Wound Closure Manual (PDF) - Penn Medicine

with absorbable suture material
is usually preferred. Interrupted
sutures can also be used for
this procedure.
FASCIA
This layer of firm, strong connective
tissue covering the muscles is the
main supportive structure of the
body. In closing an abdominal
incision, the fascial sutures must
hold the wound closed and
also help to resist changes in intraabdominal
pressure. Occasionally,
synthetic graft material may be
used when fascia is absent or weak.
PROLENE* polypropylene mesh may
be used to replace abdominal wall
or repair hernias when a great deal
of stress will be placed on the suture
line during healing. Nonabsorbable
sutures such as PROLENE suture
may be used to suture the graft to
the tissue.
Fascia regains approximately 40%
of its original strength in 2 months.
It may take up to a year or longer to
regain maximum strength. Full
original strength is never regained.
The anatomic location and type of
abdominal incision will influence
how may layers of fascia will be
sutured. The posterior fascial layer
is always closed. The anterior layer
may be cut and may also require
suturing. Mass closure techniques
are becoming the most popular.
Most suture materials have some
inherent degree of elasticity. If not
tied too tightly, the suture will
"give" to accommodate postoperative
swelling that occurs. Stainless
steel sutures, if tied too tightly, will
cut like a knife as the tissue swells
or as tension is placed upon the
suture line. Because of the slow
healing time and because the fascial
suture must bear the maximum
stress of the wound, a moderate size
nonabsorbable suture may be used.
An absorbable suture with longer
lasting tensile strength, such as
PDS* II sutures, may also provide
adequate support. PDS II sutures
are especially well-suited for use in
younger, healthy patients.
Many surgeons prefer the use of
interrupted simple or figure-of eight
sutures to close fascia, while others
employ running suture or a
combination of these techniques.
In the absence of infection or gross
contamination, the surgeon may
choose either monofilament or
multifilament sutures. In the
presence of infection, a
CHAPTER 2 31
monofilament absorbable material
like PDS II sutures or inert nonabsorbable
sutures like stainless steel or
PROLENE* sutures may be used.
MUSCLE
Muscle does not tolerate suturing
well. However, there are several
options in this area.
Abdominal muscles may be either
cut, split (separated), or retracted,
depending upon the location and
type of the incision chosen. Where
possible, the surgeon prefers to
avoid interfering with the blood
supply and nerve function by
making a muscle-splitting incision
or retracting the entire muscle
toward its nerve supply. During
closure, muscles handled in this
manner do not need to be sutured.
The fascia is sutured rather than
the muscle.
The Smead-Jones far-and-neartechnique
for abdominal wound
closure is strong and rapid, provides
good support during early healing
with a low incidence of wound
disruption, and has a low incidence
of late incisional problems. This is
a single-layer closure through both
layers of the abdominal wall fascia,
abdominal muscles, peritoneum,
FIGURE
14
SURGICAL
OPTIONS IN
MUSCLE
Cutting Splitting Retracting
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