ISSN: 2320-5407 Int. J. Adv. Res.

11(05), 1635-1646

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/17032

DOI URL: http://dx.doi.org/10.21474/IJAR01/17032

RESEARCH ARTICLE
COMPARING THE EFFICACY OF MODIFIED CONTINUOUSSMEAD-JONES VERSUS
CONVENTIONAL CLOSURE OFMIDLINE LAPAROTOMYWOUND

Dr. Raghuveer M.N1, Dr. Chandan Kumar R.2 and Dr. Vishal Hubballi3
1. Associate Professor, Department of General Surgery, Mysore Medical College and Research Institute.
2. General Surgery Postgraduate,Mysore Medical College and Research Institute.
3. General Surgery Postgraduate, Mysore Medical College and Research Institute.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Background: Disruption of abdominal incision is a serious event.
Received: 25 March 2023 Variousmethods have been employed in abdominal surgeries to close
Final Accepted: 30 April 2023 theabdominal wall.Abdominal wound dehiscence is a common
Published: May 2023 complication of emergency laparotomy. Thereis an increase in the cost
and hospitalstays. Prevention of this complication is important
inreducingpost-operativemorbidity and mortality.
Objectives:
ThestudywascarriedoutintheDepartmentofGeneralSurgery,MMC&RI,
Mysuru.
1. ToevaluateeffectivenessofmodifiedcontinuousSmead-
JonesTechnique.
2. To compare effectiveness of modified continuous Smead-Jones
withconventionaltechniqueofabdomenwoundclosureonthebasisofin
cidenceofwounddehiscence.
Methods: The study was carried out on a total of 110 patients who
were randomized intwo groups of 55 each. 55 patients underwent
closure of mid line laparotomywound using modified continuous
Smead-Jones technique(study group)and 55 patients underwent closure
by conventionalmethod(control group).
Results: The mean age group was 46 to 49. Male patients were more
common
comparedtofemale.Outofthevariouscausesofacuteabdomen,Prepyloricpe
rforationwasthemostcommoncause,followedbyduodenalperforation.Out
of 11 cases who had wound dehiscence,mostofthemwere for Pre pyloric
perforation(55%), second most common was ileal perforation(27%).
Patientswith risk factors had higher incidence of wound infection and
wound dehiscence. Outof 110 patients, 32(29.1%) had wound infection,
12(21.8%) in the study group and20(36.3%) inthecontrolgroup.A total
of 11(10%) patients had wound dehiscence, only 2 (3.6%) patients in
the studygroup, whereas 9 (16.3%) in thecontrol group.
Interpretationandconclusion:ModifiedSmead-
Jonestechniquedecreasestheincidenceofwounddehiscenceand can be
used to close the midline laparotomy wound in cases requiring
emergencymidlinelaparotomy.

Corresponding Author: -Dr. Raghuveer M.N

1635
Address: -Associate Professor, Department of General Surgery, Mysore Medical College
and Research Institute.
ISSN: 2320-5407 Int. J. Adv. Res. 11(05), 1635-1646

Copy Right, IJAR, 2023,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
In a midline Laparotomy, the incision passes through different layers of theanterior abdominal wall from skin,
subcutaneous tissue, linea alba and
peritoneum.Healingcanoccurthroughprimaryorsecondaryintention.Wheneverthereisinterferenceintheusualcascadeofab
dominalwoundhealingprocess,thereisdisruptionin the abdominal woundthatisalsoknownaswounddehiscence. 1

Abdominal wound dehiscence or burst abdomen is a severe post-operativecomplication which is defined as post-
operative separation of abdominal musculo-
aponeuroticlayers,whichisrecognizedwithindaysaftersurgeryandrequiressomeformofintervention.Theincidence,asdescr
ibedintheliterature,rangesfrom0.4% To3.5%with associatedmortalityof9to44%.Prolonged hospital stays, high
incidenceofincisionalhernia,andsubsequentre-operationsunderlinetheseverityofthiscomplication. 2

This abdominal wall disruption can be partial or complete. Partial disruptionoccurs when one or more layers have
been separated but the underlying sheath
andperitoneumremainsintact.Completedisruptionoccurswhenallthelayershavedisruptedwhichsubsequentlyleadstoviscer
alevisceration.

Various risk factors are responsible for wound dehiscence. General parameterslike age, sex, nutritional status, pre-
operative medical condition like anemia,
diabetes,jaundice,renalfailure,badASA(AmericanSocietyofAnesthesiologists)scoring,type and duration of surgery and
post-operative wound infection or increase in intra-abdominal pressure, intra-operative knot breakage, suture material
rupture or suturecutthrough,emergencyorelectivesurgeryarethevariousfactorsleadingtoabdominalwall dehiscence. 3,4

The mass closure technique incorporates all layers of abdominal wall exceptskin in continuous technique offers
certain benefits over the layered closure techniquewith respect to the time required for incision closure, incidence of
wound dehiscenceandincisionalhernia.Therearestillcontroversiesregardingthebestmethodofmidline abdominal wall
closure in emergency, contaminated cases and no consensusexistsaboutthisissue. 5

We have designed a study to compare the risk of wound infection and wounddehiscence between modified continuous
Smead-Jones technique and conventionalcontinuous technique in emergency midline laparotomy. We randomized two
groupsin 1:1 in which, Group A constituted modified Smead-Jones closure (far-near-near-far) and Group B
constituted conventional abdominal closure studied on 110 patientswhounderwent midline laparotomies fordifferent
emergency indications.

Objectives:-
Thestudywasconductedbasedonfollowing moralities.
1. Toevaluateeffectivenessof modifiedcontinuousSmead-JonesTechnique.
2. To compare effectiveness of modified continuous Smead-Jones with
conventionaltechniqueofabdomenwoundclosureonthebasisofincidenceofwounddehiscence.

Methodology:-
Thiswasacomparativestudyconductedon110patientswhounderwentemergencymidlinelaparotomy.Afterbeinginductedin
tothestudypopulationfollowing informed written consent, patient will be subjected to a detailed history
andclinicalexamination,followedbypreoperativeinvestigationsandintraoperativefindingswererecordedin
aspectrumofproforma.

Sourceofdata
Alltheeligiblepatients admitted toDepartmentofGeneralSurgery,Krishna Rajendra Hospital, Mysore Medical College
and Research Institute, Mysore,Karnataka.

Studydesign:
A Prospectivecomparativestudy.

1636
ISSN: 2320-5407 Int. J. Adv. Res. 11(05), 1635-1646

Samplesize:
110

Studyplace:
DepartmentofGeneralSurgery,MMC&RI,Mysore.

Study period:
1.5 years (1st December 2020 to 30th June 2022)

Inclusion criteria:
Allthepatientsundergoingmidlinelaparotomybetweentheagegroupof18 to 70 years.

Exclusioncriteria:
1. Presenceorsuspicionofabdominalcompartmentsyndrome.
2. Patientundergoingre-laparotomywithintheperiodofonemonth
3. Patientswhodiedwithin10daysaftersurgery
4. Patientswhounderwentsurgeryotherthanmidlineincisions.
5. Samplingtechniqueandstudypopulation

Samplingtechnique:
Purposive
1. Alleligiblepatientswere allocated to either studyorcontrolgroupalternativelytill 55 patients in each group.
2. In group A, 55 patients will undergo closure of mid line laparotomy wound usingmodifiedcontinuousSmead-
Jonestechniqueandaretakenasstudygroup. This method comprisessuture approximation of rectus sheath with
peritoneum and muscle in one layer,
incontinuousfashion.TheentryandexitofPDSis2cmfromwoundedgesand1cm from the edge of linea alba on
either side. The distance between two adjacent sutures is not more than 2cm and they are in continuous
manner.
3. In group B, 55 patients will undergo closure of midline laparotomy wound byconventionalmethod and are
taken as control group. Conventional closure included closure of rectus fascia with musclefirst in a continuous
fashion. The sutures are placed 2cm from the edge of
lineaalbaonbothsidesand1cmismaintainedbetweentwoadjacentsutures.
4. In both groups, no. 1 synthetic, monofilament, delayed absorbable polydiaxonesuture (PDS) was used to suture
the fascia, followed by closure of subcutaneoustissueusingvicryl2-
0interruptedsutureandskinclosedusingethilon2-0interruptedmattresssuture.
5. Other infection control measures such as pre-operative surgical site
preparation,asepsis,antibioticprophylaxisweremaintainedinbothgroups.
6. Appropriateantibioticandanalgesicsweregivenbeforeandaftertheprocedure.
7. PrimaryoutcomemeasurestheefficacyofmodifiedcontinuousSmead-Jonestechnique on midline laparotomy
wound closure by measuring the incidence ofabdominalwalldehiscenceclinically
attheendof15daysbyevaluatingsurgeon.

Statisticalanalysis
After calculating the sample size as described below, the data were collectedfrom the study group and will be entered
in Microsoft excel software program
andeachvariablewasanalyzedusingSPSSsoftwareversion21.0andtabulated.Descriptive statistics, mean, standard
deviation, percentage, test of proportion, barcharts,pie charts wereusedwhereverapplicable.

Results:-
Atotalof110patientswereincludedinthestudy.Resultsofthestudyarediscussedaccordingtovarious parameters as below.

Table1:- Agedistribution.
Groups Number of patients Mean age (years)
Study 55 49.09 + 14.22

1637
ISSN: 2320-5407 Int. J. Adv. Res. 11(05), 1635-1646

Control 55 46.45 +13.26

Total 110

Figure1:- Agedistribution.

Themean age of patients was 47 years.

Themeanageamongthe studygroupwas49yearsandthemeanageamongthe control group was 46 years.

Table2:- Sexdistribution.
Male Female
Groups TotalNumber Percentage (%) Percentage (%)
Number Number
Study 55 38 69.1 17 30.1
Control 55 39 70.1 16 29.1
Total 110 77 70 33 30

Figure2:- Sexdistribution.

1638
ISSN: 2320-5407 Int. J. Adv. Res. 11(05), 1635-1646

Among110patients,77(70%) weremaleand33(30%)werefemale.

Among 55 patients in each group, 38(69.1%) were male and 17(30.1%) werefemale in the study group and 39(70.1%)
were male and 16(30%) were females in thecontrol group.

Table 3:- Comorbidities.

TotalNumb Diabetes Hypertension Both
Groups er No. % No. % No. %
Study 55 9 16.3 9 16.3 4 7.2
Control 55 7 12.7 9 16.3 4 7.2
Total 110 16 14.5 18 16.3 8 7.2

Figure 3:- Comorbidities.

Among110patients,16(14.5%)werediabetic and18(16.3%) werehypertensive,whereas8(7.2%)were bothhyper-

tensive and diabetic.

Table 4:- Personalhabits.

TotalNumber Smokers Alcoholic Both
Groups No. % No. % No. %
Study 55 18 32.7 14 25.4 8 14.5
Control 55 15 27.2 15 27.2 6 10.9
Total 110 33 30 29 26.3 14 12.7

1639
ISSN: 2320-5407 Int. J. Adv. Res. 11(05), 1635-1646

Figure 4:- Personalhabits.

Among 110 patients, 33(30%) were smokers and 29(26.3%) consumed alcoholregularly, while 14(12.7%) had a
history of both smoking and consumed alcoholregularly.
In the study group, 18(32.7%) were smokers, 14(25.4%) were alcoholics and8(14.5%)consumed both.
In the control group, 15(27.2%) were smokers, 15(27.2%) were alcoholics and6(10.9%)consumed both.

Table 5:- Risk factors.

Patientswithriskfactors
Groups Total Number Number Percentage
Study 55 14 25.4
Control 55 16 29.1
Total 110 30 27.2

Figure5: -Riskfactors.

1640
ISSN: 2320-5407 Int. J. Adv. Res. 11(05), 1635-1646

Risk factors (other than smoking, alcoholism, DM, HTN) such as Anemia,COPD,Chronic liver disease,
immunosuppression,renal failure, hypoalbuminemia,malnutrition,radiation exposure was identified.
Among 110 patients 30 (27.2%) of the patients has at least 1 risk factor.In the study group, 14(25.4%) of the patients
had at least 1 risk factor.Inthe control group,16(29.1%) of thepatientshad atleast1riskfactor.

Table 6:- Wound infection.

Wound infection
Groups Total Number Number Percentage
Study 55 12 21.8
Control 55 20 36.36
Total 110 32 29.1

Figure6:-Woundinfection.

Outof 110 patients, 32(29.1%)had wound infection.

Inthestudygroup,12(21.8%)hadwoundinfection,whereas20(36.3%)hadwoundinfectioninthecontrolgroup.

Table7:- Wounddehiscence.
Groups Total Number Wound dehiscence
Number Percentage
Study 55 2 3.6
Control 55 9 16.3
Total 110 11 10

1641
ISSN: 2320-5407 Int. J. Adv. Res. 11(05), 1635-1646

Figure7:-Wounddehiscence.

A total of 11(10%) patients had wound dehiscence. Only 2 (3.6%) patients

inthestudygrouphadwounddehiscencewhereas9(16.3%)patientshadwounddehiscenceinthecontrolgroup.P-
value<0.05andisstatisticallysignificant.

Chi-SquareTests
Value df Asymp.Sig.(2-sided) Exact Sig. (2-sided)
PearsonChi-Square 4.949 1 .026
Fisher’s Exact Test .050

Thus, the statistical analysis concludes that midline laparotomy wound closurewith modified Smead-Jones technique
is better in preventing the incidence of wounddehiscence.

Table8:- Woundinfectionanddehiscenceamongpatientswithriskfactors.
Wound infection Wounddehiscence
Groups Number Percentage(%) Percentage(%)
Number Number
Smokers 33 13 40 6 54.5
Alcoholic 29 13 40 5 45.4
DM 16 7 21.8 2 18.1
HTN 18 9 28.1 3 27.2
Other riskfactors 30 23 71.8 9 81.1

1642
ISSN: 2320-5407 Int. J. Adv. Res. 11(05), 1635-1646

Figure8:-Woundinfectionanddehiscence amongpatientswithriskfactors.

Among the patients who had wound infection and wound dehiscence, patientswith risk factors had higher incidence of
wound infection and wound
dehiscence.Woundinfectionamongsmokersandalcoholicswas40%.Similarly,wounddehiscenceamongsmokersandalcoh
olicswas54.5%and45.4%respectively.Incidence of wound infection among non-smokers was 25.9% and non-
alcoholics was24.6%.

Table 9:- Abdominal wound dehiscence according to underlying intra-abdominalpathology.

Intraabdominalpathology Study Control Total
Prepyloricperforation 1 5 6
Ruturedsplenicabscess 0 1 1
Ileal perforation 1 2 3
Duodenal perforation 0 1 1
Total 2 9 11

1643
ISSN: 2320-5407 Int. J. Adv. Res. 11(05), 1635-1646

Figure9:- Abdominalwounddehiscenceaccordingtounderlyingintra-abdominalpathology.

Out of 11 cases who had wound dehiscence of midline laparotomy wound,most of them were for Pre pyloric
perforation (55%), second most common was ilealperforation (27%), followed by ruptured
splenicabscessandduodenalperforation.

Discussion:-
Separation of abdominal wounds (i.e.,dehiscence) with or without protrusionofintra-
abdominalcontents(i.e.,evisceration)causessignificantmorbidityandmortality. The mean time to wound dehiscence is 8
to 10 days after operation. Wounddehiscence is characterized bypink serosanguinous discharge fromthe wound.
Sometimes it may present acutely with a large subcutaneous hematoma ora swelling that distends the wound reflecting
herniation of bowel through the walls oftheabdomen.

Risk factors for wound dehiscence includeadvanced age (>65 years), ascites, obesity, steroid use, hypoalbuminemia,
anemia,prolongedileus,coughing,woundinfection,COPD,pneumonia,strokewithresidualdeficit,emergencyoperationand
operativetimegreaterthan 2.5 hours.

Acutewoundfailureisoftenrelatedtotechnicalerrorsinplacingsuturestooclosetotheedge,toofarapart, or under too much

tension.

Acutewoundfailurecanbepreventedbyproper spacing of the suture,relaxation of the patient during closure, adequate

depth of bite of the fascia andachievingatension-freeclosure.Interruptedclosureisawisechoiceforveryhigh-risk patients.
Alternative methods of closure must be selected when primaryclosureisimpossiblewithoutunduetension.

Inpost-operativeperiodwhenabdomendistends,thecontinuoussuturesreadjust themselves because of its inherent

elasticity in such a way that there isuniform distribution of tension along the suture line by to and fro movements of
loops of suture.

ArandomizedcontrolstudyconductedbyRaxithSringerietalin2017,on100 consecutively enrolled patients who underwent

emergency midline laparotomyandlaparotomywoundwasclosedbymodifiedSmead-Jonestechniqueinstudygroup and
conventional technique in control group. The study showed that among thecauses of peritonitis, duodenal ulcer

1644
ISSN: 2320-5407 Int. J. Adv. Res. 11(05), 1635-1646

perforation was the most common cause and alsoshowed that rate of wound dehiscence in study group (1%) was much
lesser than thatin control group (14.9%). The study concluded that modified version of Smead-Jonestechnique of
laparotomy wound closure with prolene loop has very low incidence ofearly complication and may reduce the late
complication and this technique wassuperiorto other conventional method of closure.6

A prospective comparative study was conducted by Chirag B Aghara et al, in2020 on 100 patients concluded that
Modified Smead-Jones technique is better
thanconventionalcontinuoustechniqueinmanagementofmidlinelaparotomyclosurewithrespecttowoundinfectionandwou
nddehiscence.7

A systematic review and meta-analysis of randomized control trails conductedbyNicole CF Hodgson

ontodeterminewhich suture material and technique reducetheoddsof incisional hernia,concludedthatabdominal fascial
closure with continuous non absorbablesuturesignificantlyreducestherateof incisionalhernia.8

Smead proposed interrupteddoubleloopfascialclosure,whichwaslaterpopularized by Jones in 1941. In this technique

there is no much loss in elasticity orcompliance of suture material and it causes more secure approximation of
fascialedges. Wound edges remain well approximated due to distribution of the tensionbetweentwo loops and the
suture does not cut throughthe fascia.

We modified original interrupted Smead-Jones to continuous Smead-Jones ascontinuous suturing is faster and
simultaneously preserving advantages of originalSmead-Jones technique of distributing
tensionloaduniformlyalongthesuture lineandtherebyeffectiveinpreventing abdominal wound dehiscence.

In our study we found that wound dehiscence rate in conventional closure wasabout 16.3% and in modified
continuous Smead-Jones technique was 3.6% and thedifference is statistically significant (p<0.05), thus inferring that
modified continuousSmead-Jonestechnique is betterthantheconventionalclosure.

We did not study the late complications (i.e., development of incisional hernia)in both groups as it requires longer
follow up period, but studies show that the rate of development of incisional hernia is proportional to rate of incidence
of wounddehiscence.

Accordingtous,modifiedSmeadmethodofclosurecanbeusedasapreferential method of abdominal wall closure in all

midline laparotomy incisions,even in cases more prone for abdominal dehiscence due to patient factors such
asabdominalsepsis.

Conclusions:-
In our study, 110 cases that underwent midline laparotomy for acute abdomenduringtheperiodofoneandhalfyear,the
followingobservationsweremade:
1. Thepresentstudyshowedthatamongthepatientswho underwent midlinelaparotomy,the mean age group was 46-
49 years.
2. Malepatientsweremorecommonascomparedtofemale.
3. Out of the various causes of acute abdomen, Pre pyloric perforation was the mostcommon cause, followed by
duodenal perforation.
4. Outof11caseswhohadwounddehiscenceofmidlinelaparotomywound,mostof them were for Pre pyloric
perforation (55%), second most common was ilealperforation (27%),
5. Inemergencysetting,patientswithgeneralizedperitonitisneedspecialattentionto wound closure. Our new
technique of closure of midline laparotomy
wound,especiallyinIndiansetup,decreasestheincidenceofwounddehiscence.
6. Thus, our study concludes that modified continuous Smead-Jones technique ofmidline laparotomy wound
closure had low incidence of wound dehiscence
andmightalsodecreasetheincidenceofincisionalherniaonlongterm.

References:-
1. Ramneesh G, Sheerin S, Surinder S, Bir S. A prospective study of predictors forpostlaparotomyabdominal
wounddehiscence.JClinDiagnRes.2014;8(1):80-8.

1645
ISSN: 2320-5407 Int. J. Adv. Res. 11(05), 1635-1646

2. Poole GV. Mechanical factors in abdominal wound closure.The prevention offascialdehiscence. Surg.1985;
97:631-9.
3. Van RamshorstGH,NieuwenhuizenJ,HopWC, ArendsP,BoomJ,JeekelJ,etal.Abdominal wound dehiscence in
adults: development and validation of a riskmodel.World J Surg. 2010;34(1):20-7.
4. Riou JP, Cohen JR, Johnson H, Jr. Factors influencing wound dehiscence. Am JSurg.1992;163:324-30.
5. GislasonH,VisteA.Closureofburstabdomenaftermajorgastrointestinaloperations: comparison of different surgical
techniques and later development ofincisionalhernia. Eur J Surg. 1999; 165:958.
6. RaxithS,ThulasiV.Comparisonofconventionalclosureversusre-modifiedSmead-Jones technique of single layer
mass closure with Polypropylene(prolene)loop suture after midline laparotomy in emergency cases.
International SurgeryJournal.2018 Aug24;4(9):3058-61.
7. ChiragA,RajyaguruAM,JatinG.Bhatt.ProspectivecomparativestudyofmodifiedSmead-
Jonesversusconventionalcontinuousmethodoffascialclosureinemergencymidlinelaparotomy.
InternationalSurgeryJournal.2020;7(11):3713-7.
8. HodgsonNC,MalthanerRA,OstbyeT.Thesearchforanidealmethodofabdominalfascialclosure:ameta-
analysis.AnnSurg.2000;231(3):436-42.

1646