Mechanical factors in abdominal wound closure: the prevention of fascial dehiscence

The incidence of fascial disruption after major abdominal operations is 1% to 3%, and dehiscence is associated with a mortality rate of 15% to 20%. Although several systemic factors (e.g., malnutrition, increased age, male sex, and chronic treatment with steroids) have been associated with an increased risk of wound disruption, their clinical importance has been overstated. Local, mechanical factors such as wound infections, abdominal distention, and pulmonary complications appear to be more important and should be prevented or treated aggressively should they occur. Paramedian wounds are less secure than are midline wounds, but the latter, when closed properly, are probably equivalent to transverse wounds. The peritoneum need not be closed, but the fascia should be sutured securely. Monofilament suture materials are preferred, and the continuous suturing technique has theoretic and practical advantages. Retention sutures are unnecessary if the fascia is closed properly, and the wound itself should not be violated by a drain or stoma. Although fascial dehiscence may not be eliminated, its incidence can certainly be reduced with proper attention to the mechanics of fascial closure.