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\title{Abdominal Wall Closure in Emergency Laparotomy: Management and Outcome in Omdurman Teaching Hospital}
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             \author[1]{Lodu S  Kuju}

             \affil[1]{  Sudan Medical Specialization Board}

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\date{\small \em Received: 13 April 2013 Accepted: 3 May 2013 Published: 15 May 2013}

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\begin{abstract}
        


Background : The incisions those applied in approaching those operations, were vertical anterior abdominal incisions (midline or paramedian), and the way these incisions were closed, it was either mass or layered abdominal wall closure and types of suture materials used in the closure, non-absorbable/absorbable, monofilament (Nylon)/ polyfilament (Vicryl).Objectives : To study a series of patients those who underwent vertical incisions, either midline or paramedian and how they were closed, mass or layered closure and suture materials used inclosing the abdomen and the outcome.

\end{abstract}


\keywords{laparotomy incision closure, suture material, closure technique.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
losure of the abdominal wall is a common denominator of all abdominal surgery. The methods of closure are often based on local traditions and preference of the teacher and the surgeon is often reluctant to change these methods later on in his or her career. Abdominal closure is performed in multitude of fashions and an abundance of differently tailored studies on this matter. The goal to wound closure is to restore function of abdominal after a surgical procedure. The optimal method should be so technically simple that its results are as good for the hands of the trainee as they are for the experienced surgeon. It should leave the patient with a reasonably aesthetic scar and most importantly, it should minimize the frequency of wound rupture, incisional hernia (IH) wound infection and sinus formation. Mass closure involves a single layer closure of all musculofascial layers and may or may not include the peritoneum. Numerous clinical trials have compared layered to mass abdominal closure. Some studies have shown an increased incidence of burst abdomen and incisional hernia with layered closure and some studies show no difference in these complications, but no studies demonstrate advantage of layered over mass closure \hyperref[b0]{(1)} . 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 improvement in the materials of surgical sutures \hyperref[b1]{(2)} .\par
When this surgical procedure is conducted in an emergency setting and depending on the type of surgery (clean and/or contaminated), the incidence of complications may be particularly high, especially when acute dehiscence of the wall occurs. Furthermore, the rate of herniation related to midline laparotomy is still high approximately 16\% of cases. Despite efforts to evaluate different suture techniques, suture threads (reabsorbable or non-absorbable) and general factors that may interfere with the repair process, the incidence  
\section[{Conclusion: Mass abdominal wall closure technique}]{Conclusion: Mass abdominal wall closure technique}\par
is the preferable technique by the surgeons than layered closure technique, for it is less time consuming and it has got a disadvantage of forming an incisional hernia, when it got dispted by any assault to area of suture line.\par
of complications associated with this approach has been reduced \hyperref[b2]{(3)} .\par
Access to the abdominal cavity must be performed in such a way that surgical treatment procedures can be performed safely. For skin incision, scalpel and electrocautery are equivalent. Subcutaneous tissues and fascias must be divided by electrocautery to minimize blood loss. The best way to close abdominal cavity is by an all layer, slowly absorbable, running suture with suture: wound length ratio 4:1. Closing the peritoneal layer is not necessary. Subcutaneous suture and drains do not reduce the risk of wound complications. Staples should be used for skin \hyperref[b3]{(4)}\hyperref[b4]{(5)}\hyperref[b5]{(6)}\hyperref[b6]{(7)}\hyperref[b7]{(8)}\hyperref[b8]{(9)} .\par
A similar technique is used for closure of the paramedian incision (PMI). The anterior and the posterior rectus sheaths are packed up in one bite. A transrectus incision will incorporate the medial sliver of the rectus muscle into the suture loops. Mass closure of the lateral (PMI) is not possible. For this incision, the anterior and posterior rectus sheaths are closed separately \hyperref[b0]{(1)} .\par
Mass closure techniques (MCT) with the one loop suture technique allow give of suture with coughing, respiration and movement. It basically holds the wound together and allows the properties of wound healing, the strongest of the all wound healing techniques, to take place without necrosis and closure by second intention \hyperref[b1]{(2)} .\par
The choice of suture material is more complex. They prefer to use absorbable sutures with delayed degradation, such as polydioxanone (PDS). Among nonabsorbable sutures, monofilament suture is recommended. Whether the incision is vertical or transverse, the steps for closure are more or less the same \hyperref[b0]{(1,}\hyperref[b9]{(10)}\hyperref[b10]{(11)}\hyperref[b11]{(12)}\hyperref[b12]{(13)}\hyperref[b13]{(14)}\hyperref[b14]{(15)}\hyperref[b15]{(16)}\hyperref[b16]{(17)}\hyperref[b17]{(18)}\hyperref[b18]{(19)}\hyperref[b20]{(20)}\hyperref[b21]{(21)} . 
\section[{II.}]{II.} 
\section[{Patients and Methods}]{Patients and Methods}\par
This is an observational prospective analytical study hospital based study, conducted at Omdurman Teaching Hospital. The study population was composed of male and female patients who underwent vertical abdominal wall closure during the period Nov.2012 Oct.2013. A total number of 124patients were the use of predesigned and pretested structured questionnaire.\par
Non probability sampling including all patients operated in the emergency theatre during the allocated period of study. Data analysis by using SPSS version 20.The percentage was calculated and chi-square test was used for the analysis. Test of significance was analytically accepted and P value0.000. Ethical clearance and approval for conducting this study was obtained from the ethical committee of Omdurman Teaching Hospital. Informed verbal consent was obtained from the patients participating in this study after full explanation of the study objectives. 
\section[{III.}]{III.} 
\section[{Results}]{Results}\par
A total of 124 patients were included in the study of emergency laparotomy. The surgical access in all these laparotomies was through vertical incisions, either midline or paramedian. The mean age range was 37.5 (SD\textunderscore +19.4) years, ranged from 13to 90 years. Seventy seven (62.1\%) were forty or younger and only one patient above 80 years (Table1). Male patients constituted 104(83.9\%) and female 20 (16.1\%) ratio of male: female was 5.2: 1.  P value 0.000\par
Mass closure technique was used in 111(89.5\%) while layered closure in 13 (10.5\%). The later technique was used in all cases of paramedian incision and only three cases of midline incision. 97.4\% of midline was closed in mass closure, which was found to be statistically significant P value 0.000(Table3). The continuous mode of closure was adopted in all cases (100\%). This was used in mass closure of midline and layered closure of paramedian incisions. Interrupted fasial closure was not practiced in this study.\par
Vicryl was applied in 21 (16.9\%). The most commonly used size of suture material was size 2\# in106 (85.5\%), size 1\# 17 (13.7\%) and 0\# is only one suture. Of Nylon type of suture size 2\# was commonly used 90 (87.4\%) of Vicryl variety, size2\# was 16 (76.2\%) of patients (Table \hyperref[tab_4]{4}). In all ten patients of paramedian incisions and three midline incision, layered closure was applied. Vicryl was used in closing both fascial layers. The first layer was of peritoneum and posterior rectus sheath and second layer of the anterior rectus sheath) P value 0.000. Closure of the abdominal incisions took between 5-10minutes 76 (61.3\%) of patients, however, those who took >10mkinutes 48 (38.7\%) of patients. Regarding type of incision incisions, out of 114 midline incisions 68 (59.6\%) < 10 minutes. In the paramedian incision the great majority 10 (80\%) took less than10 minutes though this was statistically not significant P value 0.205.\par
In all cases, conventional interrupted skin closure was practice. Suture size 0\# was used in 66 (53.2\%), 2/0 \# in 48 (38.7\%) and size 1\# or2 \# were used in 5 (4\%) each. Regarding type, the majority 120 (96.8\%) Nylon was used and 4 (3.2\%) other types were employed (Silk in one and Vicryl in three patients. Most of abdominal wall closure 118 (95.2\%) wre by done by the registrars; remaining six patients (4.8\%) were completed by either surgeons' two patients or house officers' four patients.\par
Length of hospital stay varies 55 (44.4\%) were discharge in less than five days, 52 (41.0\%) discharged between5-10 days and 16 (13.7\%) discharged in more than 10 days.\par
Ninety seven of patients (78.2\%) discharged home without any complications. The morbidity 12 (9.7\%) and mortality was seen in 15 (12.1\%). The morbidity and mortality were seen in 10.9\% and14.1\% respectively in patients with acute abdomen, where as in 3.7\% and7.4\% of patients with abdominal trauma.\par
Wound infection 7 (5.6\%), burst abdomen 4 (3.2\%) and (IH) 1(0.8\%) were complications encountered. All seven cases of wound infection and single case that developed (IH) in the study had mass closure of their anterior abdominal wall. Out of four patients who developed burst abdomen, three followed mass closure. Out of 15 mortality 14 (93.3\%) followed mass closure whereas one patient (6.7\%) from layered closure. 
\section[{IV.}]{IV.} 
\section[{Discussion}]{Discussion}\par
Midline incision is still the most frequently used to access the abdominal cavity in emergency surgery. In our study midline incisions are the most which constitutes about 97.4\% and this comply the previous international studies \hyperref[b4]{(5,}\hyperref[b5]{6,}\hyperref[b6]{7)} .\par
Mass closure where all layers of the abdominal wall were closed as one structure (except skin), 89.5\% whereas layered closure was less utilized 10.5\% \hyperref[b4]{(5)} .\par
Most suture materials used Nylon 103 (83\%) and Vicryl 21(17\%). The most commonly used size of suture materials was 2\# and1\# Nylon and Vicryl 2\#. Surgical-site infection remains the important early postoperative complications as within the first 30 days postoperatively 5.6\%, burst abdomen 3.2\% and incisional hernia 11.2\% \hyperref[b17]{(18)} , V. 
\section[{Volume XIII Issue IV Version I}]{Volume XIII Issue IV Version I} 
\section[{Conclusion}]{Conclusion}\par
Mass closure technique is most preferred by the surgeons than the layered closure for it is less time consuming, it has got disadvantage of forming incisional hernia when it gets disrupted by any assault to the area of suture line.\begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.5946009389671362\textwidth}P{0.25539906103286386\textwidth}}
Of the emergency wall closure, 92(74.2\%) were\tabcellsep (84.6\%) of abdominal trauma and stab wounds 6\\
acute abdomen, 28 (22.4\%) abdominal trauma and 4\tabcellsep (21.4\%) (Table2).\\
(3.2\%) other abdominal conditions. Gunshot account 22\tabcellsep \end{longtable} \par
 
\caption{\label{tab_1}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.4485791610284167\textwidth}P{0.07706359945872801\textwidth}P{0.2104871447902571\textwidth}P{0.1138700947225981\textwidth}}
\multicolumn{4}{l}{Abdominal Wall Closure in Emergency Laparotomy: Management and Outcome}\\
\tabcellsep \multicolumn{2}{l}{in Omdurman Teaching Hospital}\tabcellsep \\
013\tabcellsep \tabcellsep \tabcellsep \\
2\tabcellsep \tabcellsep \tabcellsep \\
Year\tabcellsep \tabcellsep \tabcellsep \\
Volume XIII Issue IV Version I\tabcellsep \tabcellsep \tabcellsep \\
( ) I\tabcellsep \tabcellsep \tabcellsep \\
Age\tabcellsep \multicolumn{2}{l}{Frequency}\tabcellsep Percentage\\
00-20\tabcellsep 27\tabcellsep \tabcellsep 21.8\%\\
21-40\tabcellsep 50\tabcellsep \tabcellsep 40.3\%\\
41-60\tabcellsep 29\tabcellsep \tabcellsep 23.4\%\\
61-80\tabcellsep 17\tabcellsep \tabcellsep 13.7\%\\
81-100\tabcellsep 01\tabcellsep \tabcellsep 0.8\%\\
Total\tabcellsep 124\tabcellsep \tabcellsep 100\%\\
Causes\tabcellsep Midline\tabcellsep Para median\tabcellsep Total\%\\
Acute abdomen\tabcellsep 83\tabcellsep 9\tabcellsep 92(74.2\%)\\
Stab wound\tabcellsep 21\tabcellsep 1\tabcellsep 22(17.7\%)\\
Gunshot\tabcellsep 6\tabcellsep 0\tabcellsep 6(4.8\%)\\
Others\tabcellsep 4\tabcellsep 0\tabcellsep 4(3.2\%)\\
Total\tabcellsep 114\tabcellsep 10\tabcellsep 124(100.0\%)\\
\multicolumn{2}{l}{Midline was 114 (91.9\%) and paramedian}\tabcellsep \multicolumn{2}{l}{abdominal trauma and 4 (3.5\%) patients other}\\
\multicolumn{2}{l}{incision was10 (8.1\%) of vertical in the study. Out of114}\tabcellsep \multicolumn{2}{l}{abdominal emergencies. Whereas those of paramedian}\\
\multicolumn{2}{l}{patients operated through midline incision 83 (72.8\%)}\tabcellsep \multicolumn{2}{l}{incision nine were acute abdomen and one patient of}\\
\multicolumn{2}{l}{were cases of acute abdomen, 27 (23.8\%) were}\tabcellsep \multicolumn{2}{l}{stab wound (Table3).}\end{longtable} \par
 
\caption{\label{tab_2}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.14782608695652172\textwidth}P{0.2481366459627329\textwidth}P{0.25869565217391305\textwidth}P{0.19534161490683227\textwidth}}
Closure type\tabcellsep Midline\tabcellsep Paramedian\tabcellsep Total\\
\tabcellsep Incision\tabcellsep incision\tabcellsep \\
Mass\tabcellsep 111(97.4\%)\tabcellsep 00 (0.00\%)\tabcellsep 111(89.5\%)\\
Layered\tabcellsep 03 (2.6\%)\tabcellsep 10 (100\%)\tabcellsep 013(10.5\%)\\
Total\tabcellsep 114 (100\%)\tabcellsep 10 (100\%)\tabcellsep 124(100\%)\end{longtable} \par
 
\caption{\label{tab_3}Table 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{4} \par 
\begin{longtable}{P{0.12338709677419356\textwidth}P{0.19193548387096773\textwidth}P{0.19193548387096773\textwidth}P{0.1827956989247312\textwidth}P{0.15994623655913978\textwidth}}
Suture type\tabcellsep Suture 2\#\tabcellsep Suture1\#\tabcellsep Suture0\#\tabcellsep Total\%\\
Nylon\tabcellsep 90 (87.4\%)\tabcellsep 12 (11.7\%)\tabcellsep 01 (0.9\%)\tabcellsep 103(100\%)\\
Vicryl\tabcellsep 16 (76.2)\tabcellsep 05 (23.8\%)\tabcellsep 00 (0.00\%)\tabcellsep 21(100\%)\\
Total\tabcellsep 106(185.5\%)\tabcellsep 17 (13.7\%)\tabcellsep 01 (0.8\%)\tabcellsep 124(100\%\end{longtable} \par
 
\caption{\label{tab_4}Table 4 :}\end{figure}
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\end{document}
