Closing midline abdominal incisions

The most important wound complications are surgical site infection, wound dehiscence and incisional hernia. Experimental and clinical evidences support that the development of wound complications is closely related to the surgical technique at wound closure.

The suture technique monitored through the suture length-to-wound length ratio is of major importance for the development of wound complications. The risk of wound dehiscence is low with a high ratio. The ratio must be higher than 4; otherwise, the risk of developing an incisional hernia is increased four times. With a ratio higher than 4, both the rate of wound infection and incisional hernia are significantly lower if closure is done with small stitches placed 5 to 8 mm from the wound edge than with larger stitches placed more than 10 mm from the wound edge.

Midline incisions should be closed in one layer by a continuous suture technique. A monofilament suture material should be used and be tied with self-locking knots. Excessive tension should not be placed on the suture. Wounds must always be closed with a suture length-to-wound length ratio higher than 4. The only way to ascertain this is to measure, calculate and document the ratio at every wound closure. A high ratio should be accomplished with many small stitches placed 5 to 8 mm from the wound edge at very short intervals.