Massive Closure of the Abdominal Wall With a One-Knot Loop Suture

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Massive Closure
of the Abdominal Wall
With a One-Knot Loop Suture

Techniques for closure of the midline abdominal incision have varied over time with better understanding of the physiology and engineering of closure of the abdominal wall and changes in materials in surgical suture. Closure of the midline through multiple layers including (1) the peritoneum and (2) the edges of the rectus fascia has evolved from braided products such as silk and cotton to synthetic braided products such as Teflon and braided nylon.

Contemporary surgical data show that closure of the peritoneum in a single layer in the pelvis or on the abdominal wall is unnecessary. Engineering sciences applied to wound healing have shown that the interrupted sutures have a weaker suture line than do running sutures. The weakest point in any suture line is the knot. Therefore more knots equal a weaker suture line, and less knots equal a stronger suture line. With the advent of delayed synthetic absorbable sutures, especially monofilament sutures, an entire abdominal midline incision from xiphoid to symphysis can be closed with the mass closure technique utilizing one knot.

Physiologic Changes. The physiology and engineering of this suture rely on the give and take of a suture line or cable line in any situation where total fixation of a suture through tissue with movement results in a "giggly saw" technique of tearing the tissue. Mass closure with the one-knot loop suture technique allows give of the suture with coughing, respiration, and movement. It basically holds the wound together and allows the properties of wound healing, the strongest of all wound-healing techniques, to take place without necrosis and closure by second intention.

Points of Caution. Monofilament suture should be used. Most wounds can be completely closed with delayed monofilament synthetic suture. There may be a place for monofilament synthetic permanent suture such as nylon or Prolene. The loop suture eliminates all the knots except one. Care must be taken to allow a 3-cm margin, wider than a man's finger, and to place the sutures 2 1/2 -3 cm apart. These characteristics of the length and width of the mass closure are necessary to conform to engineering principles.

Technique

An incision has been made from the xiphoid to the abdomen.

At the xiphoid end of the incision, the needle is placed through point a to point a' through all layers of the rectus fascia muscle and peritoneum. When the needle is brought out of point a', it is passed through the loop end of the suture.

The needle is brought through point b to point b', 2 1/2 cm from point a to point a'.

The sutures are not pulled taut for the remainder of the suture from c through n, m, etc. By leaving the sutures loose, the surgeon has the best opportunity to place the sutures precisely. When the sutures have been completely placed, they can be cinched up taut. Here one sees the technique of placing the final sutures from m' to n. One strand of the double suture is cut, while the uncut strand is passed through the wound opening beneath the abdominal wall and out of point n from inside to out.

The sutures are cinched up snugly but are not tight. The two single-suture strands are tied after all loops have been tightened. Multiple throughs, more than five, are placed in this knot.

The sutures have been tied. To date, there have been no item of data to show that this closure has any less or any greater strength than the more time-consuming Smead-Jones closure using a running far-to-near-near-to-far suture.