Poland
             

    
S. Dąbrowiecki. S. Pierściński. A. Kapała. S. Prywiński. W. Szczęsny. W. Gniłka.
J. Pypkowski. J. Szopiński. D. Sosnowski. J.Szmytkowski. P.Wierzchowski. J.
Andruszkiewicz

Loop suture in abdominal wound closure –

advantages or illusions?     

Dept. of General & Endocrine Surgery, Collegium Medicum,

Bydgoszcz, Poland
 PDS II
Ethicon Needle Needle Suture
Material
Needle Type Shape Length Length

CT 1/2 40mm Violet 36"

Circle Monofil ~90cm
ament

Absorption time
180 – 210 days
Engelova D.. Antos F.: Surgical wound dehiscence and a technique
for laparotomy closure with continuous loop sutures. Rozhl Chir.
1995;74:172-5.

Results: frequency of a burst abdomen: silon – 2.2% vs PDS loop

1.2%
Hoch J.. Murinova D. Laparotomy closure with continuous
polydioxanone sutures Rozhl Chir. 1995;74:198-200.

Results: PDS loop suture utilized in 166 laparotomies; fast, simple,

and safe method

Bohanes T. Role of modern absorbable suture materials in

decreasing the occurrence of early complications after laparotomy.
Rozhl Chir. 2002; 81: 24-6
Results: PDS loop & Vicryl - less freq. early complication, less
infection;
burst abdomen and hernia - more frequent in Silon group; PDS loop
vs Vicryl - no difference between group
Conclusion: Running, mass closure is the best method of lap wound
closure
RCT: polyglactin 910 (Vicryl) vs

polydioxanone loop (PDS loop)

340 pts. elective procedure,

layered abdominal closure

Results: at FU 2y  2.9%

incisional hernias
 Research design

• Pts with the elevated risk of the complications in laparotomy wound healing

• Standardized technique of laparotomy wound closure

• End points:

– Primary: wound dehiscence. incisional hernia

– Secondary: infection, edema, erythema, seroma, suture sinus, and pain

• FU: examination at the outpatient department at 1, 3, and at least at 12 ms

after the surgery

 Inclusion criteria
• anemia < 10g%
• sepsis with abdominal origin

com
• pneumonia or COPD
• hemodynamic instability

bine
• age > 65 y
• BMI > 30

d in
• neoplasmatic disease (life expectancy >1 y)

dica
• hipoalbuminemia <3.4 g/L
• ascites
• hypercortisolemia

tion
• any condition deteriorating wound healing

s
• re-laparotomy
• wound contaminated during the surgery and dirty wound
• surgery time > 2.5 h
Surgical technique
 Surgical technique

A B
• obligatory: mass closure, running

suture, monofilament, PDS 2-0

C
• randomization: single vs loop

suture

• registered values : wound length,

suture length, number of loops

• calculated variables : SL/WL,

loops distance, width of sutured

 Patients
• Indication to surgery
– 32 diseases; the most frequent:
• 42 ca colonis
• 41 morbid obesity
• 33 different path. of biliary tract
• 19 dig. tract perforation
• 7 ca ventriculi
• 6 abdominal trauma
 Evaluation
• P-ts lost to FU
» following 1 ms – 8 pts
» 3 ms – 17 pts
» 12 ms – 27 pts

• Statistical analysis:
– Kaplan & Meier product-limit method comparing two and
multiple samples
– Cox's Proportional Hazard Model
– Mann-Whitney U Test
 Groups comparison

All Loop Single Difference

Pts number 185 85 100
Age years; mean
56.3 (21-92) 55.4 56.9 ns
(range)
Hospitalization (days) 12.5 (2-79) 11.9 13.2 ns
Possum scale points 13.6 (6-37) 13.8 13.5 ns

M/F; ASA; lap wound healing risk factors (surgical vs medical vs combined); urgent vs elective
treatment; indication to surgery – no difference

laparotomy localisation; wound drainage; skin closure technique; skin healing on discharge –
no difference
Results – the whole group
 Results in the compared groups

All PDS Loop PDS Single

Incisional hernia 27 10 17
Burst abdomen 10 5 5
Deaths 10 5 5
Cumulative prop. of surviving w/o burst abdomen or hernia

months
Cumulative prop. of surviving w/o burst abdomen
Cumulative prop. of surviving w/o incisional hernia
Not always „more” - means „better”
 Groups comparison
Rank Sum Rank Sum U Z p-level single loop

3776.00 -1.0697
wound length 7346.000 9490.00 0.284727 18,4 18,9
0 6
3294.50 2.5348 0.01125
suture length 8775.500 8244.50 71 60
0 3 1
2834.50 3.7063 0.00021
SL/WL 9051.500 7784.50 3.8 3.1
0 7 0
3467.00 2.0559 0.03979
SL/loop 8603.000 8417.00 2.9 2.6
0 0 3
suture 2902.00 -3.5173 0.00043
6472.000 10364.00 0.8 0.9
distance 0 4 6
2834.50 3.7063 0.00021
fascia margin 9051.500 7784.50 0.9 0.8
0 7 0
                                                   

           
Poland
             

     S. Pierściński, A. Kapała, S. Prywiński, W. Szczęsny, W. Gniłka, J. Pypkowski,

S. Dąbrowiecki,
J. Szopiński, D. Sosnowski, J. Szmytkowski, P. Wierzchowski, J. Andruszkiewicz

Insights into individual technique of

post-laparotomy wound closure    

Dept. of General & Endocrine Surgery, NCU College of Medicine, Bydgoszcz,

Poland
vertical midline incision, 12 ms FU  5% - 15% incisional hernias (= 50%
whole hernias)

burst abdomen  up to 3%; mortality rate > 25%

What matters more?

OR
Israelsson LA:The surgeon as a risk factor for
complications of midline incisions. Eur J Surg.
1998;164(5):353-9

CONCLUSION: The suture technique, monitored by the

SL:WL ratio, is the most important factor for variability in

the incidence of incisional hernia among surgeons in

continuously sutured midline incisions. The suture

technique may also help to explain the variability in rates

of wound infection.
SL / WL 

The width of the

sutured fascia margin

The distance of the

subsequent suture loops
 Research design

• Pts with the elevated risk of the complications in laparotomy wound healing

• Standardized technique of laparotomy wound closure

• Endpoints:

– Primary: wound dehiscence. incisional hernia

– Secondary: infection, edema, erythema, seroma, suture sinus, and pain

• FU: examination at the outpatient department at 1, 3, and at least at 12 ms

after the surgery

 Inclusion criteria
• anemia < 10g%
• sepsis with abdominal origin

com
• pneumonia or COPD
• hemodynamic instability

bine
• age > 65 y
• BMI > 30

d in
• neoplasmatic disease (life expectancy >1 y)

dica
• hipoalbuminemia <3.4 g/L
• ascites
• hypercortisolemia

tion
• any condition deteriorating wound healing

s
• re-laparotomy
• wound contaminated during the surgery and dirty wound
• surgery time > 2.5 h
 Patients n=185
Gender F = 94 M = 91
Mean age 56.3 (21-92)
(50,8%) (49,2%)

Elective = 64 Urgent =121

Procedure
(34,4%) (65,6%)

I=8 III = 64 IV = 6
ASA II = 93 (54,4%)
(4,7%) (37,4%) (3,5%)

Other =
Indication to Cancer =53 BMI = 41
92
procedure (29%) (21,9%),
(49,2%)

I = 26 II = 89 III = 26 IV = 29
Contamination
(15,3%) (52,4%) (15,3%) (17,1%)
 Patients
• Indication to surgery
– 32 diseases; the most frequent:
• 42 ca colonis
• 41 morbid obesity
• 33 different path. of biliary tract
• 19 dig. tract perforation
• 7 ca ventriculi
• 6 abdominal trauma
Surgical technique
 Surgical technique

A B
• obligatory: mass closure, running

suture, monofilament, PDS 2-0

C
• randomization: single vs loop

suture

• registered values : wound length,

suture length, number of loops

• calculated variables : SL/WL,

loops distance, width of sutured

 Study group

12 physicians: SD, AK, SP, WSz, WG,

JP, SPi, JSz, KSz, DS, PC, IN

4 consultants, 8 residents
 Technical variables
• Wound length, suture length, number of suture loop accros the
wound
• SL/WL; SL/loop  fascia margin, WL/loop  suture distance

Perioperative variables
Pts: age, sex, ASA, perioperative Possum score, wound healing
complication risk factors, indications to surgery (BMI vs carcinoma vs
other)

Elective vs urgent treatment

Laparotomy localisation (median vs paramedian)
Wound contamination class
Wound closure detalis vs patients age
Wound closure detalis vs Possum score
 Perioperative variables vs wound closure

Varibles suture distance fascia margin

indication to surgery p=0.001 p=0.02

risk factors p<0.02 p=0.057
lap localisation p<0.05 p=ns
pts gender p=0.06 p=ns

Varibles w/o influence:

• urgent vs elective treatment
• ASA class,
• wound contamination class
 Conclusions
• Simple measurements and counting during wound closure allows on insight

into a individual surgical technique.

• Surgeons differ considerably in details of their surgical technique even

during the standardized closure of a operative wound

• Surgeons’ repeatability of simple manoeuvres is small/moderate („muscular

memory” is poor)

• There are probably numerous factors (patient, illness, laparotomy) which

influence beyond our consciousness the execution of a surgical technique