Obesity is a strong risk factor for wound disruption. In this communication, we report a new surgical technique for closing abdominal wounds using two large bolsters.
The procedure is quite simple. First, one end of the 1-0 monofilament nylon is inserted from the bottom of the wound and emerges from a point that is the same distance as the depth of the subcutaneous tissue using a large cutting needle. The other end emerges from the opposite side of the wound. In this procedure, the points at which the needle emerges are marked beforehand (Fig. 1, left). Then, vertical mattress sutures are performed. The same procedure is repeated at 3- to 5-cm intervals along the wound. The 1-0 monofilament nylon is not tied. Large bolsters made of rolled gauze are placed in the loops of the 1-0 monofilament nylon and positioned along both sides of the wound. A negative-pressure drainage device is placed at the bottom of the wound and then the wound is closed using the bolster technique. The surface of the wound is closed by vertical mattress suture using 4-0 monofilament nylon (Fig. 1, right).
The cause of wound complications in obese patients is related to the poor vascularity of subcutaneous tissue, serous fluid collection, and hematoma formation.1 Some reports2,3 recommend subcutaneous suture for retention of the suture and preventing subcutaneous dead space and the formation of hematomas and seromas. We consider, however, that a suture loop of subcutaneous tissue induces fat ischemia and fat necrosis if subcutaneous tissue is sutured strongly, because the blood supply of subcutaneous tissue is poor and subcutaneous tissue is fragile. Subcutaneous suture does not work effectively, because the suture loop of subcutaneous tissue itself acts as an additional foreign body and increases the risk of infection. Thus, a suturing technique where suture loops are not left in subcutaneous tissue is desirable.
Molea et al.4 reported a technique for fixation of retention sutures using two bolsters to maximize the closing force along the wound edge while keeping stress at a minimum. They also generated a formula for calculating force at the suture sites. According to the formula, stress at the suture site is reduced dramatically using the technique. Our technique applied their methods and makes it possible to achieve adherence of subcutaneous tissue and reduction of cutaneous tension by closing full-thickness subcutaneous tissue using larger bolsters. Removal of mattress suture is performed 2 weeks after the operation, because we do not perform dermis sutures. Because bilateral subcutaneous tissue of a wound causes tension to the wound, patients wore an abdominal bandage for 3 weeks. Our technique thus facilitates effective abdominal closure without complications.
Shunjiro Yagi, M.D., Ph.D.
Yuzuru Kamei, M.D., Ph.D.
Kazuhiro Toriyama, M.D.
Kosuke Nakazato, M.D., Ph.D.
Shuhei Torii, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
1. Witte MB, Barbul A. General principles of wound healing. Surg Clin North Am. 1997;77:509–528.
2. Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of subcutaneous fat and wound disruption after cesarean delivery: A meta-analysis. Obstet Gynecol. 2004;103:974–980.
3. Kore S, Vyavaharkar M, Akolekar R, Toke A, Ambiye V. Comparison of closure of subcutaneous tissue versus non-closure in relation to wound disruption after abdominal hysterectomy in obese patients. J Postgrad Med. 2000;46:26–28.
4. Molea J, Poitras DJ, Van De Water JA. Technique for fixation of retention sutures using two bolsters. Surg Gynecol Obestet. 1989;169:167–168.
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