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Research Letters |

Dynamic Parietal Closure: Initial Experience of an Original Parietal Closure Procedure for Treatment of Abdominal Wound Dehiscence FREE

Quentin Qassemyar, MD; François Browet, MD; Micheline Robbe, MD, PhD; Pierre Verhaeghe, MD, PhD; Jean-Marc Regimbeau, MD, PhD
[+] Author Affiliations

Author Affiliations: Departments of Plastic, Reconstructive, and Esthetic Surgery (Drs Qassemyar and Robbe) and General, Visceral, and Digestive Surgery (Drs Browet, Verhaeghe, and Regimbeau), Amiens North Hospital, University of Picardy Medical Center, Place Victor Pauchet, F-80054 Amiens CEDEX 01, France.


Arch Surg. 2011;146(6):762-764. doi:10.1001/archsurg.2011.112.
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Abdominal wound dehiscence complicates between 0.2% and 10% of midline laparotomies1 and is associated with significant morbidity and mortality (44% and 67%, respectively).2,3 The surgeons who perform digestive surgery and plastic surgery at our institution have considered how to treat abdominal wound dehiscence. Given that preoperative risk factors cannot be modified in an emergency setting,1,2 we added some specific plastic surgery procedures to the conventional parietal closure technique. We thus developed a “dynamic parietal closure” technique in which silicone loop sutures are used to strengthen a conventional aponeurotic closure. The procedure is simple, quick, inexpensive, and compatible with digestive stomas and complex peritoneal drainage. It has the advantages but not the disadvantages of the use of retention sutures or abdominal wall plastic surgery.4

Before dynamic parietal closure for the treatment of abdominal wound dehiscence is performed (video), if any drains are in place, then externalization of the stoma(s), bowel replacement, and parietal disinfection are performed as usual.

At the time of parietal closure, successive mass closures were performed along the entire length of the median laparotomy with elastic silicone loops (45 cm in length and 2 mm in diameter [Ethiloop; Ethicon, Somerville, New Jersey]). Each loop was screwed onto the proximal end of a needle (as in drain externalization) and was placed transfascially across the wound to obtain a U-shaped suture every 4 cm.

Once the dynamic parietal closure technique has been performed along the entire length of the laparotomy, we adjusted the tension. This pushed back the digestive tract and closed the aponeurotic edges to yield a tension-free suture. The locking system comes from the Gripper Plus safety needle (Smith Medical, Brisbane, Australia).

We used a continuous, aponeurotic suture (PDS; Ethicon, Somerville, New Jersey).5 The skin was closed conventionally. Lastly, the dynamic parietal closure's tension was adjusted, and compresses were placed between the skin and the loops (Figure).

Place holder to copy figure label and caption
Figure

A, Elastic silicone loop screwed on the noncutting end of a needle (the locking system is yellow). B, The needle was passed transfascially across the wound 4 cm from the edge. The bowel was protected by a malleable blade. C, Description of the operative technique in 5 steps: (1) the needle was inserted 4 cm back from the wound edge on the right; (2) the needle was inserted on the wound edge on the left; (3) the needle was inserted again on the wound edge on the left (2 cm apart); (4) the needle was inserted at the initial wound edge, and a U-shaped suture was obtained; and (5) the system was maintained with the locking system, and compresses protected the skin. D, Once the system was in order, tension was adjusted to close the abdominal wall.

Graphic Jump Location

The surgical site was examined every 48 hours, and the elastomer tension was adjusted so that constant force was applied. Abdominal dressings were positioned and changed conventionally until the laparotomy was dry. Abscesses were treated conventionally (vacuum therapy was feasible, if required). The surgeon removed the system 21 days later in the consultation room (by cutting and then pulling out the elastomer loops).

We performed a prospective study of 873 consecutive patients who underwent a midline laparotomy during the period from January 2009 to December 2010. The overall incidence rate for abdominal wound dehiscence (diagnosed clinically within 2 weeks of the operation) was 2.06% (n = 18), with incidence rates of emergency and planned abdominal wound dehiscence of 2.23% and 1.19%, respectively. In all cases of abdominal wound dehiscence, we performed an emergency procedure to redo the midline laparotomy, examine the abdominal cavity (to check for infection), and then perform the dynamic parietal closure technique. Two patients were excluded because they died in the hospital 18 and 20 days after surgery, respectively (mortality rate, 11.1%). Prospectively, we analyzed the data for 16 patients. The median Webster and Mäkela scores were 13 (range, 2-26) and 2 (range, 0-3), respectively. The etiology of abdominal wound dehiscence was mechanical in 12 patients and septic in 4 patients. The abdominal wound dehiscence recurrence rate was 0%. Specific and overall morbidity and mortality rates are shown in the Table. The midline incisional hernia rate was 25% (diagnosed clinically or on the basis of a computed tomographic scan) according to the medical literature criteria.3 The median follow-up period was 157 days. Material costs never exceeded $27 per patient.

Table Graphic Jump LocationTable Preoperative, Operative, and Postoperative Data on 16 Patients Who Underwent a Dynamic Parietal Closure Procedure

Dynamic parietal closure is an original, easy, inexpensive, and efficient procedure. It must be evaluated with larger numbers of patients. In individuals with a very high risk of abdominal wound dehiscence, the dynamic parietal closure technique could perhaps be performed preventively.

Correspondence: Dr Regimbeau, Department of General, Visceral, and Digestive Surgery, Amiens North Hospital, University of Picardy Medical Centre, Place Victor Pauchet, F-80054 Amiens CEDEX 01, France (regimbeau.jean-marc@chu-amiens.fr).

Author Contributions:Study concept and design: Qassemyar, Browet, Robbe, Verhaeghe, and Regimbeau. Acquisition of data: Qassemyar and Browet. Analysis and interpretation of data: Browet, Robbe, Verhaeghe, and Regimbeau. Drafting of the manuscript: Qassemyar, Browet, and Verhaeghe. Critical revision of the manuscript for important intellectual content: Robbe and Regimbeau. Administrative, technical, and material support: Qassemyar and Browet. Study supervision: Robbe, Verhaeghe, and Regimbeau.

Financial Disclosure: None reported.

Webster  CNeumayer  LSmout  RNational Veterans Affairs Surgical Quality Improvement Program, Prognostic models of abdominal wound dehiscence after laparotomy. J Surg Res 2003;109 (2) 130- 137
PubMed Link to Article
Mäkelä  JTKiviniemi  HJuvonen  TLaitinen  S Factors influencing wound dehiscence after midline laparotomy. Am J Surg 1995;170 (4) 387- 390
PubMed Link to Article
van’t  RMDe Vos Van Steenwijk  PJBonjer  HJSteyerberg  EWJeekel  J Incisional hernia after repair of wound dehiscence: incidence and risk factors. Am Surg 2004;70 (4) 281- 286
PubMed
Marwah  SMarwah  NSingh  MKapoor  AKarwasra  RK Addition of rectus sheath relaxation incisions to emergency midline laparotomy for peritonitis to prevent fascial dehiscence. World J Surg 2005;29 (2) 235- 239
PubMed Link to Article
Veljkovic  RProtic  MGluhovic  APotic  ZMilosevic  ZStojadinovic  A Prospective clinical trial of factors predicting the early development of incisional hernia after midline laparotomy. J Am Coll Surg 2010;210 (2) 210- 219
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure

A, Elastic silicone loop screwed on the noncutting end of a needle (the locking system is yellow). B, The needle was passed transfascially across the wound 4 cm from the edge. The bowel was protected by a malleable blade. C, Description of the operative technique in 5 steps: (1) the needle was inserted 4 cm back from the wound edge on the right; (2) the needle was inserted on the wound edge on the left; (3) the needle was inserted again on the wound edge on the left (2 cm apart); (4) the needle was inserted at the initial wound edge, and a U-shaped suture was obtained; and (5) the system was maintained with the locking system, and compresses protected the skin. D, Once the system was in order, tension was adjusted to close the abdominal wall.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable Preoperative, Operative, and Postoperative Data on 16 Patients Who Underwent a Dynamic Parietal Closure Procedure

References

Webster  CNeumayer  LSmout  RNational Veterans Affairs Surgical Quality Improvement Program, Prognostic models of abdominal wound dehiscence after laparotomy. J Surg Res 2003;109 (2) 130- 137
PubMed Link to Article
Mäkelä  JTKiviniemi  HJuvonen  TLaitinen  S Factors influencing wound dehiscence after midline laparotomy. Am J Surg 1995;170 (4) 387- 390
PubMed Link to Article
van’t  RMDe Vos Van Steenwijk  PJBonjer  HJSteyerberg  EWJeekel  J Incisional hernia after repair of wound dehiscence: incidence and risk factors. Am Surg 2004;70 (4) 281- 286
PubMed
Marwah  SMarwah  NSingh  MKapoor  AKarwasra  RK Addition of rectus sheath relaxation incisions to emergency midline laparotomy for peritonitis to prevent fascial dehiscence. World J Surg 2005;29 (2) 235- 239
PubMed Link to Article
Veljkovic  RProtic  MGluhovic  APotic  ZMilosevic  ZStojadinovic  A Prospective clinical trial of factors predicting the early development of incisional hernia after midline laparotomy. J Am Coll Surg 2010;210 (2) 210- 219
PubMed Link to Article

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