After a laparotomy a patient's skin has always to be closed separately, either at the operation or a few days later. There are two other layers to be closed: (1) His peritoneum, which is fused to his posterior rectus sheath. (2) His anterior rectus sheath. These layers can either be closed separately in a classical three-layer closure (the skin is the third layer). Or they can be closed together in a two-layer closure (the skin is the second layer) by Everett's or Goligher's methods. These two- layer methods: (1) Are much better at preventing a burst abdomen than the classical three-layer method. (2) Are cheaper: (a) because they are quicker and so save in anaesthetic and staff time, and (b) because they use no catgut. They use monofilament or stainless steel and take big bites which are not too tight, instead of many smaller ones. Everett's method leaves knots on the peritoneal side of the wound where they cause no discomfort.
Delayed primary skin suture will reduce the risk of wound infection in high-risk cases in the same way as in wounds of other kinds (54.1). Antibiotics help, but they are less effective than leaving the skin wound open for a few days.
DRAINING AND CLOSING THE ABDOMEN Before you close a patient's abdomen, make quite sure that, if it is contaminated, you wash it out and instil tetracycline 1 g in 1000 ml of saline or Ringer's lactate, as in Section 6.2 on peritonitis. Drains are not useful, except for localized abscesses, bleeding, or leaks of bile or urine.
SWAB COUNT, etc. Check the operation site thoroughly before you close his abdomen to make sure that you have restored his anatomy as you wish, that there is no bleeding, and no leakage from hollow viscera. Make sure that you have left no instruments, swabs, or packs behind. It is reckless to rely only on a swab count!
ABDOMINAL DRAINS are described in Section 4.10. Read this carefully!
PREVENTING ADHESIONS. Bring his greater omentum down so that it underlies the incision. This will help to prevent adhesions forming between his viscera and his abdominal wall.
EVERETT'S MASS CLOSURE METHOD should be your standard way of closing the abdomen. Take a piece of No.1 monofilament 8 times the length of the incision, fold it in half, and tie a ''figure-of-8' knot (A, and B, Fig. 9-21).
Pass the needle from the deep surface of his peritoneum, then go from the outer surface of his abdominal muscle inwards on the opposite side of the wound. Thread the needle through the loop, so as to bury the knot.
Go all the way along the wound like this taking deep bites and not pulling too tightly. Place the stitches 1 cm from the edge of the incision and 1 cm apart. At the end of the wound come out from the deep surface, and cut the needle out of the loop. Rethread one end and pass it from outside inwards. Tie the two ends together with a double surgeon's knot, and cut them short. Now either close his skin with monofiliament now, or leave it open for a few days for delayed primary skin suture. This method does not require tension sutures.
CAUTION ! (1) Don't take the bites too close to the wound edges. (2) Don't make the sutures too far apart. (3) Don't make them too tight.
GOLIGHER'S METHOD is for preventing a burst abdomen in the ultimate poor risk case. It differs from Everett's method, mainly in that it preferably uses steel instead of monofilament and the sutures are preferably interrupted instead of continuous.
Gather everything except the patient's skin together with large bites of 28 SWG steel wire. If you don't have wire, use No. 0 monofilament or thicker. Insert the sutures 1.5 cm from the wound edge, and 1 cm apart. Use interrupted sutures only. Tie them with three throws (turns) for steel, and five for monofilament. If you are using continuous sutures (you are advised not to), keep them fairly loose. Close his skin with monofilament now, or leave it open for a few days for delayed primary skin suture.
CLOSURE IN THREE LAYERS is traditional, and is included for completeness. You will find the above methods safer. (1) Use a continuous suture of No. 1 catgut to close the patient's peritoneum together with his posterior rectus sheath. (2) Use continuous or interrupted sutures of ''0' monofilament or 28 SWG stainless steel to bring the fascia of his rectus sheath together. (3) Use No. 2/0 monofilament to close his skin and subcutaneous tissues.
TENSION SUTURES are controversial, uncomfortable, and leave ugly scars. Some surgeons never use them, even for burst abdomens, when they use Goligher's method. Others use them when a patient's abdomen has already burst, and no other closure is possible because of oedema and infection.
Place haemostats at each end of the wound, and at 2.5 cm intervals all down the wound before you suture the abdomen. Use them to bring the edges of his abdominal wall together when you tie the sutures. Load up a long curved cutting needle with No. 1 monofilament. Thread a 3 cm length of fine rubber tubing on to this to prevent the monofilament biting into the skin. Insert the sutures through all layers of the abdominal wall, including the skin, taking bites at least 2.5 cm deep on each side of the wound (B, and C, Fig. 9-24). Hold each end in a haemostat. Now suture the wound in the usual way. When you have closed the skin, tie the tension sutures with triple throw surgeon's knots, making sure the rubber tubes lie over the wound itself.
Alternatively, insert the tension sutures as in D, to G, Fig. 9-24. Pass them through all coats including the skin, as is usual for tension sutures, then hold them out on artery forceps ready for tying (D, and E). Put rubber tubes on each alternate suture (F), rather than on each one (as with the usual method). G, instead of tying them across the wound, tie them to their next door neighbours.
Remove the skin sutures first at 9 days, and the deep tension sutures at 12 to 14 days.
DELAYED PRIMARY SUTURE [s7]FOR POTENTIALLY INFECTED ABDOMINAL WOUNDS INDICATIONS. Any kind of sepsis which contaminates a patient's abdominal wound puts him at risk, especially: (1) Caesarean section in the presence of infected liquor. (2) Appendicitis. (3) Perforated typhoid ulcers of the ileum. (4) Perforations of his large gut. (5) The excision of gangrenous gut. (6) Generalized peritonitis.
METHOD. Close the muscles of his abdomen with steel wire, or monofilament. Make the sutures just tight enough to bring the muscles of his abdominal wall together and prevent his gut escaping. Test this as you go along by feeling the inside of the wound with your finger, as if it were a loop of gut trying to escape. Then put a dry gauze pack on his wound, and return him to the ward. If the condition you are operating for demands antibiotics, give them.
At 3 to 5 days, examine the wound. If it is clean, close it by delayed primary closure. If it is infected, apply hypochlorite or saline dressings regularly until it is fit for secondary suture, or secondary skin grafting. Occasionally, you will find the wound already healing so well, that it will close spontaneously. If so, let it do so.
CAUTION ! (1) NEVER close the fascia or muscle of his abdominal wall with catgut. It will be absorbed too soon, and increase the risk of early bursting and later herniation. (2) Don't use braided silk, which increases the risk of sinuses. (3) Make the sutures just tight enough to bring the edges of the muscles together[md]don't strangle them. (4) Don't try to close the abdominal wall and skin in a single layer, except when a burst has already occurred, and you decide to insert deep tension sutures.
DIFFICULTIES [s7]CLOSING THE ABDOMEN If you have DIFFICULTY GETTING HIS GUT BACK INTO HIS ABDOMEN, (1)Ask the anaesthetist keep him well relaxed. (2) Use a ''fish' as in I, Fig. 10-9. This is a piece of stiff rubber sheet (such as that from a car inner tube) with a tail on it. Place this under the incision to hold his gut down; just as you are closing the incision, pull it out by its tail.
Fig. 9-21 EVERETT'S AND GOLIGHER'S METHODS OF CLOSING THE ABDOMEN. Everett's method A, to J. A, and B, take a long length of No. 1 monofilament, double it and knot it. C, D, and E, catch the end of the loop in the first bite. F, and G, make large continuous stitches. H, and I, open the loop and tie it with a surgeon's knot inside. J, the muscle sutured, and the skin left for delayed primary closure.
Goligher's method, K, and L, is an almost infallible method of closing the abdomen in high-risk cases. Use interrupted wire sutures through all layers of the abdominal wall except the skin. Take big bites and don't tie them too tight. Place all the sutures first and then tie them.