Mass closure vs. layer-by-layer closure of transverse laparotomy in children: a randomized trial with ultrasound and
Mohamed Ali Shehata1, Mohammad Gharieb Khirallah1, Mazin Kurdi2
1Pediatric Surgery Unit, Department of Surgery, Tanta University, Tanta, Egypt.
Insights
Mass closure of transverse laparotomy incisions in children leads to increased muscle sheath stiffness and fatty infiltration compared to layer-by-layer closure. This may increase the long-term risk of incisional hernias.
Area of Science:
- Pediatric Surgery
- Surgical Techniques
- Biomechanical Analysis
Background:
- Transverse laparotomy incisions are common in pediatric surgery.
- Fascial closure can be performed using mass closure or layer-by-layer techniques.
- Both methods show similar short-term outcomes.
Purpose of the Study:
- To compare mass closure versus layer-by-layer closure for transverse laparotomy incisions in children.
- To evaluate clinical, sonographic, and elastographic changes.
- To assess long-term biomechanical alterations in the muscle sheath complex.
Main Methods:
- Randomized trial comparing two closure techniques for transverse upper abdominal laparotomy incisions.
- Group A: Mass closure; Group B: Layer-by-layer closure.
- Musculoskeletal ultrasound and elastography were used to examine the wounds.
Main Results:
- Mass closure (Group A) showed significantly higher fatty infiltration (>30% vs. <40%, p=0.04) and fibrosis (20%-40%, p=0.02) in the muscle sheath complex compared to layer-by-layer closure (Group B).
- Elastography revealed significantly higher shear wave speed (6.4 m/s vs. 3.1 m/s, p=0.05) in Group A at one-year follow-up, indicating increased stiffness.
- No significant short-term clinical differences were noted.
Conclusions:
- Mass closure of pediatric transverse laparotomy incisions results in increased muscle sheath stiffness and fatty infiltration.
- These biomechanical changes may elevate the long-term risk of incisional hernia.
- Layer-by-layer closure appears to be a safer technique for long-term muscle sheath integrity.
Background:
transverse laparotomy incision presents a common and widely used one in infants and children. The fascial incision is either closed in one mass or layer-by-layer closure. Both methods nearly have the same outcomes. This study randomly compared the two main techniques of closure of the transverse laparotomy incision, regarding clinical, sonographic, and elastrographic changes.
Methods:
This trial included infants and children who were subjected to a transverse upper abdominal laparotomy incision. Patients whose muscle sheath complex defects were closed using the mass closure technique were allotted to Group A. Patients whose defects were closed using the layer-by-layer closure technique were allotted to Group B. The wounds were subjected to musculoskeletal ultrasound and elastography examination.
Results:
The age was 22.3 months and 22.5 months in Group A and Group B, respectively. Fatty infiltration >30% but <40% was observed in 35 cases in Group A and 15 cases in Group B, (p = 0.04). The 20%-40% fibrosis in the muscle sheath complex observed in 33 cases in Group A and 9 cases in Group B, (p = 0.02). During the last follow-up examination at the end of first year, the shear wave speed was 6.4 m/s in Group A and 3.1 m/s in Group B (p = 0.05).
Conclusion:
Mass closure resulted in significantly higher stiffness and fatty infiltration of the muscle sheath complex compared to layer-by-layer closure, as shown by elastography and ultrasound. These biomechanical alterations may predispose to increased long-term risk of incisional hernia despite comparable short-term outcomes.
