Fascial Closure

Rachel Deborah Miller, MD
The Operative Review of Surgery. 2023; 1:221-223.

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Table of Contents

Laparotomy Incision Closure
Port-Site Closure

References

Laparotomy Incision Closure

Optimal Technique 1-3

  • Continuous/Running Suture
  • Small Bites (5-7 mm Every 5-7 mm)
  • Slowly Absorbable Monofilament Suture (PDS)
  • Goal Suture:Wound Length: 4:1

Additional Considerations

  • Triclosan-Coated Suture (Stratafix Symmetric, PDS Plus) May Decrease the Rates of Surgical Site Infections 4,5
  • Barbed Suture (Stratafix, V-Loc) May Decrease the Risk of Evisceration 5-7

Prophylactic Mesh Placement 2,8,9

  • Decreases Risk of Hernia
  • Onlay or Retro-Muscular Plane is Preferred
  • Complications:
    • Increased Risk of Seroma
    • No Increased Risk of Infection
  • *Use is Debated and Not Clearly Defined

Abdominal Binders 10-12

  • No Evidence to Show Decreased Risk of Incisional Hernia or Burst Abdomen
  • May Decrease Postoperative Pain

Port-Site Closure

Indications to Close the Fascial Defect 2,13

  • Trocar Sites ≥ 10 mm
  • Any Size After Single-Incision Laparoscopic Surgery (SILS)
  • Any Size at the Umbilical Site

Technique for Port-Site Closure

  • Over 20+ Techniques Have Been Described 14,15
  • Three General Groups of Closure Techniques:
    • Intracorporeal Assistance (Require 2 Additional Ports – One to Visualize and One to Manipulate)
      • Ex: Maciol Needles, Grice Needles, and Endoclose Suture Device
    • Extracorporeal Assistance (Require 1 Additional Port – One to Visualize)
      • Ex: Carter-Thomason CloseSure System, Endo-Judge Wound Closure Device, and Tahoe Surgical Instrument Ligature Device
    • External Closure (No Additional Ports Required)
      • Ex: Suture Carrier, Dual-Hemostat Technique, and Standard Hand Suture Closure

Carter-Thomason Device 16

References

  1. Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, Wijnhoven BP, Schouten WR, Cense HA, Stockmann HB, Berends FJ, Dijkhuizen FPH, Dwarkasing RS, Jairam AP, van Ramshorst GH, Kleinrensink GJ, Jeekel J, Lange JF. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet. 2015 Sep 26;386(10000):1254-1260.
  2. Deerenberg EB, Henriksen NA, Antoniou GA, Antoniou SA, Bramer WM, Fischer JP, Fortelny RH, Gök H, Harris HW, Hope W, Horne CM, Jensen TK, Köckerling F, Kretschmer A, López-Cano M, Malcher F, Shao JM, Slieker JC, de Smet GHJ, Stabilini C, Torkington J, Muysoms FE. Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. Br J Surg. 2022 Nov 22;109(12):1239-1250.
  3. Henriksen NA, Deerenberg EB, Venclauskas L, Fortelny RH, Miserez M, Muysoms FE. Meta-analysis on Materials and Techniques for Laparotomy Closure: The MATCH Review. World J Surg. 2018 Jun;42(6):1666-1678.
  4. Konstantelias AA, Andriakopoulou CS, Mourgela S. Triclosan-coated sutures for the prevention of surgical-site infections: a meta-analysis. Acta Chir Belg. 2017 Jun;117(3):137-148.
  5. Ruiz-Tovar J, Llavero C, Jimenez-Fuertes M, Duran M, Perez-Lopez M, Garcia-Marin A. Incisional Surgical Site Infection after Abdominal Fascial Closure with Triclosan-Coated Barbed Suture vs Triclosan-Coated Polydioxanone Loop Suture vs Polydioxanone Loop Suture in Emergent Abdominal Surgery: A Randomized Clinical Trial. J Am Coll Surg. 2020 May;230(5):766-774.
  6. Montorfano L, Szomstein S, Valera RJ, Bordes SJ, Sarmiento Cobos M, Quirante FP, Lo Menzo E, Rosenthal RJ. Non-absorbable Barbed Sutures for Primary Fascial Closure in Laparoscopic Ventral Hernia Repair. Cureus. 2022 Feb 23;14(2):e22523.
  7. Kitano D, Nomura T, Sakakibara S, Terashi H. Absorbable Barbed Continuous versus Nonabsorbable Nonbarbed Interrupted Suturing Methods for Donor-site Closure of the Rectus Abdominis Myocutaneous Flap. Plast Reconstr Surg Glob Open. 2023 Jan 12;11(1):e4742.
  8. Jairam AP, López-Cano M, Garcia-Alamino JM, Pereira JA, Timmermans L, Jeekel J, Lange J, Muysoms F. Prevention of incisional hernia after midline laparotomy with prophylactic mesh reinforcement: a meta-analysis and trial sequential analysis. BJS Open. 2020 Jun;4(3):357-368.
  9. Tansawet A, Numthavaj P, Techapongsatorn S, Wilasrusmee C, Attia J, Thakkinstian A. Mesh position for hernia prophylaxis after midline laparotomy: A systematic review and network meta-analysis of randomized clinical trials. Int J Surg. 2020 Nov;83:144-151.
  10. Rothman JP, Gunnarsson U, Bisgaard T. Abdominal binders may reduce pain and improve physical function after major abdominal surgery – a systematic review. Dan Med J. 2014 Nov;61(11):A4941.
  11. Jiang N, Hao B, Huang R, Rao F, Wu P, Li Z, Song C, Liu Z, Guo T. The Clinical Effects of Abdominal Binder on Abdominal Surgery: A Meta-analysis. Surg Innov. 2021 Feb;28(1):94-102.
  12. Ossola P, Mascioli F, Coletta D, Pizzato M, Bononi M. Evidence on postoperative abdominal binding: A systematic review with meta-analysis of randomized controlled trials. Surgeon. 2021 Aug;19(4):244-251.
  13. Antoniou SA, Morales-Conde S, Antoniou GA, Granderath FA, Berrevoet F, Muysoms FE; Bonham Group. Single-incision laparoscopic surgery through the umbilicus is associated with a higher incidence of trocar-site hernia than conventional laparoscopy: a meta-analysis of randomized controlled trials. Hernia. 2016 Feb;20(1):1-10.
  14. Shaher Z. Port closure techniques. Surg Endosc. 2007 Aug;21(8):1264-74.
  15. Ng WT. A full review of port-closure techniques. Surg Endosc. 2007 Oct;21(10):1895-7.
  16. Eid GM, Thodiyil PA, Collins J, Bonanomi G, Mattar SG, Hughes SJ, Schauer PR, Wilson M. Laparoscopic repair of umbilical hernias in conjunction with other laparoscopic procedures. JSLS. 2006 Jan-Mar;10(1):63-5. (License: CC BY-NC0-ND 3.0)