovascular exam

‒ Patient history

Classification of wounds

Bacterial presence:

• Contamination: Bacteria are present, but not proliferating

• Colonization: Bacteria proliferating without host reaction

• Infected tissue: Deposition and proliferation of micro-

organisms in the organism, with consequent host reaction

Defining Wound Healing

A “healed wound” is one where1

Connective tissues have been repaired and

Wound has been completely epithelialized by regeneration that has returned to its normal anatomic structure and function without the need for continued drainage or dressing

Some wounds fail to heal properly - chronic, non-healing wounds- need continued management2

Aberrations in certain phases of healing -result in excessive healing (hypertrophic scars, keloids)2

1. Enoch SE and Leaper DJ. Surgery. 2008;26:31-37.

2. Ethridge RT, Leong M and Phillips LG. Wound Healing. In: Townsend CM, Beauchamp RD, Evers BM and Mattox KL, eds.

Sabiston Textbook of Surgery. 18th ed. Saunders, 2007:191-216.

Types of Wound healing

Wounds or incisions can heal in different ways: Primary healing

- direct wound healing without complications (wound is closed with sutures)

- Secondary healing - indirect wound healing with complications; wound edges are

not approached with sutures - Spaces between the wound edges are filled by granulation

Tissue Tertiary healing - wound is filled by granulation tissue & is infection free (wound edges are approximated with sutures)

Clean incision

Primary healing/healing by primary intention Wound is closed within 12-24 hours

Examples: clean surgical incision,

clean laceration

Result: optimal cosmetic outcome

Delayed primary healing

Delineated wound that is closed after a few days having been left open to prevent infection

Examples: bites, abdominal wounds after peritoneal soiling

May result in scarring

Secondary healing (healing by secondary intention)

Wound with extensive loss of soft tissue

Examples: trauma, severe burns, open abdomen

May result in scarring

Three Major Types of Wound Healing

Ethridge et al. Wound healing. In: Townsend et al, eds. Sabiston Textbook of Surgery. 18th ed. Saunders; 2007.

Stages of Primary Wound healing

Exudative /Inflammatory phase Proliferative phase Remodeling phase

0-5 days

suture material is the

sole factor in holding

together the wound

Suture – high tensile

strength

5- 14 Days

stabilization of

the wound

closure is

gradually taken

over by

collagen

Suture- highest

tensile strength

7-14 days to a

suture material

becomes

irrelevant

Foreign

material- side

effects

1. Exudative/Inflammatory phase: 0 - 5 days

Suture Material is responsible for the adaptation of the wound

Phases of Primary wound healing

4-6 days

2. Proliferative phase: 5-14 days

Collagen grows in and increases the stability of the wound

3. Reparative phase: 21 days – 1 year

Any foreign material can cause side effects

The Phases of Wound Healing

ECM = extracellular matrix; MMP = metalloproteinases; TIMP = tissue inhibitors of metalloproteinases.

Enoch S and Leaper DJ. Surgery. 2008;26:31-37.

0.1 0.3 1 3 10 30 100 300

Days after wounding (log scale)

Further synthesis

of ECM

MMP and TIMP activity

IV Remodelling and scar formation

ration

Neutrophils

Phagocytosis

Lymphocytes

Macrophages

II Inflammatory phase

ECM formation

Angiogenesis and

granulation tissue

formation

Re-epithelialization

Alterations in one or more of these

phases could result in chronic wounds

Abnormalities in these phases result

in hypertrophic scars and keloids

III Proliferative phase

Cytokines and growth factors

Stages of Secondary Wound healing

Exudative (inflammatory) phase Proliferative phase Remodeling Phase

Weeks Months Days

“Tenets of Halsted” Continue to Guide Surgeons

Gentle handling of tissue

Aseptic technique

Sharp anatomic dissection of tissue

Careful hemostasis, using fine, nonirritating suture material in minimal amounts

Obliteration of dead space in the wound

Avoidance of tension

Foy HM, Evans SRT. Teaching technical skills-Errors in the process. In: Grand SRT. Surgical Pitfalls: Prevention and

Management. Saunders; 2009:11-22.

Skin: anatomy

Wound healing

Factors Influencing Wound Healing

Operative/

Surgeon

Factors

Tissue

Factors

Patient

Factors

Healing

Classification of Factors That May Impede Wound Healing

Advanced age

Metabolic factors

Immunosuppression/ persisting disease

Deficiency syndromes

Shock of any cause

Infection

Presence of foreign body and foreign body reactions

Increased skin tension

Blood supply

Continued presence of micro-organisms

Infection

Systemic Local

Leaper. Basic surgical skills and anastomoses. In: Bailey and Love’s Short Practice of Surgery. 25th ed.

Edward Arnold Ltd; 2008.

Factors Leading to Risk of Compromised Healing

Advanced age (>70 years old)

Obesity

Smoking

Poor glucose control or hyperglycemia

Diabetes (type 1/2)

Nutritional or immunologic impairment

Low serum albumin concentration

A patient with even ONE of these risk factors is at greater risk of developing a surgical site infection (SSI)

1.Mangram AJ et al. Am J Infect Control Hosp Epidemiol. 1999;27:97-134.

2.NICE Clinical Guideline. October 2008.

3.World Health Organization. WHO Guidelines for Safe Surgery 2009. 2009.

Some Wounds Are More Likely to be Infected

Wounds are generally classified into 4 categories1:

Class 1 = Clean

Class 2 = Clean contaminated

Class 3 = Contaminated

Class 4 = Dirty infected

Contaminated or dirty/infected wound classifications are independently associated with increased risk of SSI1

1.Mangram et al. Infect Control Hosp Epidemiol. 1999;20:247-277.

Class Definition

I – Sterile

(Clean)

• No trauma effect

• No inflammation

• No breach of sterility

• Tracheobronchial system, GI tract and urogenital

tract intact

II – Mildly

contaminated

(Clean-

contaminated)

• Opening of the GI tract

• Appendectomy

• Opening of the oropharynx

• Opening of the vagina

• Opening of the urinary tract collecting system for

sterile urine

• Opening of the bile system with sterile bile

• minimal breach of sterility 29

Classification of wounds based on infection

Class Definition

III – Strongly

Contaminated

(Contaminated)

• Opening of the lower GI tract

• Traumatic wounds

• Opening of the collecting system with infected urine

• Opening of bile ducts with infected bile

• Breach of sterility

IV – Infected

(Dirty)

• Bacterial infection in OP area

• Draining of abscesses

• Traumatic wounds with necrosis, foreign bodies and

exit of faeces

• Old wounds

• Bite wounds or similar

Classification of wounds based on infection

Suture Contamination Can Increase Risk of Infection

Biofilms: every suture acts as a medical implant, increasing the risk of infection via bacterial colonization1

1. Mangram et al. Infect Control Hosp Epidemiol. 1999;20:247-277.

2. Suzuki T et al. J Clin Microbiol. 2007;45:3833-3836.

SSI Video

Local Tissue Trauma Can Impede Healing

Tissue trauma can result from:

Devices used for closure

Handling of tissue

Proper Suturing Technique: Critical Components of Wound Healing

Wound edges should be left slightly gaping to allow swelling

Edges should be everted

The knot should be placed to one side of the wound

Knots must be secure, with the ends long enough to grasp if the suture is to be removed

Use “no touch” technique whenever possible

Use appropriate needle holders

Leaper D. Basic surgical skills and anastomoses. In: Bailey and Love’s Short Practice of Surgery. 25th ed.

Edward Arnold Ltd; 2008.

Tissue Specific Healing Time Guides the Choice of Tissue Repair Material

14-28 days

7-14 days

8-12 weeks

*Minimum healing times shown here are for healthy individuals without medical complications.

14-28 days

7-14 days

8-12 weeks

5-7 days

Skin: anatomy

Wound healing

Examples of Wound Healing Complications

Dehiscence Infection Scarring

Images courtesy of David Leaper, MD.

Wound Healing Complications: Scar Formation

Typical scar characteristics

Flat surface

Narrow

Matches skin color

Harahap (ed). Surgical Techniques for Cutaneous Scar Revision. Marcel Dekker; 2000:81-106.

Téot. Wound Repair Regen. 2002;10:93-97.

Elevated Depressed Hypertrophic Keloids

Complicated scars

Wound Healing Complications: Dehiscence

Mechanism may be an underlying wound healing problem or surgical

technique

Surgical site infection (SSI) is a

major risk factor for dehiscence

Images courtesy of David Leaper, MD

Lammers. Principles of Wound Management. In Robert’s Clinical Procedures in Emergency Medicine. Saunders Press. 2010.

Wound Healing Summary

Healing of acute wounds: a complex, dynamic series of events

Optimal wound healing by primary intention; not possible in all cases

Many factors delay or impede wound healing: long-term complications-steps can be taken to ensure best outcomes

SSI prevention is a critical factor in achieving optimal acute and long-term wound healing

Skin: anatomy

Wound healing

Anterior Abdominal Wall

Fascia Anatomy

Basic Anatomy of Skin and Fascia

Epidermis

Dermis

Subcutaneous

tissue (fat)

Fascia/Muscle

Skin and Fascia

1 = skin and subcutaneous tissue; 2 = fascia

Anterior Abdominal Wall Anatomy

General Characteristics:

Three large flat sheets of muscle connecting rib

cage to hip bone (pelvis).

Muscular posteriorly and laterally.

Aponeurotic anteriorly and medially.

Muscle layers:

o External oblique.

o Internal oblique.

o Transversus abdominus.

o Rectus abdominus.

Anterior Abdominal Wall

Abdominal Wall: Muscles (I)

Consists of Three broad thin sheets that are aponeurotic in front

From exterior to interior they are:

- External oblique

- Internal oblique

- Transverse abdominus

A wide vertical muscle lies on either side of the midline anteriorly:

- Rectus abdominis muscle

Abdominal Wall: Muscles (II)

As the aponeurosis of three sheets pass forward, they enclose the rectus abdominis to form the rectus sheath

The cremaster muscle which is derived from the lower fibers of internal oblique, passes inferiorly as a covering of the spermatic cord and enters scrotum

Abdominal Wall: Muscles (III)

External Oblique Muscle: Is a broad, thin, muscular sheet Origin: Lower 8 ribs Insertion: Xiphoid process, linea alba, pubic tubercle, iliac crest Action: Supports abdominal contents, assist in forced expiration,

micturition (passing urine), defecation, parturition, vomiting

Internal Oblique Muscle: Origin: Lumbar fascia, iliac crest, lateral two-thirds of inguinal

ligament Insertion: Lower three ribs and costal cartilages, xiphoid process,

linea alba, symphysis pubis Action: Supports abdominal contents, assist in forced expiration,

micturition, defecation, parturition, vomiting

External Oblique Muscle Xiphoid process

Pubic symphysis &

tubercle

(middle part of the

pelvic or hip bone)

Costal margin (lower

margin of the rib cage)

Anterior Superior

Iliac Spine

Abdominal Wall: Muscles (IV)

Transversus Abdominus muscle:

Origin: Lower six costal cartilages, lumbar fascia, iliac crest, lateral third of inguinal ligament

Insertion: Xiphoid process, linea alba, symphysis pubis

Action: Compresses abdominal contents

Rectus Abdominus muscle: Origin: Symphysis pubis and pubic crest

Insertion: 5th, 6th and 7th costal cartilages and xiphoid process

Action: Compresses abdominal contents, flexes vertebral column, accessory muscle of expiration

Internal Obliques & Rectus Abdominus

Xiphoid process

Pubic symphysis &

tubercle

(middle part of the

pelvic or hip bone)

Costal margin

(lower margin of

the rib cage)

Anterior Abdominal Wall: Cross Section

Tissue layers of the abdominal wall

1. Skin : Epidermis

2. Subcutaneous : Fat layer underneath skin

3. Fascia : Connective tissue layer covering muscle

4. Muscles : Fibrous tissue strand 5. Peritoneum : Serous membrane that forms the lining of abdominal cavity

Rectus Sheath

Is a long fibrous sheath

Encloses the rectus abdominis

Formed mainly by aponeurosis of three lateral abdominal muscles

Between the costal margin and the level of the anterosuperior iliac spine, the aponeurosis of the internal oblique splits to enclose the rectus muscle

The external oblique aponeurosis is directed in front of the muscle

Transversus aponeurosis is directed behind the muscle

The posterior wall of the rectus sheath is not attached to the rectus abdominis muscle

The anterior wall is firmly attached to it by the muscle’s tendinous intersections

Linea Alba

The rectus sheath is separated from its fellow on the opposite side by a fibrous band called the linea alba

Extends from the xiphoid process to the symphysis pubis

Anterior Abdominal Wall: Cross Section

FASCIA (I): Anatomy

Fascia means ‘band’ in Latin

Fascia is connective tissue (see next slide)

Fascia can be found in every part of the body.

It is located between subcutaneous layer of the skin and the muscles

Non-vascularized - so it heals very slowly

FASCIA (II): Layers

Fascia is divided into 3 key layers.

1. Superficial fascia is attached to the bottom part of the dermis (the recticular dermis) and contains variable amounts of fat. It can stretch in any direction and adjusts quickly to tension, almost like a rubber band.

2. Deep fascia is thin and denser than the superficial fascia. It is also smooth and slippery, which allows the surrounding body parts to glide and slide over each other. This is the type of fascia that is found around muscles, bones, nerves, and vessels.

3. Visceral fascia is the thin, tough membrane that surrounds the viscera or internal organs and keeps them in place.

FASCIA (III): Functions

Fascia seperates tissue layers and provides a sliding/gliding environment for surfaces that need to move or slide along each other.

Fascia keeps things in place. For example: keeping suspending organs in correct orientation

Fascia provides support for blood vessels and nerves through and between muscles

FASCIA (IV): Abdominal Wall

Strongest tissue in the abdominal wall

Anterior and posterior fascia layer.

When discussing midline incisions, “fascia” usually refers to the anterior rectus fascia, the fascia above the rectus muscles. This fascia holds the abdominen together and is the most important layer of closure.

The fascia can extend beyond the muscles and bind to other fascia.

An extension of the fascia is called an aponeurosis.

Midline Abdominal Wall Incision

Midline incisions are made in the midline of the rectus abdominis muscle. The rectus abdominis is actually 2 muscles united by the aponeurosis, which is called the linea alba or “white line.”

Advantages of midline incisions:

1. Safe, as no major vessels nor nerves in the area

2. Faster than transverse incisions

3. Very good access to abdomen

FASCIA: Most Important layer in Closure

The fascia is considered the most important layer in closure of an abdominal surgical wound because it must bear the maximum stress on the incision.

Because of the slow healing time of fascia, immediate and extended wound support is a primary concern.

stress stress

suture in fascia holding

maximum stress on the

incision

Anterior Abdominal Wall Wound complications

Factors affecting healing

Goals of fascia closure

Optimal fascial closure – prevent Early and Late Cx

EARLY Cx: Most concern for all Surgeons

- Infection

- Dehiscence

• LATE Cx:

- Incisional Hernia

- Suture Sinus

- Wound Pain

Surgical Site Infection 19 %

Wound dehiscence 4 %

Incisional hernias 16-23 %

Most common complications 123

1. Seiler Ann Surg 2009;249:576-82

2. Bloemen Br J Surg 2011 67

Dehiscence Infection Incisional Hernia

Recent publications show this might be achievable

1. Seiler Ann Surg 2009;249:576-82

2. Bloemen Br J Surg 2011

3. Millbourn Arch Surg 2009, RCT 737 patients

Surgical Site Infection 19 % < 5 %

Wound dehiscence 4 % < 0,5 %

Incisional hernias 16-23 % < 10 %

Reference:

Millbourn Arch Surg 2009, RCT 737 patients

Strong correlation between complications

1. Israelsson Eur J Surg 1996, van Ramshorst World J Surg 2010

2. van’t Riet Am Surg 2004

3. Bucknall TE Br Med J (Clin Res Ed.) 1982, Fischer JD, Turner FW. Can J Surg 1974

Incisional

hernia

dehiscence

44% of dehiscenced patient

suffer from subsequent

incisional hernia (2)

48% - 88% of patients with

incisional hernia had previously

had an SSI (3)

SSI is an independent risk

factor for both dehiscence and

incisional hernia (1)

Surgical Site infection (I)

Rate: as high as 10-19% reported

• Can extend hosp. stay by 2-11 days

Pathogens : E Coli, Staph. A, Enterococcus

Route of contamination: GI flora, skin flora

Wound infection: independent risk factor for both dehiscence and incisional hernia

Surgical technique :

- normal technique 30-50% of infected patients end up with IH

- small bites- no correlation

- More tissue necrosis with large bites

SSI (II)

• Incidence up to 19% in midline closure, typically > 10% (1)

• Risk factors influenced by wound status

1. Seiler Ann Surg 2009, Justinger Surg 2009, Millbourn Arch Surg 2009

2. Justinger 2009

Example of wound status in 2087 laparotomies in German general surgery department (2)

Wound status n %

Clean 847 41%

Clean contaminated 598 29%

Contaminated 470 23%

Dirty 172 8%

Total 2.087 100%

High impact on patients’ life… and health economics

Surgical Site Infection – A European Perspective of Incidence and Economic Burden David J Leaper, Harry van Goor,

Jacqueline Reilly, Nicola Petrosillo, Heinrich K Geiss, Antonio J Torres, Anne Berger. Int Wound J 2004;1:247—273

High cost of prolonged hospitalisation, medication & additional surgery. €600-8.100 in case of SSI after abdominal surgery1.

Dehiscence (I)

– Rate:0.4% - 3.5 %

– Longer stay and mortality

– Mean: post-op day 9 (Douglas: 0-5 days no strength)

Risk factors (Niggebrugge 1995, van Ramshorst 2010)

Systemic factors: Old age, male gender, malignancy etc.

Local factors:

Layered closure (p<0.001)

post-operative wound infection (p<0.001)

pulmonary complications (p<0.001)

Emergency surgery

Dehiscence (II)

Dehiscence (III)

Local/mechanical factors (more important than systemic factors )

o wound infections

o abdominal distension

o pulmonary complications (Poole GV Jr. Mechanical factors in abdominal wound closure: the prevention of fascial dehiscence. Surgery 1985 Jun;97(6):631-40.)

44% of patients develop incisional hernia after dehiscence (van’t RM et al. Incisional hernia after repair of wound dehiscence: incidence and risk factors. Am Surg 2004 Apr;70(4):281-6)

Adequate tissue breaking strength is necessary to provide support for sutures!

Dehiscence (IV)

IMPLICATIONS:

Prolonged hospital stays

Burst abdomen, exposure of abdominal contents - requires

immediate treatment

Incisional hernia

Re-operations

Increased risk of morbidity and mortality

Dehiscence: Reported causes(1) (V)

1. Poole GV Jr,1985 Jun; 97(6):631-40.) Van Ramshorst et al. Abdominal wound dehiscence in adults. World J

Surg 2010 Jan;34(1):20-7.

2. Poole GV Jr, Surgery 1985 Jun; 97(6):631-40.)

NOTE Can we reduce the risk of cut-through by modifying the suture technique? (2)

Suture related:

Broken suture

Slipping knots

Tissue related:

Suture cutting

through the tissue

• Tissue necrosis

• SSI

Dehiscence : Role of Sutures (VI)

Fascia depends on wound closure device for support during healing!

Patient Movement (bending, jumping, lifting) – increased intra-abd. Pressure > strain on wound and suture

Suture cutting through fascia (± patient factors)

Suture comes UNTIED

Suture Choice: Immediate & extended support

wound edges together

Prevent Infection

Incisional hernias (I)

Most common long-time complication after midline incision

Rate 9% - 20% (Seiler CM et al. Interrupted or continuous slowly absorbable sutures for closure of primary elective midline

abdominal incisions. Ann Surg 2009 Apr;249(4):576-582.)

Mechanism

oWound edges separate > 12 mm after 4 weeks

oIncisional hernia develops within weeks after surgery

Playforth MJ et al. The prediction of incisional hernias by radio-opaque markers. Ann R Coll Surg Engl 1986;68:82-

4. PMID: 3954314

Burger JW et al. Incisional hernia: early complication of abdominal surgery. World J Surg. 2005 Dec;29(12):1608-13. PMID: 16311846

Incisional hernias (II): Clinical Studies

Article: The prediction of incisional hernias by radio-opaque markers

Journal: Ann R Coll Surg Engl. 1986 Mar;68(2):82-4

Authors: Playforth MJ, Sauven PD, Evans M, Pollock AV

Abstract: On the hypothesis that incisional defects occur soon after operation but the resulting

hernia may not be diagnosed until months or years later, we attached three to five pairs of stainless steel haemostatic clips to the cut edges of the anterior aponeurosis during the closure of 59 major laparotomy incisions and X-rayed the abdomen one month later. Three patients were withdrawn and the remaining 56 were examined with special reference to incisional herniation at their six-month follow-up visit. The senior author subsequently arranged a series of extra clinics for surviving patients up to three years later (median 30 months after operation). He had no knowledge of the results of the abdominal X-rays when assessing whether or not the patient had a hernia. Six patients were found to have incisional hernias, and correlation with the measurements on the one-month X-rays showed separation of pairs of clips ranging from 12-70 mm (median 40). Three of the six hernias were discovered within seven months, the remaining three at 13, 28 and 29 months. In contrast none of the 50 patients without incisional hernias had more than 9 mm of separation of any pair of clips on the one-month X-ray. We conclude that the origins of incisional hernias can be traced back to events during the first month after operation and that they are not the result of later weakening of a well-healed laparotomy wound.

Incisional hernias (III): Clinical Studies

Article: Incisional hernia: early complication of abdominal surgery

Journal: World J Surg. 2005 Dec;29(12):1608-13

Authors: Burger JW, Lange JF, Halm JA, Kleinrensink GJ, Jeekel H

Abstract: It has been suggested that early development of the incisional hernia is caused by

perioperative factors, such as surgical technique and wound infection. Late development may implicate other factors, such as connective tissue disorders. Our objective was to establish whether incisional hernia develops early after abdominal surgery (i.e., during the first postoperative month). Patients who underwent a midline laparotomy between 1995 and 2001 and had had a computed tomography (CT) scan of the abdomen during the first postoperative month were identified retrospectively. The distance between the two rectus abdominis muscles was measured on these CT scans, after which several parameters were calculated to predict incisional hernia development. Hernia development was established clinically through chart review or, if the chart review was inconclusive, by an outpatient clinic visit. The average and maximum distances between the left and right rectus abdominis muscles were significantly larger in patients with subsequent incisional hernia development than in those without an incisional hernia (P < 0.0001). Altogether, 92% (23/25) of incisional hernia patients had a maximum distance of more than 25 mm compared to only 18% (5/28) of patients without an incisional hernia (P < 0.0001). Incisional hernia occurrence can thus be predicted by measuring the distance between the rectus abdominis muscles on a postoperative CT scan. Although an incisional hernia develops within weeks of surgery, its clinical manifestation may take years. Our results indicate perioperative factors as the main cause of incisional hernias. Therefore, incisional hernia prevention should focus on perioperative factors.

Incisional hernia (IV): Most common long-term complication

Worrying facts:

• Incidence 9 to 25%, even higher for high risk patients

• Risk of obstruction (10%), strangulation (2%)

• Never resolve spontaneously

Recurrence 24% – 58%

Diener Ann Surg 2010 Bloemen Br J Surg 2011, Van’t Riet M, Jeekel J. Br J Surg 2002, 89, 1350-1356

Dubay DA, Franz MG. Surg Clin N Am 83 (2003) 463-481

IH can start developing after 4

weeks after closing!

Incisional hernia (V): Factors

Israelsson Eur J Surg 1997;163:175-80 Murray et al. Am J Surg 2011

Surgical Technique ( x 3 )

Wound Infection ( x 2 )

Overweight

Patient factors

are important.

But technique

above all!

Abdominal Wall Complications & Risk factors summary

Complications

Factors contributing to outcomes:

A. Patient factors Chronic disease, age, overweight etc

B. Tissue factors

Tissue cutting through, necrosis

C. Surgeon factors Broken suture, loose knot

Incisional

hernia

dehiscence

Tissue factors

Surgeon factors

Patient factors

Factors contributing to outcomes

Patient factors

Patient factors influence wound healing process Age

Gender

Malnutrition

Systemic Infection

Immunosuppression / Corticosteroids

Underlying disease

Co-morbidities, e.g. diabetes

Hypotension

Overweight

Lifestyle, e.g. smoking

Justinger Surgery 2009

Tissue factors Tissue

factors

Aponeurosis/Fascia: Function is purely mechanical- high proportion of fibres with comparatively little cellularity

Density of blood vessels: most poorly vascularized tissues

Aponeurosis wound repair process: requires considerably more

Rath AM, Chevrel JP. The healing of laparotomies: review of the literature. Hernia 1998;2:145-149

Healing of the abdominal wall FASCIA

In an investigation of the healing of lumbodorsal aponeurotic incisions in rabbits, Douglas5 noted that the strength of any of the wounds could not be detected until the sixth day after wounding. All wounds showed measurable strength by the eighth day, and thereafter, a rapid increase until about the end of the second month, when the curve of healing began to flatten out. Subsequently, a slow increase in strength was detectable, which continued throughout the duration of the study (one year). At the end of two weeks, the wound approached 20% of that of unwounded tissue; at the end of one month, 50%; at two months, 60% to 80%; and one-year values, up to 90%

(Douglas DM. The healing of aponeurotic incisions. Br J Surg 1952; 40: 79-84.)

Fascial healing is slow and unpredictable

Rath AM, Chevrel JP. The healing of laparotomies: review of the literature. Part 1. Physiologic and pathologic

aspects. Hernia. 1998;2:145–149.

At 14-28 days, the fascia is

self-supportive but still weak

Even at 2 months, it still has

less than half its original

strength

Fascia Healing: Initial type III collagen is weaker than the definite scar type I

J.J. Hoer etl.al Hernia (2002) 6: 93–98. Dubay and Franz. Surg Clin N Am 83 (2003) 463–481. Hawley PR et al. The

aetiology of colonic anastomosis leaks. Proc R Soc Med. 1970; 63(Suppl 1): 28–30

• Initial phase of wound healing

• Type III (weak) collagen (80%)

• Low tissue tensile strength

• Definite scar

• Type I (strong) collagen (80%)

• High tissue tensile strength

Scar formation regenerative phase

Type I Type III

Extensive inflammation due to i.e. infection leads to

increased break-down of mature collagen and lower

tensile strength of the wound Tensile Strength

Initial wound is totally dependent on suture for strength (I)

Dubay and Franz. Surg Clin N Am 83 (2003) 463–481

Suture strength

needed

Build up of type 1 collagen Time

Initial wound is totally dependent on suture for strength (II)

Dubay and Franz. Surg Clin N Am 83 (2003) 463–481

Suture strength

needed

Build up of type 1 collagen Time

The wound is at its weakest at post-op day 3

Greenfield’s Surgery, Scientific Principles&Practice, 2001: Chapter 3; Wound Healing:© LIPPINCOTT

WILLIAMS&WILKINS

Synthesis

Total collagen

Surgeon factors

Factors under surgeon’s influence

• Antibiotics

• Wound preparation

• Incision location: midline vs.

Transverse

• Suture technique Postop

management: Drainage &

compression

1. Continuous vs. interrupted

2. Knotting technique

3. Suture length / wound length

4. Bite size

5. Mass closure vs.

Aponeurosis only

6. Tension

7. Suture material

8. Anti-SSI measures

Midline v/s other incisions Advantages

no major vessels/nerves in the area

Faster

Excellent access to abdomen

Disadvantages

More pain than transverse or paramedian incisions

Higher rate of incisional hernia

Burger JWA et al. SJS 2002

8 Strategies

reduce complications

1 2 3 4 5 6 8 7

No consensus* on technique

12 centers to report closure tactics for primary, elective laparotomies(1)

* >75% of surgeons acting similarly

1. Rahbari et al BMC Surgery 2009

Elective primary

laparotomies

Midline incision 54%

Continuous suture 65%

Interrupted 19%

Combination 15%

Transverse incisions 35%

Other incisions 11%

No consensus* on material

* >75% of surgeons acting similarly 1. Rahbari et al BMC Surgery 2009

12 centers to report closure tactics for primary, elective

laparotomies(1)

Suture type

Monofilament 60%

Braided suture 40%

Suture material

Non-absorbable 5%

Medium term abs

Slowly absorbable

Suture technique

Continuous or interrupted

1 2 3 4 5 6 8 7

Continuous is Easy, faster (half time) & less suture material

Continuous is faster

Accomodates wound lengthening due to distension

Bursting strength of wound signif. higher

Minimizes number of knots-equivalent or lower incidence of incisional hernia

Disadv (theorotical): Wound security depends on singls strand of suture and limited number of knots

Interrupted vs. Continuous technique

Continuous suturing technique

A continuous suture provides:

• More collagen type1

• Higher wound strength

A significantly lower incisional hernia rate (p=0.001)

Markus K. Diener et al. Elective Midline Laparotomy Closure,

Annals of Surgery (2010) vol251, nr 5

Continuous suturing technique

Markus K. Diener et al. Elective Midline Laparotomy Closure,

Annals of Surgery (2010) vol251, nr 5

Continuous suture: Greater tensile strength

Höer et al. Langenbeck’s Arch Surg (2001) 386:218–223

Potential problem: full dehiscence

Continuous suture increases the risk of single point of failure

This can lead to dehiscence (1)

1. Gupta Asian J Surg 2008

Knotting technique

Use self-locking knot

2 3 4 5 6 8 7 1

Good knotting technique

SELF LOCKING KNOT

High knot security

High knot efficiency

Minimal volume

Self-locking knot

Israelsson Eur J Surg 1994;160:323-7 1

Does not slip

Minimal effect on suture strength

Small in volume

Knot efficiency (1) Knot tensile strength : Straight tensile strength (USP 1 polydioxanone)

1. Israelsson Eur J Surg 1994

Tensile strength %

Straight suture 100%

Conventional knot 58%

Self-locking knot 94%

Suture length / Wound length ratio

SL:WL ratio ≥ 4

1 2 3 4 5 6 8 7

What is the suture length to wound length ratio?

Jenkins Br J Surg 1976

SL:WL ≥4 reduces the rate of incisional hernia (1)

1. Israelsson Eur J Surg 1996;162:605-9

SL:WL ratio Incisional Hernia rate (%)

< 4.0 21%

≥ 4.0 10%

N: 808

SL:WL ≥4 greater tensile strength

J.J. Höer K. Junge A. Schachtrupp U. Klinge V. Schumpelick Hernia (2002) 6: 93–98

Cengiz Eur J Surg 2000;166:647-9

… and increases the quality and

amount of collagen

SL:WL ≥4 compensates for wound extension

Abdominal distension may lengthen the wound up to 30%!

Jenkins TPN Br J Surg 1976

SL:WL ≥4 compensate for wound extension

SL:WL < 4 SL:WL > 4

✖ ✔

SL:WL<4 may cause necrosis

SL:WL < 4 SL:WL > 4

✖ ✔

Bite size

5-8 mm from wound edges

1 2 3 4 5 6 8 7

SL:WL>4 should be accomplished with small bites

1) Cengiz Arch Surg 2001;136:272-5

Harlaar JJ et al. Small stitches with small suture distances increase laparotomy closure strength. Am J Surg 2009

Sep;198(3):392-5

2) Millbourn Arch Surg 2009

SL:WL ≥4 Small bites 5-8 mm preferable

Higher wound strength(1), lower complication rate(2)

Smaller bites: lower complication rate

Correct placement approximately 5-8 mm from wound edges (1)

Millbourn Arch Surg 2009

Closure technique

1 2 3 4 5 6 8 7

Mass closure or aponeurosis only?

Mass closure v/s layered closure Mass closure: - Incorporate all layers of abd. Wall (except skin) as 1 structure - Statistically significant hernia & dehiscence Layered: - Peritoneum, musculo-aponeurotic layer, skin - incidence adhesions, surgery time, compromises adequacy of subsequent layer closure Bucknall (1982) Prospective study, 1129 abd. Surgeries: significantly higher dehiscence in layered (3.81%) v/s mass closure (0.76%)

Mass closure stitch

Cengiz Eur J Surg 2001;167:60-3

suboptimal

approximation of

the aponeurosis

leads to suture

cutting through

fat and muscle.

Suture cutting through weak tissue

Large bites (>10mm from wound edge), porcine abdominal wall:

1. Harlaar Am J Surg 2009

2. Rath, Chevrel Hernia 1998

Small bites: No separation of wound edges observed(1)

Suture cutting through weak tissue

Large bites (>10mm from wound edge), porcine abdominal wall

1. Harlaar Am J Surg 2009

2. Rath, Chevrel Hernia 1998

Small bites: No separation of wound edges observed(1)

• Sutures first cut through

the relatively weak tissue

lateral to aponeurosis,

causing wound edges to

separate (1)

• This may lead to

developing of an incisional

hernia (2)

Aponeurosis only: Recommended technique

• Good approximation of the edges of aponeurosis

• No separation of wound edges

• No soft tissue necrosis

Tension

1 2 3 4 5 6 8 7

High tension less collagen content lower tensile strength

J.J. Höer K. Junge A. Schachtrupp U. Klinge V. Schumpelick Hernia (2002) 6: 93–98

Rule of thumb:

The stitches in

aponeurosis

should at least be

visible

Choice of suture material

Absorbable or non-absorbable

1 2 3 4 5 6 8 7

Choice of suture material (I)

Suture material

Non-Absorbable

Braided (Polyester)

Monofilament (Polypropylene,

Nylon)

Absorbable

Medium term

Wound support

3-4 weeks

Braided (Polyglactin 910, Polyglicolid acid)

Monofilament (Polyglecaprone, Glycomer 631)

Long term

Wound support

6 weeks or more

Monofilament

(Polydioxanone, Polyglyconate

Choice of suture material (II)

Suture material

Non-Absorbable

Braided (Polyester)

Nylon)

Absorbable

Medium term

Wound support

3-4 weeks

Long term

Wound support

6 weeks or more

Monofilament

(Polydioxanone, Polyglyconate

+ Long term strength

- Risk of sinus

- Patient discomfort and

pain on longer term

Choice of suture material (III)

Suture material

Non-Absorbable

Braided (Polyester)

Nylon)

Absorbable

Medium term

Wound support

3-4 weeks

Long term

Wound support

6 weeks or more

Monofilament

(Polydioxanone, Polyglyconate)

Choice of suture material (IV)

Suture material

Non-Absorbable

Braided (Polyester)

Nylon)

Absorbable

Medium term

Wound support

3-4 weeks

Long term

Wound support

6 weeks or more

Monofilament

- Long term strength

- Higher risk of Incisional

Hernia

Choice of suture material (V)

Suture material

Non-Absorbable

Braided (Polyester)

Nylon)

Absorbable

Medium term

Wound support

3-4 weeks

Long term

Wound support

6 weeks or more

Monofilament

Choice of suture material (VI)

Suture material

Non-Absorbable

Braided (Polyester)

Nylon)

Absorbable

Medium term

Wound support

3-4 weeks

Long term

Wound support

6 weeks or more

Monofilament

+ Long term strength

+ No patient discomfort or pain on long term

+ Incisional Hernia risk similar to non-absorbing

sutures

Evidence: Choice of suture material

Absorbable vs. Non-absorbable

Non-absorbable sutures associated to more pain and suture sinuses (1,2)

Equally good results with slowly absorbable sutures

Slowly absorbing vs. Fast absorbing suture

Fast absorbing sutures related to higher rate of incisional hernias (1,3)

Refs: see next page

Evidence: Choice of suture material

Polydioxanone vs. Non-absorbable sutures

Incisional hernia rate after closure with polydioxanone similar to non-absorbable sutures (4,5,6,7)

1. Wissing J et al. Fascia closure after midline laparotomy: results of a randomized trial. Br J Surg 1987 Aug;74(8):738-41. PMID: 3307992

2. van´t Riet M et al. Meta-analysis of techniques for closure of midline abdominal incisions. Br J Surg 2002;89:1350-6. PMID: 12390373

3. Hodgson NC et al. The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg 2000; Mar;231(3):436-42

4. Israelsson LA, Jonsson T. Closure of midlöine laparotomy incisions with polydioxanone and nylon: the importance of suture technique.

Br J Surg 1994;81(11):1606-8. PMID: 7827883

5. Docobo-Durantez F et al. [Randomized clinical study of polydioxanone and nylon sutures for laparotomy clousure in high-risk patients].

Cir Esp. 2006 May;79(5):305-9. PMID: 16753121

6. Hodgson NC et al. The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg 2000; Mar;231(3):436-42

7. Bloemen 2011

Wound support times of different suture materials

Polyglyconate (6wk)

Polyglycolic acid (3wk)

Polyglactin 910 (4wk)

Polydioxanone (10wk)

Wound support times of different suture materials

Impaired wound

Polyglyconate (6wk)

Polyglycolic acid (3wk)

Polyglactin 910 (4wk)

Polydioxanone (10wk)

Anti-bacterial (PLUS) Sutures to prevent SSI

1 2 3 4 5 6 8 7

Multicenter RCT Hygiene measures according to guidelines, correct antibiotic prophylaxis, Monofilament suture

• Despite taking measures, 19% infection rate persists

• Is there a need for additional measures?

Prevention of suture bacterial colonization

• Presence of suture material may increase

the risk of infection (1)

• Bacterial growth on suture material appeared to have the characteristics of biofilm formation(2)

1. Mangram Infect Control Hosp Epidemiol 1999

2. Henry-Stanley et al. Surgical Infections 2010

3. Edmiston et al. J Am Coll Surg 2006

Contamination

Easy to prevend

Biofilm formation

Difficult to treat

Colonization

Prevention of suture bacterial colonization

• Suture with antiseptic provides an effective strategy in reducing perioperative surgical morbidity(3)

1. Mangram Infect Control Hosp Epidemiol 1999

2. Henry-Stanley et al. Surgical Infections 2010

3. Edmiston et al. J Am Coll Surg 2006

Antibacterial sutures are associated with reduced number of infections in abdominal wall closure

Justinger

C et al. Surgery 2009 Prospective

Midline

incision

Significant reduction of wound infections, from

10,8% to 4,9% (2088 patients) (p<0.001)

malairak J Med Assoc Thai 2009 Randomized

Appen-

dectomy

No difference in

appendectomies (100 patients)

Justinger

C et al.

Langenbecks Arch

Surg 2011 Prospective

Transverse

incision

Significant reduction of wound infections, from 9,2%

to 4,3% (839 patients) (p<0.005)

Rasic Z

et al.

Collegium

Antropologicum 2011 Randomized

Midline

incision

Significant reduction in the wound infection rate

(p=.035) and the dehiscence rate (p=.027)

Galal I, El-

Hindawy K Am J Surg 2011 Randomized

General

surgery

Significant reduction in the

wound infection rate (p=.011)

All publications on antibacterial sutures in abdominal wall closure:

Conclusions (I)

To reduce the complication rates in abdominal midline closure:

(1) Use correct suture technique

• Continuous suture with self-locking knot(s)

• SL:WL ratio > 4

Small stitches at close intervals

• Aponeurosis only

• Minimal tension

• Monofilament, slowly absorbable suture

Conclusions (II)

(2) Prevent wound infections

• Correct suture technique

• Attention to hygiene measures

• Additional measures, e.g. antibacterial sutures

THANK YOU!

Abdominal Wall Anatomy & Fascia Closure_sept

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