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Reduced Rate of Dehiscence After Implementation of a Standardized Fascial Closure Technique in Patients Undergoing Emergency Laparotomy

Tolstrup, Mai-Britt MD; Watt, Sara Kehlet MD; Gögenur, Ismail MD, DMSc

doi: 10.1097/SLA.0000000000001762
Original Articles

Objective: In elective surgery, it is well documented that a midline laparotomy should be closed with a slowly absorbable monofilament suture material in a continuous technique, in a ratio of at least 4 : 1. The evidence concerning the suture material or suturing technique in the emergency setting is lacking. We aimed to investigate whether this technique would reduce the rate of dehiscence.

Methods: A standardized procedure of closing the midline laparotomy by using a “small steps” technique of continuous suturing with a slowly absorbable (polydioxanone) suture material in a wound-suture ratio of minimum 1 : 4 was introduced in June 2014. All patients scheduled for any gastrointestinal emergency midline laparotomy were included until October 2015. Pre-, intra-, and postoperative data were registered. All emergency laparotomies performed from 2009 to 2013 served as reference. Chi-squared tests and multivariate Cox regression analysis were performed.

Results: We included 494 patients from 2014 to 2015 and 1079 patients from our historical cohort for comparison. All patients had a midline laparotomy in an emergency setting. The rate of dehiscence was reduced from 6.6% to 3.8%, P = 0.03 comparing year 2009 to 2013 with 2014 to 2015. Factors associated with dehiscence were male gender [hazard ratio (HR) 2.8, 95% confidence interval (95% CI) (1.8–4.4), P < 0.001], performance status ≥3 [HR 2.1, 95% CI (1.2–3.7), P = 0.006], cirrhosis [HR 3.8, 95% CI (1.5–9.5), P = 0.004], and retention sutures [HR 2.8, 95% CI (1.6–4.9), P < 0.000]. The 30-day mortality rate was 18.4% in the standardized group vs 22.4% in 2009 to 2013, P = 0.057 and 90-day mortality 24.2% vs 30.4%, P = 0.008.

Conclusion: The standardized procedure of closing the midline laparotomy by using a “small steps” technique of continuous suturing with a slowly absorbable (polydioxanone) suture material reduces the rate of fascial dehiscence.

*Department of Gastrointestinal Surgery, Copenhagen University Hospital, Herlev, Denmark

Zealand University Hospital. Dept. Surgery, Center for Surgical Science, Copenhagen University, Koege, Denmark.

Reprints: Mai-Britt Tolstrup, MD, Rosenvaenget 3, DK-3480 Fredensborg, Denmark. E-mail: m.tolstrup@dadlnet.dk.

The authors report no conflicts of interest.

This study was not supported by any funding.

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