Principles of abdominal wall closure

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Principles of abdominal wall closure

AUTHOR: Jason S Mizell, MD, FACS
SECTION EDITOR: Michael Rosen, MD
DEPUTY EDITOR: Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2024.

This topic last updated: Apr 20, 2022.
INTRODUCTION
The ideal abdominal wound closure provides strength and a barrier to infection. In addition, the
closure should be efficient, performed without tension or ischemia, comfortable for the patient,
and aesthetic.
Closure of abdominal incisions will be reviewed here. Incisions for opening the abdomen,
wound healing, and wound complications are discussed separately. (See "Incisions for open
abdominal surgery" and "Complications of abdominal surgical incisions".)
MATERIALS
Sutures — Wounds have less than 5 percent of normal tissue strength during the first
postoperative week; thus, wound security is dependent solely upon the suture closure. (See
"Skin laceration repair with sutures" and "Skin laceration repair with sutures", section on 'Suture
selection'.)
Size — The suture should be the smallest caliber that is strong enough to reapproximate the
tissue and keep the wound intact during normal postoperative activity [1]. Suture caliber is one
factor in minimizing the amount of foreign material in the wound.
Synthetic versus natural — A critical element of effective closure is the choice of suture
material. Sutures can be made from natural fibers or produced synthetically. Natural suture
materials include silk, linen, and catgut (dried and treated bovine or ovine intestine). Synthetic
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sutures are made from a variety of textiles such as nylon or polyester, formulated specifically for
surgical use.
Advantages of synthetic suture over natural fibers include:
● Greater uniformity
● Greater tensile strength
● Longer duration of support during wound healing
● Greater wound security
● Less inflammatory response [2,3]
● Less theoretical risk of disease transmission from animals (eg, bovine spongiform
encephalopathy)
Absorbable versus nonabsorbable — Synthetic and natural sutures can be either absorbable
or nonabsorbable. Each has characteristics that make them appropriate in various
circumstances, depending on the circumstance.
Synthetic absorbable sutures are made from polyglycolic acid or other glycolide polymers and
are generally degraded within days to weeks, although delayed absorbable suture may retain
strength for up to two months ( table 1 and table 2). They generally produce less tissue
reaction than natural absorbable sutures (eg, plain gut, chromic catgut), which is thought to be
due to the nature of suture breakdown. Synthetic absorbable sutures are broken down by
hydrolysis, whereas natural absorbable sutures are degraded by proteolysis.
Common types of synthetic absorbable sutures and their in vivo half-lives are listed below [4]:
● Polyglactin 910 (Vicryl) – Two weeks

● Polyglycolic acid (Dexon) – Two weeks
● Poliglecaprone (Monocryl) – Two weeks
● Polydioxanone (PDS) – Three weeks
● Polyglyconate (Maxon) – Six weeks
Nonabsorbable suture typically maintains tensile strength for more than two months, and
many synthetics remain in the incision permanently. In theory, nonabsorbable sutures made of
natural fibers, such as cotton, linen, and silk, remain permanently in the wound, although, in
reality, they gradually disappear.
Synthetic nonabsorbable sutures generate similar tensile strength and tissue reaction as
synthetic absorbable sutures, but they have longer wound security (300 days or more). Some

examples of this type of suture include polyamide (Nylon), polypropylene (Prolene),

polybutester (Novafil), and polyester (Mersilene).
As a result of their increased and prolonged tensile strength, it might be predicted that
nonabsorbable sutures should decrease the risk of wound dehiscence and hernia, compared
with absorbable sutures. However, the superiority of nonabsorbable sutures has not been
consistently found in meta-analyses of randomized trials for midline closure [5-7].
Nonabsorbable sutures are associated with an increased risk of suture sinus and prolonged
wound pain compared with synthetic absorbable suture (odds ratio [OR] 2.18, 95% CI 1.48-3.22;
OR 2.05, 95% CI 1.52-2.77, respectively) [5]. (See 'Midline' below and 'Knots' below.)
Monofilament versus multifilament — Another important characteristic of suture that

determines its behavior is whether it is monofilament or multifilament. Synthetic
nonabsorbable monofilament sutures (eg, polyamide and polypropylene) are more resistant to
serious infection than are multifilament sutures and natural fibers. Thus, the composition of the
suture, as well as the structure, influences the rate of bacterial absorption and proliferation [8].
This was illustrated in the following representative reports:
● In a study designed to determine the risk of infection for different suture materials,
synthetic nonabsorbable monofilament sutures of nylon, wire, and polypropylene were
associated with less serious infection than multifilament and natural fiber sutures [9]. This
was determined by placing sutures in rabbit subcutaneous tissue; the tissue was then
inoculated with staphylococcus.
● In another study, both braided silk and braided nylon absorbed similar numbers of
bacteria, while monofilament sutures absorbed significantly less. Braided polyglycolic acid
absorbed an intermediate number of bacteria [10]. In this guinea pig study, sutures were
placed in solutions containing bacteria and then the number of bacteria absorbed by each
suture was quantified.
Multifilament sutures generally provide greater knot security than monofilament sutures, which
have more "memory" and can return to their original position rather than remaining as a knot.
Sutures usually are weakest at the knot, and knot strength depends upon a number of factors.
(See 'Knots' below.)
Triclosan-coated versus noncoated sutures — Sutures coated with antimicrobial compounds

may decrease the rates of surgical site infection [11-18]. However, the development of surgical
site infection following midline laparotomy is multifactorial, and manipulation of a single factor
(eg, suture) is not likely to provide a significant benefit for all patients. Further studies are

needed to determine which subsets of patients undergoing abdominal wall closure might
benefit from triclosan-coated sutures to justify the added cost.
Various sutures including polyglactin 910 (Vicryl), polydioxanone (PDS), and poliglecaprone
(Monocryl) coated with triclosan (5-chloro-2-[2,4-dichlorophenoxy] phenol) have been used and
appear to perform technically as well as standard sutures. A systematic review and meta-
analysis that included 17 trials involving 3720 patients undergoing a variety of procedures
(including nonabdominal surgery) found a significantly lower risk of surgical site infection for
triclosan-coated versus noncoated sutures (relative risk [RR] 0.70, 95% CI 0.57-0.85) [17,18].
Subgroup analysis supported the use of triclosan-coated sutures in adult (not pediatric)
patients, abdominal procedures, and clean or clean-contaminated (not dirty) wounds. For
abdominal wound closure (n = 1562), triclosan-coated sutures reduced the rate of surgical site
infection from 9.8 to 7.6 percent (RR 0.50, 95% CI 0.50-0.97).
However, a later multicenter German trial randomly assigned 1224 patients to polydioxanone
suture without triclosan (PDS-II) or polydioxanone with triclosan (PDS Plus) for continuous
closure of midline abdominal wounds in patients undergoing laparotomy for a variety of intra-
abdominal conditions (PROUD trial) [16]. The incidence of surgical site infection did not differ
between groups (14.8 versus 16.1 percent), nor did the rate of serious adverse events (25 versus
22.9 percent), including wound dehiscence, which can be related to surgical site infection or
suboptimal technique. In this study, the majority of the cases were clean or clean-contaminated
(97.8 percent in triclosan coated, 98.4 percent uncoated), and antibiotic prophylaxis was used in
>98 percent of patients. Logistic regression identified extended operative procedures with a
combination of target organs (colon, rectum, liver, pancreas, and stomach [OR 6.4, 95% CI 2.7-
14.9]), missing antibiotic prophylaxis (OR 5.2, 95% CI 1.6-17.3), chronic renal insufficiency (OR
2.9, 95% CI 1.4-6.5), anemia (OR 1.7-2.6), increased body mass index, and surgeon expertise (OR
1.73, 95% CI 1.02-2.9) as increasing the risk for surgical site infection. Interestingly, a meta-
analysis of prior trials including these results favored triclosan-coated suture (OR 0.67, 95% CI
0.47-0.98) but over a wide confidence interval. Further studies are needed to determine which
subsets of patients are more likely to benefit to justify the added cost.
Another trial published after the meta-analysis that enrolled over 1000 patients undergoing
gastrointestinal surgery found that abdominal wall closure with triclosan-coated sutures did not
reduce the incidence of surgical site infection (6.9 percent triclosan versus 5.9 percent control)
[19].
Needles — Although many types of needles are available, most are designed for very special
suturing needs. Needles are classified according to shape, caliber, degree of curvature, type of
point, and how the suture is attached (swaged or threaded) ( figure 1). Most surgeons use
only a few needle types. (See "Skin laceration repair with sutures" and "Skin laceration repair
with sutures", section on 'Suture selection'.)
Straight or curved — Straight needles are used primarily for skin closure but are not
commonly used. They are of the cutting variety and are designed to be handheld. Curved
needles require a needle driver. They are characterized by the diameter of their arc, degree of
curvature, and caliber. Degree of curvature is one-fourth, three-eighths, one-half, and five-
eighths of a circle. Selection of size and curvature depends upon the tissue to be sutured and
the depth of dissection. The greater the curvature, the easier it is to manipulate the needle in
deep or confined spaces.
Diameter — Needle caliber is dependent upon the wire diameter from which the needle is
made. These are defined as fine, medium, and heavy. Medium needles, which are sometimes
called general closure needles, have utility in most tissues and are especially useful for pedicles
and fascia. Fine needles are sometimes called intestinal needles because of their frequent use
in gastrointestinal surgery. They are commonly used for delicate or thin tissue, small pedicles,
and blood vessels. The heavy needles are often referred to as hernia needles. They are designed
for use on fascia, ligaments, and other dense tissues.
Point — Most abdominal incisions can be closed with one-half or five-eighths circle, taper
point, general closure needles. Hernia needles may be used if the fascia is thickened or scarred.
A cutting needle is rarely necessary for standard fascial closures.
● Taper – Taper point needles are atraumatic. They create the smallest holes because the
tissues are stretched and can retract around the suture. These are the most commonly
employed needles and have utility in all tissues except skin.
● Blunt – Taper point needles can also be blunted. Blunt needles may give an extra measure
of protection to both surgical personnel and patients from exposure to bloodborne
pathogens because penetration of the skin is less likely even when penetration of gloves
occurs [20,21]. Glove punctures and finger sticks with surgical needles account for up to
80 percent of accidental exposures to body fluids and potentially serious pathogens such
as hepatitis B, hepatitis C, and HIV [22]. Double gloving also reduces exposure risk. (See
"Prevention of hepatitis B virus and hepatitis C virus infection among health care
providers" and "Management of health care personnel exposed to HIV".)
Blunt needles may be used to close fascia satisfactorily, but, because of the blunt tip, they
do not immediately pierce the tissue, and extra force is usually needed [23]. On occasion,
the surgeon may have to change to a traditional taper point or cutting needle.

● Cutting – Cutting needles have at least two honed edges and are used in dense or scarred
tissue. These are the most commonly employed for skin closure. Care must be taken with
cutting needles to prevent laceration of tissue and accidental cuts to surgical personnel.
The conventional cutting needle has three sharpened edges on its surface. It cuts tissue
easily in the direction of the pull of the needle.
● Reverse cutting – A reverse cutting needle has a cutting edge on its convex surface. It
generally cuts tissue away from the pull of the needle. Although it may prevent accidental
cutting through the tissue edges, it will produce larger holes. These needles are useful for
the placement of retention sutures.
● Free versus swaged – A free needle must be threaded through an eyelet, while swaged
needles are a single unit with the suture attached directly. The swaged needles may have
the sutures attached to needles permanently or in a way that allows the needle to be
pulled off with a gentle tug. The latter are known as control release or "pop-off" needles
and may save time when numerous interrupted sutures are necessary. Swaged needles
cause less tissue injury because they are smaller and always remain sharp. There is less
chance of metal fatigue since they are disposable. Less handling and manipulation is
needed with swaged needles, which may lower the risk of glove punctures and needle
sticks.
KNOTS
Secure knots are critical for a strong closure. Most suture failures occur at the knot. Knot
security is a function of how the loops and throws are configured, as well as the type and size of
the suture.
Many studies have been performed to determine which sutures have the best knot security, but
results are mixed. It appears that braided suture consistently tends to have better knot security
compared with monofilament suture when the same size, suture, and number of knots are
used.
In most situations, a single strand of suture should be tied to a single strand. Tying a single
strand of suture to a double strand of suture may reduce knot security [24]. This is especially
important if the suture will significantly experience tension, such as with fascia closure.
There is no benefit to the use of a surgeon's knot (a double throw in the first loop) over a square
knot ( figure 2) [25,26]. The primary benefit of a square knot is that it becomes tighter when
the ends of the suture are pulled [25]. Although knots are the weakest part of the suture,
square knots maintain 90 percent of the tensile strength of untied sutures. If nonidentical
sliding knots are used, then six throws are needed for adequate knot security [24].
Knots always provide space in which bacteria can become enmeshed and therefore are the
most common site of sinus formation. Early attempts to exploit greater tensile strength of
nonabsorbable sutures were thwarted by the frequency of suture sinuses when natural fiber
multifilament sutures were used. The risk of sinus formation may approach 80 percent if a
contaminated wound is closed with natural multifilament suture [27].
A lower risk of suture sinus formation with synthetic suture was illustrated in a study that
compared continuous closure using polydioxanone (PDS) with interrupted closure using
braided silk in clean and contaminated abdominal wounds [28]. The incidence of sinus
formation was 1.3 percent in the PDS group compared with 7.1 percent in the silk group. Also,
sinus formation following use of PDS healed within one week after percutaneous drainage
alone without removal of the suture, whereas sinus formation associated with braided silk
required excision of the sinus tract and removal of the infected suture. Wound dehiscence, early
wound infection, and incisional hernia did not differ significantly between the two groups.
Additionally, the use of absorbable suture may eliminate palpation of the knot through the skin,
a potentially distressing problem in thin patients.
WOUND CLOSURE TECHNIQUE BY LAYER
The method of closure of the abdominal wall is a critical aspect of an effective incision closure,
in addition to choice of suture material. Layered closure is described as the separate closure of
the individual component of the abdominal wall, specifically the peritoneum and distinct
musculoaponeurotic layers, whereas mass closure is the closure of all layers of the abdominal
wall (except the skin) as a single structure. An evidence-based review identified three separate
meta-analyses, each of which found that mass closure was associated with a lower incidence of
incisional hernia [6,29-31]. In addition to mass closure, this review determined that the optimal
method of abdominal wall closure is mass closure using absorbable suture in a simple running
technique with a suture length to wound length ratio of 4 to 1. (See 'Mass closure' below.)
Peritoneum — Surgical closure of the peritoneum does not impact incision strength or healing.
There is overwhelming evidence from randomized trials that peritoneal closure is unnecessary
because the peritoneum reepithelializes within 48 to 72 hours [32-34]. Furthermore, peritoneal
closure results in more advanced adhesion formation at the time of a subsequent procedure
[35]. (See "Postoperative peritoneal adhesions in adults and their prevention".)

Also, there are insufficient data to suggest that aggressive peritoneal lavage is beneficial if
there is no gross contamination [36]. Lavage may impede host defenses and spread previously
localized infection.
Fascia — The fascia is the most critical layer because this tissue provides the greatest wound
tensile strength during healing.
Tensile strength of the fascial wound — The inflammatory process at the wound edge
produces collagenase, which assists digestion of necrotic debris but also results in lysis of
collagen and partial digestion of fascia. During these first few postoperative days, tensile
strength of the sutured wound may actually decline by as much as 50 percent before a slow
increase in tensile strength begins [37,38]. (See "Basic principles of wound healing", section on
'Wound healing'.)
Tensile strength of a wound follows a characteristic nonlinear pattern and depends upon the
synthesis of new connective tissue by fibroblasts ( figure 3). Adequate blood supply is critical
to supply nutrients and oxygen. Wounds have less than 5 percent of the tensile strength of
unwounded tissue in the first postoperative week; thus, wound security is dependent solely
upon suture that has been secured in strong healthy tissue. Maximum strength rarely, if ever,
exceeds 80 to 90 percent of intact fascia. Fortunately, only 15 to 20 percent of maximum
strength is necessary for normal daily activities [39]. Since return of tensile strength can take
more than 70 days, sutures that maintain their strength for at least this length of time are
preferred. Therefore, most surgeons select a delayed absorbable or nonabsorbable suture for
abdominal wall closure. (See 'Materials' above.)
Technique — Fascial closure should reapproximate the wound edges without undue tension
or tissue ischemia. Although interrupted closure has the advantage of not relying on the
security of a single knot, this technique is associated with tissue ischemia due to an uneven
distribution of tension. Fortunately, dehiscence due to knot slippage is rare [40]. Continuous
closure distributes tension evenly along the entire length of the incision, allows better tissue
perfusion, and saves time. A meta-analysis evaluating midline abdominal closure techniques
supports closure of elective midline incisions with a continuous technique using slowly
absorbable sutures [7]. (See 'Midline' below.)
The amount of suture used depends upon the size of each stitch (ie, distance from fascial edge)
and stitch interval (ie, space between stitches). For continuous closure, the total length of the
suture should be approximately four times the length of the incision [41,42]. The use of a
shorter length suture due to a reduced stitch size and/or stitch interval increases the risk of
hernia formation [42-44]. In a randomized trial, the incidence of hernia formation (9 versus 21.5

percent, respectively) was lower when the suture length/wound length (SL/WL) ratio was ≥4
compared with <4 [43].
Regardless of whether interrupted or continuous closure is chosen, sutures should be placed

approximately 10 mm from the fascial edge. Suture widths in excess of 10 mm may increase the
magnitude of compressive forces on the tissue contained between the suture hole and fascial
edge [45].
In Europe, a further reduction in suture width from 10 mm to 5 to 8 mm is advocated by the

2015 European Hernia Society guidelines on the closure of abdominal wall incisions [41], largely
based upon the results of two randomized trials [42,46].
● A randomized trial comparing long stitch width (>10 mm) with shorter stitch width (5 to 8
mm) identified longer stitch width as an independent risk factor for the development of
both incisional hernia and surgical site infection [42]. Incisional hernia occurred in 49 of
272 patients (18.0 percent) in the long stitch group and in 14 of 250 (5.6 percent) in the
short stitch group.
● In a second trial (STITCH), 560 patients were randomly assigned to undergo continuous
suture closure of a midline incision with either a long (10 mm) or short (5 mm) suture
width [46]. Significantly fewer patients in the short, compared with long, suture width
group developed incisional hernia at one year (13 versus 21 percent). The rates of
complications (including surgical site infections) were not different.
Further studies with different needle/suture types, as well as with a longer follow-up, are
required before a suture width of less than 10 mm can be recommended for routine closure of
all midline incisions.
Retention sutures have traditionally been used in wounds thought to be at a high risk for
dehiscence, but data consistently supporting this technique are lacking, and this technique is
associated with increased wound complications and difficulty with ostomy placement and care.
(See "Complications of abdominal surgical incisions".)
Mass closure — Mass closure may be performed in either a continuous or interrupted fashion.
Mass closure significantly reduces the incidence of wound dehiscence and is performed by
incorporating a small amount of subcutaneous fat, rectus muscle, rectus sheaths, transversalis
fascia, and, optionally, the peritoneum. Techniques for mass closure include the Smead-Jones
and continuous single or double loop closures.

Continuous mass closure with nonabsorbable or slowly absorbable suture is safe and as
effective as interrupted techniques ( figure 4). In addition, studies in animals and humans
have found continuous mass closures to be faster and more cost effective [47-49].
To perform the Smead-Jones closure, sutures are placed in a vertical mattress fashion.
Continuous double loop mass closure may be superior to single loop mass closure. A study that
compared the double and single loop mass closure in midline laparotomy wounds reported that
wound dehiscence was 0 with the continuous double loop closure technique compared with 8
percent for single loop mass closure [50].
Prophylactic mesh — The incidence of incisional hernia following laparotomy varies widely
and depends upon the patient's risk factors for hernia formation and the nature of the surgery,
with most studies reporting rates between 10 and 15 percent [51]. (See "Clinical features,
diagnosis, and prevention of incisional hernias", section on 'Epidemiology and risk factors'.)
For high-risk patients (eg, those with obesity or undergoing open abdominal aortic aneurysm
repair), there has been some interest in placing mesh prophylactically at abdominal wall closure
to prevent incisional hernia formation. However, no data are available regarding potential long-
term adverse outcomes, such as chronic pain and mesh complications. Given these limitations,
we do not place mesh prophylactically at the time of abdominal wall closure. Data on
prophylactic mesh use are presented elsewhere. (See "Clinical features, diagnosis, and
prevention of incisional hernias", section on 'Prophylactic mesh placement'.)
Subcutaneous — A systematic review identified eight trials evaluating subcutaneous closure

for non-cesarean delivery, concluding that the low-quality evidence available was insufficient to
support or refute subcutaneous closure [52]. By eliminating dead space, closure of
subcutaneous tissue may help prevent superficial wound disruption, which is often associated
with wound seroma, hematoma, or infection. Meticulous attention to control of subcutaneous
bleeding or the use of closed suction drainage can help prevent the development of hematoma
or subcutaneous fluid collection and may have a similar effect on wound disruption as
subcutaneous closure [53,54], although this is controversial [55]. Further randomized trials with
stratification for incision type and other components of perioperative care (eg, use of
antibiotics, type of suture material) are needed to examine these approaches.
A trial of 456 elective laparotomies found that wound irrigation with 0.04% polyhexanide
solution reduced surgical site infection rate compared with saline irrigation (34.7 versus 21.5
percent) [56].
Skin — Closure of the skin may be performed with subcuticular suture, stainless steel staples,
subcuticular absorbable staples, surgical tape, or wound adhesive glue.
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Subcuticular closure obviates the need to remove surgical staples, is more comfortable for the
patient, and is less costly [57]. Whether subcuticular suture results in a more cosmetically
pleasing scar is debated [58,59]. Suture knots have potential disadvantages in subcuticular
wound closure because they may cause tissue ischemia, act as a nidus for infection, and can
extrude through the skin weeks after surgery. One option is to anchor the suture above the skin
away from the incision. Another alternative is self-anchoring barbed polyglycolic acid or
polydioxanone suture (Quill, Contour Thread), which requires no knots [60]. These have a
similar cosmetic and safety profile as conventional suture but avoid the drawbacks inherent to
suture knots [60].
Staples are quicker to place, give an acceptable cosmetic result, are associated with a low rate
of infection, and allow small portions of the wound to be opened easily when needed [61].
Staple closure is less likely to obscure wound drainage and impending separation compared
with subcuticular closures but is more likely to be a source of postoperative pain [57]. Staples
are preferred for reentry incisions. An experimental study found no staple displacement or
increase in skin temperature for stapled closure exposed to magnetic resonance imaging [62].
Absorbable staples (eg, Insorb) potentially combine the benefits of subcuticular closure with the
speed and precision of staple placement [63]. In a study that compared skin incision closure by
absorbable subcuticular staples, cutaneous metal staples, and polyglactin 910 suture in a pig
model, absorbable subcuticular staples induced a less severe inflammatory response in the
early stages of healing.
Surgical tape and adhesives are alternatives to suture or staples. In particular, use of tissue
adhesives, such as octyl cyanoacrylate (Dermabond) and butylcyanoacrylate (Histoacryl), may
potentially save time and have wound infection rates and cosmetic outcomes that are
comparable to those of nonabsorbable monofilament sutures [64]. A systematic review
supported these findings but also noted that the tissue adhesives are associated with a small
but significant increased rate of wound dehiscence, which must be considered when choosing
the closure method [65]. (See "Minor wound repair with tissue adhesives (cyanoacrylates)".)
WOUND CLOSURE BY INCISION TYPE
Abdominal wall incisions are generally closed using the principles described above; however,
there are a few points specific to the type of incision.
Midline — We suggest placing the omentum beneath a longitudinal incision to reduce the risk
of adhesions between bowel and the anterior abdominal wall. The posterior rectus sheath is

included in the fascial closure to increase tensile strength of the closure.
To minimize the risk of incisional hernia, elective midline abdominal closure (first operation or
reoperation) should be performed using a continuous technique with slowly absorbable
sutures. A meta-analysis of 14 randomized trials of midline fascial closure in 7711 patients
compared the incidence of incisional hernia for elective abdominal wall closure performed with
continuous versus interrupted closure, rapidly absorbable versus slowly absorbable, and
nonabsorbable versus slowly absorbable suture [7].
Rapidly absorbable sutures included polyglactin 910 (Vicryl) and polyglycolic acid (Dexon).
Slowly absorbable sutures included polydioxanone (PDS, MonoPlus) and polyglyconate +
trimethylene carbonate (Maxon). Nonabsorbable sutures included polyamide (nylon),
polypropylene (Prolene), and polyester (Ethibond) ( table 2).
Results were as follows:
● The incidence of incisional hernia was significantly higher in the interrupted compared
with continuous closure group (12.6 versus 8.4 percent) regardless of the type of suture
material used (ie, absorbable versus nonabsorbable).
● The incidence of incisional hernia was significantly lower for absorbable sutures compared
with nonabsorbable sutures (6.1 versus 26.3 percent) regardless of suture technique (ie,
continuous versus interrupted).
● The incidence of incisional hernia was significantly lower for slowly absorbable sutures
compared with rapidly absorbable sutures (8.1 versus 10.8 percent) regardless of suture
technique (ie, continuous versus interrupted).
No conclusions could be drawn regarding optimal closure techniques for abdominal closure in
an emergency setting.
Since this meta-analysis, another trial randomly assigned 456 patients to closure of the midline
abdominal fascia to nonabsorbable (polypropylene; Prolene) or absorbable (polydioxanone;
PDS) suture material. In contrast, there were no significant differences in the incidence of
incisional hernia or secondary outcomes measures between the groups [66]. This trial included
both emergency and elective cases and did not stratify the analysis.
A 2017 Cochrane review of 55 randomized trials (19,174 patients) compared absorbable versus
nonabsorbable sutures, continuous versus interrupted closure, mass versus layered closure,
monofilament versus multifilament sutures, and slow versus fast absorbable suture in terms of
incisional hernia (at one year), wound infection, wound dehiscence, wound sinus, or fistula
formation. The only significant findings were that monofilament sutures may reduce the risk of
incisional hernia (relative risk 0.76, 95% CI 0.59-0.98) and that absorbable sutures may reduce
the risk of sinus or fistula tract formation (relative risk 0.49, 95% CI 0.26-0.94). However, only
about one-half of the included trials (26) enrolled patients who underwent midline incisions
exclusively; the others included patients who underwent paramedian, subcostal, or transverse
incisions [67].
Transverse
Upper abdominal transverse incision — A randomized trial of 268 patients undergoing

upper abdominal transverse incision closure compared mass versus layered continuous closure
[68]. Layered closure resulted in a lower incidence of surgical site infection (6 versus 18
percent). The follow-up was too short to detect incisional hernias.
Pfannenstiel and Cherney incision — The Pfannenstiel and Cherney incisions are closed in a
similar manner. The rectus muscles will usually approximate themselves, but if rectus diastasis
is present, the muscles can be pulled to the midline with several loosely tied absorbable
sutures. The aponeurosis is closed with interrupted or continuous suture. Both absorbable and
nonabsorbable sutures have been used for closure. Skin can be reapproximated by any method.
A subcuticular technique using 4-0 suture is easily performed since the edges are readily
brought together.
The only difference for the Cherney incision is the need to reattach the tendons to the lower
aponeurosis of the anterior rectus sheath rather than to the periosteum of the symphysis
directly. One option for this is horizontal mattress sutures of 2-0 permanent suture material;
delayed absorbable sutures are an alternative.
Maylard incision — With the Maylard incision, oozing from the cut muscle and extensive
tissue fluid collection may rarely be significant enough to warrant placement of a closed suction
drainage system under the fascia. The drain is brought out through a stab wound separate
from the incision. The fascia may then be closed with interrupted or continuous sutures, usually
of 1 or 0 suture caliber. Permanent or delayed absorbable suture is preferred, and a mass
closure technique can be used. A common method is closure of the fascia with running
permanent suture of 0 suture caliber in a mass technique and closing the skin using a
subcuticular technique with absorbable 4-0 suture.
Oblique — Oblique incisions (eg, McBurney) are muscle splitting; therefore, the muscles
reapproximate by their own contraction when anesthetic paralysis resolves. The wound would
likely heal with skin closure only; however, we suggest a deep simple closure. The internal
oblique and transversus abdominis are approximated with loosely tied absorbable sutures
spaced 1 cm apart in the internal oblique layer. The external oblique aponeurosis can be closed
with interrupted or continuous 2-0 absorbable sutures. The skin can be closed by any method.
When oblique incisions are used in the face of intra-abdominal infection, delayed primary
closure should be considered ( figure 5) [69]. Alternatively, the skin can be closed with staples
so that the incision can be easily be reopened, as needed.
DRAINS
Prior to closure, it may be necessary to place temporary drainage systems. Drains are
categorized as passive or active, meaning that they rely upon gravity or negative pressure
suction, respectively. Examples of passive drains include the Penrose drain, Foley catheter, Word
catheter, and Malecot catheter. Active drains may be open (eg, Salem sump) or closed systems
(eg, Jackson-Pratt). One disadvantage of open systems is the potential for bacterial
contamination of the tubing. Therefore, most surgeons prefer closed systems with negative
pressure suction. Because closed suction systems ( figure 6) require smaller incisions,
herniation is uncommon.
The primary indication for the placement of a drain is the prevention of fluid collection and
subsequent infection. Intra-abdominal procedures frequently associated with large collections
of blood and serum (eg, hepatic, pancreatic surgery) may benefit from prophylactic drainage.
Drains are placed adjacent to the injured tissue (eg, liver, pancreas) or in the vicinity of an
anastomosis at risk for leakage (ie, choledochoenteric, pancreaticoenteric). Other procedures
that may require drainage include radical pelvic surgery, entry into the space of Retzius, or
muscle-splitting incisions. Although the data are mixed, randomized trials and meta-analyses
have found that closed drainage of the subcutaneous tissue does not prevent significant wound
complications [70,71].
Thus, the value of prophylactic drains remains controversial. Complications from drains may
include infection, hemorrhage, kinking, and hernia formation. Good surgical technique with
adequate hemostasis, the elimination of dead space, and the use of prophylactic antibiotics
obviate the need for drains in most patients.
Irrigation of wounds with antibiotics initially was thought to lower the incidence of wound
infection, but contemporary reviews suggest there is no benefit to routine irrigation of a midline
wound, provided the patient received appropriate antibiotic prophylaxis [72]. Additionally,
antibiotic solutions are toxic to the cellular elements necessary for healing. For this reason,
delayed closure of an abdominal incision with or without the use of a negative pressure wound

system is an alternative to irrigation in certain circumstances. (See "Negative pressure wound

therapy".)
Placement — Drains should be placed through a small incision separate from the primary
incision ( figure 7) [1]. The drain should have a direct path to prevent kinking and subsequent
obstruction. Care must be taken to avoid injury to the abdominal wall vessels (eg, epigastric),
which can lead to significant bleeding. A stab wound involving the rectus sheath must be
adequate to prevent kinking of the drain and to allow its removal, but not so large that a hernia
may form. Normally, an incision greater than 5 mm but less than 10 mm is ideal. Care must also
be taken to avoid suturing the drain to the fascia during closure. Once placed, the drain should
be properly dressed and placed in a position that avoids traction and potential fracture [73].
WOUND PACKING
Contaminated wounds should generally be packed open. (See "Basic principles of wound
management", section on 'Wound packing'.)
Options for wound closure include healing by secondary intention, which requires ongoing
wound packing, negative pressure wound therapy, or delayed primary closure. Whether
primary closure necessarily leads to a higher incidence of surgical site infection under this
circumstance has not been definitively proven. A systematic review identified eight trials that
randomly assigned patients to primary closure or delayed primary closure following a variety of
procedures, including perforated appendicitis, perforated viscus, ileostomy closure, trauma,
and intra-abdominal abscess [74]. Primary closure appeared to increase the risk for surgical site
infection; however, significant heterogeneity was noted, and with a random (rather than fixed)
effects model, the effect was no longer significant.
DRESSINGS
A sterile dressing is generally used to protect the closed surgical wound for 24 to 48 hours
postoperatively. There are no convincing data to suggest that one type of dressing is better
than another with respect to surgical site infection (SSI). Systematic reviews have found no
significant difference in SSI rates for surgical wounds covered with different dressings (basic
wound contact dressing, film dressing, hydrocolloid dressing) and those left uncovered for a
variety of wound conditions (clean, mixed contamination levels) [75,76]. As such, the choice of
surgical wound dressing should be made with regard to the ability of the dressing to manage
absorption of exudate upon the nature of the surgical wound and any properties and qualities

that a particular dressing can offer. Although the dry sterile dressing has been a standard for
decades, wounds heal better in a moist environment. Thus, modern film dressings that are
impermeable to fluid and bacteria but allow passage of moisture vapor may be preferable
[1,77]. These do not appear to increase the frequency of wound infection, and they permit
visual assessment of the wound and improved patient comfort. (See "Basic principles of wound
management", section on 'Common dressings'.)
Negative pressure dressings — Following their use in orthopedic and sternal surgery [78],
negative pressure dressings have been applied to closed abdominal wounds in general and
colorectal surgery [79-81]. In a systematic review and meta-analysis of five randomized trials
and 16 nonrandomized comparative studies (2930 patients), negative pressure dressings, when
used on closed abdominal incisions, were associated with reduced surgical site infections
(pooled risk difference -12 percent, 95% CI -17 to -8 percent) [82]. The benefit was more
pronounced in studies with an infection rate of 20 percent or greater in the control arm; the
significance was lost when pooling only high-quality observational studies (642 patients) or
randomized trials (527 patients).
Further studies are required to identify the patient population that would benefit most from the
negative pressure dressings (eg, patients with obesity or contaminated wounds). Routine use of
negative pressure dressings after abdominal closure is costly and therefore will need to be
justified by a significant reduction in complication rates. One study found the use of negative
pressure dressings cost effective in the treatment of high-risk abdominal wounds [83].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Abdominal incisions and
closure".)
SUMMARY AND RECOMMENDATIONS
● The suture chosen for closure should be absorbable and have a caliber that will provide
adequate strength to the wound while minimizing foreign body content. Multifilament
sutures provide better knot strength but are more prone to infection and sinus formation.
(See 'Sutures' above.)
● Most abdominal incisions can be closed with one-half or five-eighths circle, taper point,
general closure needles. Hernia needles can be used if the fascia is thickened or scarred. A
cutting needle is rarely needed for standard closures. (See 'Needles' above.)
● Continuous mass closure is the ideal closure method using a suture length to wound
length ratio of 4:1 in a simple running technique. The tissue should be reapproximated
with low tension to prevent ischemia. A single strand should be tied to another single
strand using a square knot or surgeon's knot. (See 'Fascia' above and 'Knots' above.)
● We suggest not closing the peritoneum, as this appears to confer no benefit (Grade 2C).
(See 'Peritoneum' above.)
● To reduce the incidence of incisional hernia following elective midline abdominal closure
(first-time closure or repeat closure), we recommend a continuous suture technique using
slowly absorbable monofilament suture (Grade 1A). The optimal closure technique in the
emergency setting has not been defined. The fascia of nonmidline abdominal incisions can
be closed in a similar fashion. (See "Complications of abdominal surgical incisions", section
on 'Suture'.)
● There appears to be no benefit to subcutaneous closure. Good surgical technique with

adequate hemostasis and the use of prophylactic antibiotics obviate the need for drains in
most patients. (See 'Subcutaneous' above and 'Drains' above.)
● Staples, subcuticular suture, and tissue adhesives are appropriate for skin closure; the
wound should be covered with a semipermeable film or hydrocolloid dressing. (See 'Skin'
above and 'Dressings' above.)
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Pearl ML, Rayburn WF. Choosing abdominal incision and closure techniques: a review. J
Reprod Med 2004; 49:662.
2. Yaltirik M, Dedeoglu K, Bilgic B, et al. Comparison of four different suture materials in soft
tissues of rats. Oral Dis 2003; 9:284.
3. MADSEN ET. An experimental and clinical evaluation of surgical suture materials. Surg
Gynecol Obstet 1953; 97:73.
4. Ethicon wound closure manual. Available at: http://media.xn--benersttning-lcb.se/2012/04/
Ethicon-wound-closure-manual.pdf (Accessed on June 29, 2020).

5. Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial
closure: a meta-analysis. Ann Surg 2000; 231:436.
6. van 't Riet M, Steyerberg EW, Nellensteyn J, et al. Meta-analysis of techniques for closure of
midline abdominal incisions. Br J Surg 2002; 89:1350.
7. Diener MK, Voss S, Jensen K, et al. Elective midline laparotomy closure: the INLINE
systematic review and meta-analysis. Ann Surg 2010; 251:843.
8. Thiede A, Jostarndt L, Lünstedt B, Sonntag HG. [Controlled experimental histological and
microbiological studies on the inhibitory effect of polyglycolic acid sutures in infections].
Chirurg 1980; 51:35.
9. Alexander JW, Kaplan JZ, Altemeier WA. Role of suture materials in the development of
wound infection. Ann Surg 1967; 165:192.
10. McGeehan D, Hunt D, Chaudhuri A, Rutter P. An experimental study of the relationship
between synergistic wound sepsis and suture materials. Br J Surg 1980; 67:636.
11. Justinger C, Moussavian MR, Schlueter C, et al. Antibacterial [corrected] coating of
abdominal closure sutures and wound infection. Surgery 2009; 145:330.
12. Ford HR, Jones P, Gaines B, et al. Intraoperative handling and wound healing: controlled
clinical trial comparing coated VICRYL plus antibacterial suture (coated polyglactin 910
suture with triclosan) with coated VICRYL suture (coated polyglactin 910 suture). Surg Infect
(Larchmt) 2005; 6:313.
13. Galal I, El-Hindawy K. Impact of using triclosan-antibacterial sutures on incidence of
surgical site infection. Am J Surg 2011; 202:133.
14. Nakamura T, Kashimura N, Noji T, et al. Triclosan-coated sutures reduce the incidence of
wound infections and the costs after colorectal surgery: a randomized controlled trial.
Surgery 2013; 153:576.
15. Justinger C, Slotta JE, Ningel S, et al. Surgical-site infection after abdominal wall closure with
triclosan-impregnated polydioxanone sutures: results of a randomized clinical pathway
facilitated trial (NCT00998907). Surgery 2013; 154:589.
16. Diener MK, Knebel P, Kieser M, et al. Effectiveness of triclosan-coated PDS Plus versus
uncoated PDS II sutures for prevention of surgical site infection after abdominal wall
closure: the randomised controlled PROUD trial. Lancet 2014; 384:142.
17. Wang ZX, Jiang CP, Cao Y, Ding YT. Systematic review and meta-analysis of triclosan-coated
sutures for the prevention of surgical-site infection. Br J Surg 2013; 100:465.
18. Edmiston CE Jr, Daoud FC, Leaper D. Is there an evidence-based argument for embracing
an antimicrobial (triclosan)-coated suture technology to reduce the risk for surgical-site

infections?: A meta-analysis. Surgery 2013; 154:89.

19. Ichida K, Noda H, Kikugawa R, et al. Effect of triclosan-coated sutures on the incidence of
surgical site infection after abdominal wall closure in gastroenterological surgery:
a double-blind, randomized controlled trial in a single center. Surgery 2018.
20. Montz FJ, Fowler JM, Farias-Eisner R, Nash TJ. Blunt needles in fascial closure. Surg Gynecol
Obstet 1991; 173:147.
21. Mingoli A, Sapienza P, Sgarzini G, et al. Influence of blunt needles on surgical glove
perforation and safety for the surgeon. Am J Surg 1996; 172:512.
22. Marcus R. Surveillance of health care workers exposed to blood from patients infected with
the human immunodeficiency virus. N Engl J Med 1988; 319:1118.
23. Nordkam RA, Bluyssen SJ, van Goor H. Randomized clinical trial comparing blunt tapered
and standard needles in closing abdominal fascia. World J Surg 2005; 29:441.
24. Ivy JJ, Unger JB, Hurt J, Mukherjee D. The effect of number of throws on knot security with
nonidentical sliding knots. Am J Obstet Gynecol 2004; 191:1618.
25. van Rijssel EJ, Trimbos JB, Booster MH. Mechanical performance of square knots and sliding
knots in surgery: comparative study. Am J Obstet Gynecol 1990; 162:93.
26. Muffly TM, Boyce J, Kieweg SL, Bonham AJ. Tensile strength of a surgeon's or a square knot.
J Surg Educ 2010; 67:222.
27. Cutler EC, Dunphy JE. The use of silk in infected wounds. N Engl J Med 1941; 224:101.
28. Iwase K, Higaki J, Tanaka Y, et al. Running closure of clean and contaminated abdominal
wounds using a synthetic monofilament absorbable looped suture. Surg Today 1999;
29:874.
29. Weiland DE, Bay RC, Del Sordi S. Choosing the best abdominal closure by meta-analysis. Am
J Surg 1998; 176:666.
30. Rucinski J, Margolis M, Panagopoulos G, Wise L. Closure of the abdominal midline fascia:
meta-analysis delineates the optimal technique. Am Surg 2001; 67:421.
31. Ceydeli A, Rucinski J, Wise L. Finding the best abdominal closure: an evidence-based review
of the literature. Curr Surg 2005; 62:220.
32. Gurusamy KS, Cassar Delia E, Davidson BR. Peritoneal closure versus no peritoneal closure
for patients undergoing non-obstetric abdominal operations. Cochrane Database Syst Rev
2013; :CD010424.
33. Jenkins TR. It's time to challenge surgical dogma with evidence-based data. Am J Obstet
Gynecol 2003; 189:423.

34. Tulandi T, Al-Jaroudi D. Nonclosure of peritoneum: a reappraisal. Am J Obstet Gynecol 2003;

189:609.
35. Komoto Y, Shimoya K, Shimizu T, et al. Prospective study of non-closure or closure of the
peritoneum at cesarean delivery in 124 women: Impact of prior peritoneal closure at
primary cesarean on the interval time between first cesarean section and the next
pregnancy and significant adhesion at second cesarean. J Obstet Gynaecol Res 2006;
32:396.
36. Platell C, Papadimitriou JM, Hall JC. The influence of lavage on peritonitis. J Am Coll Surg
2000; 191:672.
37. Foresman PA, Edlich RF, Rodeheaver GT. The effect of new monofilament absorbable
sutures on the healing of musculoaponeurotic incisions, gastrotomies, and colonic
anastomoses. Arch Surg 1989; 124:708.
38. Rath AM, Chevrel JP. The healing of laparotomies: review of the literature. Hernia 1998;
2:145.
39. DOUGLAS DM. The healing of aponeurotic incisions. Br J Surg 1952; 40:79.
40. Gislason H, Grønbech JE, Søreide O. Burst abdomen and incisional hernia after major
gastrointestinal operations--comparison of three closure techniques. Eur J Surg 1995;
161:349.
41. Muysoms FE, Antoniou SA, Bury K, et al. European Hernia Society guidelines on the closure
of abdominal wall incisions. Hernia 2015; 19:1.
42. Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after
closure of midline incisions: a randomized controlled trial. Arch Surg 2009; 144:1056.
43. Israelsson LA, Jonsson T. Closure of midline laparotomy incisions with polydioxanone and
nylon: the importance of suture technique. Br J Surg 1994; 81:1606.
44. Millbourn D, Israelsson LA. Wound complications and stitch length. Hernia 2004; 8:39.
45. Cengiz Y, Gislason H, Svanes K, Israelsson LA. Mass closure technique: an experimental
study on separation of wound edge. Eur J Surg 2001; 167:60.
46. Deerenberg EB, Harlaar JJ, Steyerberg EW, et al. Small bites versus large bites for closure of
abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled
trial. Lancet 2015; 386:1254.
47. Seid MH, McDaniel-Owens LM, Poole GV Jr, Meeks GR. A randomized trial of abdominal
incision suture technique and wound strength in rats. Arch Surg 1995; 130:394.
48. Meeks GR, Nelson KC, Byars RW. Wound strength in abdominal incisions: a comparison of
two continuous mass closure techniques in rats. Am J Obstet Gynecol 1995; 173:1676.
49. Colombo M, Maggioni A, Parma G, et al. A randomized comparison of continuous versus

interrupted mass closure of midline incisions in patients with gynecologic cancer. Obstet
Gynecol 1997; 89:684.
50. Nasir GA, Baker KK. Continuous double loop closure for midline laparotomy wounds. Saudi
Med J 2001; 22:351.
51. Nachiappan S, Markar S, Karthikesalingam A, et al. Prophylactic mesh placement in high-
risk patients undergoing elective laparotomy: a systematic review. World J Surg 2013;
37:1861.
52. Gurusamy KS, Toon CD, Davidson BR. Subcutaneous closure versus no subcutaneous
closure after non-caesarean surgical procedures. Cochrane Database Syst Rev 2014;
:CD010425.
53. Cardosi RJ, Drake J, Holmes S, et al. Subcutaneous management of vertical incisions with 3
or more centimeters of subcutaneous fat. Am J Obstet Gynecol 2006; 195:607.
54. Magann EF, Chauhan SP, Rodts-Palenik S, et al. Subcutaneous stitch closure versus
subcutaneous drain to prevent wound disruption after cesarean delivery: a randomized
clinical trial. Am J Obstet Gynecol 2002; 186:1119.
55. Ramsey PS, White AM, Guinn DA, et al. Subcutaneous tissue reapproximation, alone or in
combination with drain, in obese women undergoing cesarean delivery. Obstet Gynecol
2005; 105:967.
56. Strobel RM, Leonhardt M, Krochmann A, et al. Reduction of Postoperative Wound Infections
by Antiseptica (RECIPE)?: A Randomized Controlled Trial. Ann Surg 2020; 272:55.
57. Frishman GN, Schwartz T, Hogan JW. Closure of Pfannenstiel skin incisions. Staples vs.
subcuticular suture. J Reprod Med 1997; 42:627.
58. Koskela A, Kotaluoto S, Kaartinen I, et al. Continuous absorbable intradermal sutures yield
better cosmetic results than nonabsorbable interrupted sutures in open appendectomy
wounds: a prospective, randomized trial. World J Surg 2014; 38:1044.
59. Nygaard IE, Squatrito RC. Abdominal incisions from creation to closure. Obstet Gynecol
Surv 1996; 51:429.
60. Murtha AP, Kaplan AL, Paglia MJ, et al. Evaluation of a novel technique for wound closure
using a barbed suture. Plast Reconstr Surg 2006; 117:1769.
61. Edlich RF, Becker DG, Thacker JG, Rodeheaver GT. Scientific basis for selecting staple and
tape skin closures. Clin Plast Surg 1990; 17:571.
62. Gayton JC, Sensiba P, Imbrogno BF, et al. The effects of magnetic resonance imaging on
surgical staples: an experimental analysis. J Trauma 2011; 70:1279.

63. Fick JL, Novo RE, Kirchhof N. Comparison of gross and histologic tissue responses of skin
incisions closed by use of absorbable subcuticular staples, cutaneous metal staples, and
polyglactin 910 suture in pigs. Am J Vet Res 2005; 66:1975.
64. Dowson CC, Gilliam AD, Speake WJ, et al. A prospective, randomized controlled trial
comparing n-butyl cyanoacrylate tissue adhesive (LiquiBand) with sutures for skin closure
after laparoscopic general surgical procedures. Surg Laparosc Endosc Percutan Tech 2006;
16:146.
65. Chow A, Marshall H, Zacharakis E, et al. Use of tissue glue for surgical incision closure: a
systematic review and meta-analysis of randomized controlled trials. J Am Coll Surg 2010;
211:114.
66. Bloemen A, van Dooren P, Huizinga BF, Hoofwijk AG. Randomized clinical trial comparing
polypropylene or polydioxanone for midline abdominal wall closure. Br J Surg 2011; 98:633.
67. Patel SV, Paskar DD, Nelson RL, et al. Closure methods for laparotomy incisions for
preventing incisional hernias and other wound complications. Cochrane Database Syst Rev
2017; 11:CD005661.
68. Grąt M, Morawski M, Krasnodębski M, et al. Incisional Surgical Site Infections After Mass
and Layered Closure of Upper Abdominal Transverse Incisions: First Results of a
Randomized Controlled Trial. Ann Surg 2021; 274:690.
69. Gottrup F, Fogdestam I, Hunt TK. Delayed primary closure: an experimental and clinical
review. J Clin Surg 1982; 1:113.
70. Hellums EK, Lin MG, Ramsey PS. Prophylactic subcutaneous drainage for prevention of
wound complications after cesarean delivery--a metaanalysis. Am J Obstet Gynecol 2007;
197:229.
71. Gates S, Anderson ER. Wound drainage for caesarean section. Cochrane Database Syst Rev
2005; :CD004549.
72. Falagas ME, Vergidis PI. Irrigation with antibiotic-containing solutions for the prevention
and treatment of infections. Clin Microbiol Infect 2005; 11:862.
73. Pesce C, Galvagno SM Jr, Efron DT, et al. Retained drains causing a bronchoperitoneal
fistula: a case report. J Med Case Rep 2011; 5:185.
74. Bhangu A, Singh P, Lundy J, Bowley DM. Systemic review and meta-analysis of randomized
clinical trials comparing primary vs delayed primary skin closure in contaminated and dirty
abdominal incisions. JAMA Surg 2013; 148:779.
75. Dumville JC, Gray TA, Walter CJ, et al. Dressings for the prevention of surgical site infection.
Cochrane Database Syst Rev 2014; :CD003091.

76. Walter CJ, Dumville JC, Sharp CA, Page T. Systematic review and meta-analysis of wound
dressings in the prevention of surgical-site infections in surgical wounds healing by
primary intention. Br J Surg 2012; 99:1185.
77. Rubio PA. Use of semiocclusive, transparent film dressings for surgical wound protection:
experience in 3637 cases. Int Surg 1991; 76:253.
78. Hyldig N, Birke-Sorensen H, Kruse M, et al. Meta-analysis of negative-pressure wound
therapy for closed surgical incisions. Br J Surg 2016; 103:477.
79. O'Leary DP, Peirce C, Anglim B, et al. Prophylactic Negative Pressure Dressing Use in Closed
Laparotomy Wounds Following Abdominal Operations: A Randomized, Controlled, Open-
label Trial: The P.I.C.O. Trial. Ann Surg 2017; 265:1082.
80. Bueno-Lledó J, Franco-Bernal A, Garcia-Voz-Mediano MT, et al. Prophylactic Single-use
Negative Pressure Dressing in Closed Surgical Wounds After Incisional Hernia Repair: A
Randomized, Controlled Trial. Ann Surg 2021; 273:1081.
81. Murphy PB, Knowles S, Chadi SA, et al. Negative Pressure Wound Therapy Use to Decrease
Surgical Nosocomial Events in Colorectal Resections (NEPTUNE): A Randomized Controlled
Trial. Ann Surg 2019; 270:38.
82. Meyer J, Roos E, Abbassi Z, et al. Prophylactic Negative-pressure Wound Therapy Prevents
Surgical Site Infection in Abdominal Surgery: An Updated Systematic Review and Meta-
analysis of Randomized Controlled Trials and Observational Studies. Clin Infect Dis 2021;
73:e3804.
83. Chopra K, Gowda AU, Morrow C, et al. The Economic Impact of Closed-Incision Negative-
Pressure Therapy in High-Risk Abdominal Incisions: A Cost-Utility Analysis. Plast Reconstr
Surg 2016; 137:1284.
Topic 4 Version 29.0

GRAPHICS
Classification of common suture materials
Type Generic name
Absorbable
Natural fibers Plain catgut
Chromic catgut
Synthetics Polyglycolic acid (Dexon)
Polyglactin 910 (Vicryl)
Polydioxanone (PDS)
Polyglyconate (Maxon)
Poliglecaprone (Moncryl)
Permanent
Natural fibers Cotton
Linen
Silk
Synthetics Polyamide (Nylon)
Polypropylene (Prolene)
Polybutester (Novafil)
Polyester (Mersilene)
Coated polyester (Ti-cron, Tevdek)
Metal Stainless steel (Flexon)
Silver
Graphic 66977 Version 2.0

Characteristics of sutures
Knot Tensile Tissue Wound security,

Material
security strength reaction days
Plain gut + + ++++ 5
Chromic gut ++ ++ ++++ 14
Polyglycolic ++++ +++ ++ 21

acid
Polyglactin +++ +++ ++ 30
Polydioxanone ++ ++++ ++ 60
Polyglyconate ++ ++++ ++ 60
Poliglecaprone ++ +++ ++ 14
Polyamide + +++ + 300
Polyester ++++ ++++ ++ 300+
Polybutester +++ ++++ ++ 300+
Polypropylene +++ ++++ + 300+
Stainless steel ++++ ++++ ++ 300+

Types of surgical needles

Surgical knots
Square knot and surgeon's knot.
Courtesy of William J Mann, Jr, MD.

Collagen synthesis and tensile strength
Relation of the rate of collagen synthesis to the gain of tensile strength of rat skin wounds.
Reproduced from: Madden JW, Peacock EE Jr. Studies on the biology of collagen during wound healing. 1. Rate of collagen
synthesis and deposition in cutaneous wounds of the rat. Surgery 1968; 64:288. Illustration used with the permission of Elsevier
Inc. All rights reserved.

Mass closure of abdominal incisions
(A) Smead-Jones closure. Far-far-near-near. Suture passes laterally through rectus sheath and peritoneum
and adjacent fat. The suture crosses midline to pick up medial edge of fascia on opposite side of incision.
(B) Alternative closure. Far-near-near-far. The far bite is 1 to 1.5 cm away from the edge. The near bite is 5
mm from the edge.
(C) Running mass closure. Two sutures are used, beginning from each pole of the incision. Sutures are 1
cm away from edge and 1 cm apart. The sutures are tied at the midpoint of the incision.
Courtesy of Therese Trenhaile, MD.

McBurney abdominal incision and closure
(A) Incision through McBurney's point. (B) Fibers of exterior oblique separated. Internal oblique muscle
split. (C) Peritoneum and transversalis fascia incised. (D) Internal oblique closed with interrupted suture.
(E) External oblique closed with running suture. (F) Delayed closure of skin.
Courtesy of Therese Trenhaile, MD.

Tubes for closed suction drainage
Many sizes are available.

Drain placement at surgery

Contributor Disclosures
Jason S Mizell, MD, FACS No relevant financial relationship(s) with ineligible companies to
disclose. Michael Rosen, MD Employment: Medical Director of AHSQC (Americas Hernia Society Quality
Collaborative) [Health information]. Equity Ownership/Stock Options: Ariste Medical [Mesh]. All of the
relevant financial relationships listed have been mitigated. Wenliang Chen, MD, PhD No relevant financial
relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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Official reprint from UpToDate®

Literature review current through: Feb 2024.

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Advantages of synthetic suture over natural fibers include:

● Polyglactin 910 (Vicryl) – Two weeks

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examples of this type of suture include polyamide (Nylon), polypropylene (Prolene),

Monofilament versus multifilament — Another important characteristic of suture that

Triclosan-coated versus noncoated sutures — Sutures coated with antimicrobial compounds

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WOUND CLOSURE TECHNIQUE BY LAYER

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Regardless of whether interrupted or continuous closure is chosen, sutures should be placed

In Europe, a further reduction in suture width from 10 mm to 5 to 8 mm is advocated by the

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Subcutaneous — A systematic review identified eight trials evaluating subcutaneous closure

WOUND CLOSURE BY INCISION TYPE

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included in the fascial closure to increase tensile strength of the closure.

Results were as follows:

Upper abdominal transverse incision — A randomized trial of 268 patients undergoing

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system is an alternative to irrigation in certain circumstances. (See "Negative pressure wound

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SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● There appears to be no benefit to subcutaneous closure. Good surgical technique with

Use of UpToDate is subject to the Terms of Use.

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infections?: A meta-analysis. Surgery 2013; 154:89.

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34. Tulandi T, Al-Jaroudi D. Nonclosure of peritoneum: a reappraisal. Am J Obstet Gynecol 2003;

49. Colombo M, Maggioni A, Parma G, et al. A randomized comparison of continuous versus

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Classification of common suture materials

Type Generic name

Natural fibers Plain catgut

Synthetics Polyglycolic acid (Dexon)

Polyglactin 910 (Vicryl)

Natural fibers Cotton

Synthetics Polyamide (Nylon)

Coated polyester (Ti-cron, Tevdek)

Metal Stainless steel (Flexon)

Graphic 66977 Version 2.0

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Knot Tensile Tissue Wound security,

Plain gut + + ++++ 5

Chromic gut ++ ++ ++++ 14

Polyglycolic ++++ +++ ++ 21

Polyglactin +++ +++ ++ 30

Polyamide + +++ + 300

Polyester ++++ ++++ ++ 300+

Polybutester +++ ++++ ++ 300+

Polypropylene +++ ++++ + 300+

Stainless steel ++++ ++++ ++ 300+

Graphic 65396 Version 2.0

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