Laparotomy closure

Before closing - always stop and think, 'did we forget anything?'

Haemostasis
Source control
Wash and suction
Anastomosis sitting well and viable
Internal herniation sites closed
Small bowel arranged nicely
Omentum between intestine and incision, and if possible covering the anastomosis
Fascial defects closed
NGT in position
Drains in place
Count ok
Feeding access required?
Should I close the abdomen at all, or leave it open?

Causes of dehiscence:

Small bite technique (STITCH trial) - 5mm from fascial edge at intervals of 5mm
- Previously, 1cm/1cm was recommended, and is still recommended in 2022 on UTD
- However STITCH RCT showed a reduction in incisional hernia rate from 21 to 13 % with small bite technique
Suture to incision length ratio of at least 4 to 1
Slowly absorbable monofilament - PDS (has a longer strength retention profile and absorption time than Vicryl, and may resist infection better too since it is a monofilament)
- Use of nonabsorbable sutures has been associated with increased pain and sinus tract formation, and hasn't shown significant improvements in incisional hernia formation, wound dehiscence or SSI than absorbable sutures
- Barbed sutures have a similar efficacy to smooth
No separate closure of peritoneum
No evidence that retention sutures prevent complications, and may increase pain/infection
Patients at high risk of dehiscence (age >70, obese, smoker, COPD, steroids, DM, malnutrition, ascites, previous laparotomies) may benefit from prophylaxis:
- Mesh - onlay or sublay, although onlay causes more seromas
- Retention sutures

2/0 Prolene with anchor (all knots 6-10 throws)
- Anchoring interrupted suture on my RHS (knot outside, single long tail)
- Start at apex on my LHS (knot outside, tail short)
- Work from left to right with 5mm bites, 5mm from fascial edge
- If the suture runs out, tie it off and start a new one
- Tie to anchoring suture at the end
Loop 0 PDS (all knots 6-10 throws)
- Start LHS apex, looped knot outside
- Work down left to right
- Then start separate loop at RHS apex, work back towards other end, and tie (prefer to tie single thread, no need to bury)
2/0 Prolene without anchor (all knots 6-10 throws)
- Start at apex on my LHS (knot outside, tail short)
- Work from left to right with 5mm bites, 5mm from fascial edge
- If the suture runs out, tie it off and start a new one
- Tie to itself when you get to the other apex, with knot on the outside

Consider usage when delayed healing is anticipated - see above factors
Leave in until healing is complete, as signified by previously snug retention sutures becoming loose as the wound contracts - about 3 weeks
Be careful - can cause ECF if there is too much tension