Choosing abdominal incision and closure techniques: a review

This review summarizes contemporary concepts of abdominal surgical incision creation and closure. The Ovid computerized database was searched for articles published in English from 1996 to 2003 using keywords pertaining to the specific topic of interest (e.g., suture, drain, surgical technique, fascia). Human prospective, randomized trials; meta-analyses; and evidence-based-focused reviews were assessed and data abstracted. Several earlier and animal-based studies on specific issues were included. The data indicate that: (1) the direction of the incision should be based upon obtaining adequate exposure; (2) hair should either be left in place or clipped at the time of surgery; (3) a single dose of prophylactic antibiotics should be given 30 minutes prior to surgery; (4) using a "deep" scalpel is unnecessary; (5) a scalpel and electrocautery are comparable for deepening the incision; (6) minimal peritoneal lavage with non-antibiotic containing solutions is adequate; (7) the peritoneum should not be routinely closed; (8) the fascia should be loosely approximated by a continuous mass closure using a slowly absorbable, monofilament suture with the smallest possible caliber and a suture:wound length ratio of at least 4:1; (9) retention sutures, subcutaenous sutures and drains do not appear to reduce the risk of wound complications; and (10) the skin may be closed in a variety of methods, but a semiocclusive dressing should be applied. As scientific evidence accumulates to refute traditional dogma, management of the surgical patient has undergone substantial changes. Surgeons should now be able to create and close an abdominal wound based upon sound scientific principles rather than simply "doing what I always do."