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Chapter 13

Contents

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 Surgical Group, 2,258 records were sufficiently complete to permit an analysis of the technique of incision and closure, as well as an analysis of the 36 wound dehiscenses which occurred in these cases within the period of postoperative observation at forward hospitals (a usual range of 8 to 14 days).

INCISIONS

Of the abdominal incisions in these 2,258 cases, 2,072 (91.8 percent) were vertical, and the remainder were transverse (table 25). The great preponderance of vertical incisions reflects the consensus of the surgeons of the group

TABLE 25.-Distribution of abdominal incisions 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

---

---


Total

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


Total

186

100.0

2

---


Grand total

2,258

---

36

1.6


1All midrectus, midline, and paramedian incisions are arbitrarily grouped with the appropriate high incisions.
2This was an upper abdominal incision used to connect wounds of entry and exit.


192

that transverse incisions were of very limited value in war wounds of the abdomen. There were two principal reasons for this opinion:

1. Vertical incisions permitted the extensions which were often necessary to secure satisfactory access to injuries not diagnosed before the abdomen was open.

2. Vertical incisions left the lateral and medial portions of the abdominal wall free for separate incisions for colostomies. Exteriorization of the colon was necessary in a great many of these cases and was best accomplished through another incision rather than through the surgical incision.

CLOSURES

Forty different methods of closure were used in the 2,258 laparotomy wounds on which this chapter is based, the different techniques representing the individual choices of the various surgeons. In general, these methods fell into four large groups (table 26), with closure of the wound in layers by means of catgut sutures supplemented by retention sutures comprising more than two-thirds of the cases. Mass closure, which was utilized in only 252 cases, was usually accomplished by means of heavy braided silk, steel wire, or doubled silkworm gut.

In some of the cases classified as layer closures, the peritoneum was closed with a running suture of catgut, and the other layers were approximated with retention sutures which incorporated skin, fascia, and muscle, or merely skill and fascia. In some cases, interrupted sutures of silk or chromic catgut were used in the anterior fascial layer, while the other layers were approximated with through-and-through sutures. In some cases, the peritoneum was closed by the usual running catgut suture, while nonabsorbable sutures were used in the anterior fascial layer and retention sutures were placed by some one of the usual techniques. When retention sutures were omitted, interrupted cotton or silk sutures were used for all layers, including the peritoneal layer.

TABLE 26.-Distribution of wound dehiscences in relation to techniques of closure in 2,258 abdominal injuries

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


Total

2,258

100.0

36

1.6


1The majority of patients in this category were submitted to exploration with negative findings or had only minimal lesions. For purposes of comparison, this group should therefore be excluded.


193

One variation in the technique of closure was the use of a small gauze or rubber drain, placed just beneath the anterior fascia and usually removed about the third day after operation. Gauze or rubber drains were frequently placed in the subcutaneous tissue, to maintain separation of the skin edges for 2 or 3 days. Drainage of the incision was frequently carried out in contaminated wounds. Sometimes the skin was left open; sometimes it was partially closed; and, in selected cases in which hollow viscera had not been perforated, both subcutaneous and subfascial drainage were omitted, and it was sutured primarily.

In spite of the wide variety of techniques of closure which they employed, it was the general feeling of the surgeons in the group that there was no satisfactory substitute for accurate approximation of the various layers of the abdominal wall, combined with some method of retention suturing that would actually maintain wound closure. Mass closure, although it had a real place in the management of patients in precarious condition, invariably meant the sacrifice of accurate layer approximation in the interest of saving time. As a rule, therefore, it was resorted to only when the condition of the patient on the operating table was so serious that prolongation of the procedure seemed likely to deny him his best chance for recovery. Under these circumstances, mass closure was thought to be entirely justified and definitely indicated.

WOUND DEHISCENCES

The 36 wound dehiscences observed in the 2,258 abdominal injuries on which this analysis is based (1.6 percent) all occurred in forward hospitals in 1944 and 1945. If all the casualties could have been traced through the hospitals to which they were evacuated, the incidence might have been considerably higher, as the following figures indicate: Of 250 patients who lived more than 7 days (out of 346 casualties with abdominal and thoracoabdominal injuries operated on by surgeons of the group in 1943), 30 sustained 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 lapse of time being about 8 days. Exploration of the abdomen had been negative in only one instance; all the other patients had sustained some sort of intra-abdominal injury. The small bowel was injured 21 times, the colon 17, the liver 9, the stomach 7, the kidney 4, the spleen twice, and the urinary bladder twice (the figures are overlapping). The diaphragm was injured in 7 cases, and retroperitoneal hematomas were present in 4 cases. The order of frequency of visceral injuries thus coincided with the order of frequency in the entire series of 3,154 cases (table 7, p. 92), which suggests that wounds to specific viscera cannot be regarded as predisposing to wound disruption.

1Report on the Surgery of Abdominal Wounds (unpublished data), submitted to the commanding officer, 2d Auxiliary Surgical Group, 14 April 1944.


194

The precise cause of the accident was not evident in any of these 36 cases, but the following conditions (multiple in 1 instance) probably contributed to the disruptions: Distention, in 10 cases; wound sepsis, in 7 cases; excessive coughing, in 4 cases; vomiting, spontaneous fistula of the small bowel, delirium, and clostridial myositis which required removal of the entire rectus muscle, in 3 cases each; severe nutritional deficiency in 2 cases; and spontaneous gastric fistula and the use of the laparotomy incision for the colostomy, in 1 case each.

All the principal methods of closure failed at least once in these 36 cases (table 26), and most of them failed in several. Layer closure with nonabsorbable sutures of silk or cotton in the anterior fascia showed no superiority over closure with catgut sutures. In fact, on the basis of the available figures (table 26), the frequency was somewhat greater when nonabsorbable sutures were used. The incidence of disruption, as might have been expected, was higher for mass closure than for either of the two principal methods of layer closure.

Retention sutures were used in the primary closure in 35 of the 36 cases. In the single case in which they were omitted, a running suture of plain catgut was used in the peritoneal layer, the anterior fascia was closed with interrupted sutures of chromic catgut, and a Penrose drain was placed in the subfascial space.

The figures concerning dehiscence in relation to the method of 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 a loop 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 2.1 disruptions in each 100 cases. When mass closure was employed, there were 2.4 disruptions in each 100 cases. When, however, layer closure (closure of one or more layers, with the skin usually left widely open) was combined with through-and-through retention suturing, with all layers of the abdominal wall, including the peritoneum, incorporated in the retention sutures, there was only 1 disruption in each 480 cases (0.2 percent).

TABLE 27.-Distribution of wound dehiscences in relation to techniques of retention suturing in 2,121 abdominal injuries

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


Total

2,121

100.0

35

1.6


1In 1 case of wound separation not included in this table, retention sutures were not used.


195

Catgut was used for the layer closure in the majority of cases in which this combined technique was employed. The through-and-through retention sutures were inserted in one of two ways: They were either pulled up and tied fairly snugly in the midline, or they were tied laterally over rubber tubes placed on each side of the incision. In only one instance in this series did a possible mechanical intestinal obstruction result from the employment of this technique. The obstructive signs in this case disappeared when the through-and-through sutures were released on the fifth postoperative day, and recovery thereafter was smooth.

The use of pulley sutures, either for mass closure or as a method of retention suturing to supplement layer closure, produced almost uniformly poor results in this series. Reports from general hospitals mentioned a number of cases in which strangulation of the tissues was followed by massive sloughs and which usually required secondary wound closure.

Management

In 7 of these 36 instances of wound dehiscence, the wound was taped 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 through sutures in 11 cases, and silk figure-of-eight sutures in 1 case. The remaining patient died on the operating table before surgery could be started. Two patients, one of whom had been treated conservatively and the other by secondary suture, later presented small intestinal fistulas.

Causes of Death

There were 7 deaths in these 36 cases, 5 of which were apparently 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 had been exteriorized in the laparotomy wound) into the peritoneal cavity. In one case, peritonitis resulted from two leaking areas in the small bowel caused by trauma from the through-and-through wire sutures used in the secondary closure. In one case, death occurred 4 hours after secondary suture; aspiration of vomitus during anesthesia was followed by fatal pulmonary and bronchial edema. In the remaining case, which was treated conservatively, death was the result of acute mechanical intestinal obstruction.

Prophylaxis

The large number of wound dehiscences reported in 1943, to which reference has already been made,2 provoked serious consideration among the surgeons of the 2d Auxiliary Surgical Group. The whole subject of wound closure was studied, and special attention was given to measures which might prevent future accidents. Analysis of the cases reported in 1943 revealed certain

2See footnote 1, p. 193.


196

practices which could be considered as possibly causative. Thus it was not uncommon in the early experience in the North African theater to omit retention sutures in laparotomy wounds, even though the incisions were usually closed in layers. It was also not uncommon to exteriorize a damaged segment of colon in the laparotomy incision rather than in a separate small incision. Finally, it was a rather common practice to evacuate patients with abdominal wounds prematurely (that is, before the optimal interval of 10 to 14 days), even though evacuation necessitated long ambulance hauls over terrain that was often rough. The policy of eliminating all of these practices unquestionably played a part in reducing the incidence of wound dehiscence in 1944 and 1945.

No policy, however, and no technique could entirely prevent wound dehiscence, to which there existed a natural tendency in penetrating and perforating injuries of the abdomen. For this there were a number of reasons:

1. Massive soiling of the peritoneal cavity, as the result of perforation of hollow viscera, produced peritonitis, either chemical or bacterial, in a large proportion of cases and also resulted in heavy contamination of the laparotomy incision. Clinical sepsis, with its deleterious effects on sound wound healing, not infrequently followed.

2. Prolonged nasogastric suction was essential in these injuries at a time when nutritional reserves were likely to be critically low.

3. The rather high incidence of pulmonary complications, especially during the winter months, and the resulting severe and protracted cough often added considerably to the strain on the abdominal incision.

4. The tactical situation was sometimes such that patients with abdominal injuries had to be evacuated soon after operation, in spite of the undesirability of the practice. The combined effect of these various uncontrollable factors explains why even in 1944 and 1945, when conscientious efforts were made to prevent it, the incidence of wound dehiscence was far higher among military casualties with abdominal injuries than it would be in a series of nontraumatic abdominal operations in civilian life.

The measures employed to prevent wound disruption were multiple and, if they were to be effective, had to be instituted as soon as the incision was made. The trauma of both incision and closure was kept to a minimum. Gross soiling and contamination of the incision were avoided in every possible way. The Halstedian principles of tissue handling were sedulously employed to prevent wound reaction, the absence of which favored uncomplicated wound healing. Certain physiologic and chemical principles were also borne in mind: The erythrocyte count was kept at 4 million per cubic millimeter, or higher, and the hemoglobin level was kept above 12 gm. percent. Plasma was given in amounts of 250 cc. once or twice daily as long as Wangensteen decompression was required. Vitamin C was given parenterally over the same period and was given orally as soon as feeding by mouth could be resumed. The patient was evacuated with the retention sutures still in situ, and, during transit, additional abdominal support was provided by a binder, preferably of the scultetus type.

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