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COMPARISON OF CONTINUOUS VERSUS INTERRUPTED X-SUTURING TECHNIQUE FOR ABDOMINAL WALL CLOSURE IN EMERGENCY MIDLINE LAPAROTOMY WOUND.

Byline: Aamir Ali Khan, Nadim Khan, Abdul Qayyum, Hussain Jan Abbasi and Saira

KeyWords: Continuous suturing technique, Interrupted X-suturing, Burst abdomen

INTRODUCTION

Laparotomy wound dehiscence (LWD) is a term used to describe separation of the layers of a laparotomy wound before complete healing has taken place. Other terms used interchangeably are acute laparotomy wound failure and burst abdomen. Acute wound failure may be occult or overt, partial or complete. Overt wound failure follows early removal of sutures leading to evisceration. Occult dehiscence occurs with disruption of musculo-aponeurotic layer beneath intact skin sutures. Wound dehiscence has been noted to occur when a wound fails to gain sufficient strength to withstand stresses placed upon it. The separation may occur when overwhelming forces break sutures, when absorbable sutures dissolve too quickly or when tight sutures cut through tissues1.

A number of studies have been conducted in the past five years trying to explain how this problem can be overcome. Simek et al2 describe a technique of their own which they have developed in the last ten years and are currently using to prevent wound dehiscence. This technique involves the use of intraperitoneal resorbable mesh in prevention of postoperative wound dehiscence for any patient they consider at risk. Gislason et al3 and Fleischer et al4 independently published results of long term complications of burst abdomen following layered or mass closure of laparotomy wounds. In 1998, Graham et al5 demonstrated that intrabdominal infections increased wound dehiscence significantly. In the same year Soran et al6 outlined predictable risk factors as relates to burst abdomen and they recommended certain surgical measures. These measures included control of nausea and vomiting, decompression of distended abdomen, choice of appropriate sutures, control of infection and use abdominal drains.

Moreover, experience of surgeon and use of more than two abdominal drains were factors significantly associated with wound dehiscence. A number of studies have been conducted in India which suggest that new interrupted X-technique for abdominal closure after midline laparotomy significantly reduces the risk of burst abdomen7,8. Available data in Pakistan regarding comparison of continuous closure and interrupted X-closure for the risk of burst abdomen after emergency midline laparotomy is limited. Aim of the present study was to compare the frequency of burst abdomen in patients having midline abdominal wall closure done with interrupted X-suturing technique and continuous suture technique. The findings of this study may help in reducing the risk of burst abdomen in midline laparotomy wounds.

METHODOLOGY

A comparative clinical trial was conducted from February 2016 to January 2017 in the Department of General Surgery, Lady Reading Hospital, Peshawar, Pakistan. Sample size was calculated based on the study by Srivastava et al9 who reported 2.17% burst abdomen in the X-sutures and 14.8% in the continuous sutures group. WHO sample size software was used. Confidence level was kept at 95% and power of study at 95%. The calculated sample size was 99. After taking permission from hospital ethical committee, a total of 100 patients (50 in each group) were included in the study. Patients of both genders (18-60 years of age) were included who were operated through midline laparotomy for cute abdomen due to trauma, intestinal perforation and intestinal obstruction. They were operated by same level of surgeon and under same kind of anesthesia. Care was taken for selection bias by properly randomizing and allocation of patients in both groups.

Patients with history of laparotomy and patients with co-morbid conditions such as malignancy, malnutrition, diabetes mellitus, end stage renal disease, cirrhosis of liver, chronic obstructive pulmonary disease and ischemic heart disease were excluded from the study. After informed consent, data were collected from patients in Surgical D Unit of Lady Reading Hospital, Peshawar. Complete history and examination were carried out on patients who were diagnosed as case of acute abdomen and with need of emergency laparotomy. These patients were divided in two groups (A and B). In group A patients after laparotomy the abdominal wound was closed with continuous suturing technique by polypropylene No. 1, while in group B patients the abdominal wound was closed with interrupted X-technique by polypropylene No. 1. All patients were examined for burst abdomen on 1, 2, 3, 4, 5, 6, 7 and 15 postoperative days.

When there were no signs of burst abdomen (after 15 postoperative days) the laparotomy wound was considered normal. Data were entered into SPSS software version 20. Mean +- standard deviation was calculated for quantitative variables such as age. Frequencies and percentages were calculated for qualitative variables such as gender, type of injury and burst abdomen. In both the groups (A and B) burst abdomen was stratified among age, gender and type of injury to see effect modification. Chisquare test was applied for comparison of significance between the two groups keeping P value a$? 0.05 as significant.

Table 1: Baseline characteristics of patients in both groups

Characteristics###Group A###Group B###P value

###n(%)###n(%)

Age(Years)###17-30###11(22)###8(16)###0.0101

###31-60###39(78)###42(84)

Gender###Male###41(82)###42(84)###0.7900

###Female###9(18)###8(16)

Height###5-5.5 ft###34(68)###35(70)###0.8138

###5.6-6.0 ft###8(32)###15(30)

Weight###50-60 kg###30(60)###31(62)###0.5770

###61-100 kg###20(40)###19(38)

BMI###a$?25###32(64)###31(62)###1.000

###>25###18(36)###19(38)

Duration of Injury###a$?24 hours###27(54)###26(52)###1.000

###>24 hours###23(46)###24(48)

Type of Injury###Acute abdomen###34(68)###37(74)

###Perforation/Obstruction###0.5085

###Fire Arm Injuries###16(32)###13(26)

Table 2: Stratification of burst abdomen in group A (continuous suturing) and group B (Interrupted X-suturing technique)

###Variables###Burst###Group A###Group B###Total###P value

###Abdomen###n(%)###n(%)###n(%)

###17-30###Yes###2(18)###1(12.5)###3(16)###0.7373

Age(years)###No###9(82)###7(87.5)###16(84)

###31-60###Yes###6(15)###1(2)###7(9)###0.0374

###No###33(85)###41(98)###74(91)

###Male###Yes###6(15)###1(2)###7(8)###0.0446

Gender###No###35(85)###41(98)###76(92)

###Female###Yes###2(22)###1(12.5)###3(18)###0.5996

###No###7(78)###7(87.5)###14(82)

###a$?25###Yes###4(12.5)###0(0)###4(6)###0.3346

BMI###No###28(87.5)###31(100)###59(94)

###>25###Yes###4(22)###2(11)###6(16)###0.0419

###No###14(78)###17(89)###31(84)

###a$?24 hours###Yes###3(11)###1(4)###4(8)###0.3168

Duration of###No###24(89)###25(96)###49(92)

injury###>24 hours###Yes###5(22)###1(4)###41(13)###0.0711

###No###18(78)###23(96)###47(87)

###Acute abdomen###Yes###5(15)###1(3)###6(8)

###perforation/###No###29(85)###36(97)###65(92)###0.0692

Type of injury###Obstruction

###Fire arm injuries###Yes###3(19)###1(8)###4(14)###0.3904

###No###13(81)###12(92)###25(86)

RESULTS

A total of 100 patients with acute abdomen were included in the study. The mean age of group A patients was 48.60 +-12.623 years while mean age of group B patients was 42.06 +-12.466 years. Mean weight was 68.34+-10.271 kg in group A and 69.66 +-7.356 kg in group B. In both groups majority of patients were 31-60 years of age. Frequency of males was observed to be high in both the groups as compared to females. Baseline characteristics of both groups are shown in Table 1. Frequency of burst abdomen was obsrved to be low among patients of group B (n=2, 4%) as compared to group A (n=8, 16%), with p value of 0.0455. Table 2 shows stratification of burst abdomen with respect to different variables. Age and gender wise stratification shows that male subjects with 31-60 ages of group B showed highest frequency of no burst abdomen (98%) as compared to group A (85%). Whereas BMI results depict that group B patients having BMI a$?25 shows no burst abdomen (100%).

Stratification on basis of type of injury indicates that patients of group B having acute abdomen perforation/obstruction had highest frequency (97%) of no burst abdomen compared to patients of group A (85%).

DISCUSSION

Acute abdomen allocates sign and symptoms of intra-abdominal diseases usually best treated by surgical operation10,11. Intestinal perforation, peritonitis, intestinal obstruction, blunt and penetrating trauma to abdomen are the frequent surgical causes of acute abdomen12. Patients with acute abdomen may develop fluid electrolyte imbalance, septicemia, anemia and dehydration; and if these pathophysiological processes remains unchecked it can lead to high mortality and morbidity13. In majority of cases such as intestinal obstruction, gut perforation, perforation of peptic ulcer, blunt abdominal trauma and penetrating injuries to abdomen, laparotomy is done. The highly recommended method of emergency laparotomy is midline laparotomy14. Burst abdomen is a very serious postoperative problem and causes high morbidity and mortality15. It has a significant impact on health care cost both for the patient and the hospital.

Many risk factors were incriminated in causation of burst abdomen including malnutrition, anemia, hypoproteinaemia, pre and post-operative prolonged steroid therapy, peritonitis, malignancy, jaundice, uremia, prolonged post-operative abdominal distension, cough, the technique of closure and closure material. Wound dehiscence is associated with the method of closure of abdomen and the sutures used. A number of studies have been conducted to assess mystifying variety of closure techniques and suture materials16,17. Similalrly, studies conducted for suitable technique of closure of midline laparotomy wound, among which recently studies carried out in India, which shows that risk of burst abdomen considerably decreases by using interrupted X-technique for abdominal closure after midline laparotomy18-21. In the present study, all patients in both groups were operated through midline laparotomy wounds.

Our results regarding burst abdomen revealed that overall 42 (84%) patients in group A (continuous sutures group) experienced no burst abdomen compared to 48 (96%) patients in group B (interrupted X-sutures group). Whereas 8 (16%) burst in group A (continuous sutures group) and 2 (4%) burst in group B (interrupted X-sutures group) within 1 week post-operatively (p=0.0455). In our study, interrupted X-sutures group showed that burst abdomen was less frequent in all the studied categories i.e. age, gender, BMI, type of injury and duration of injury, compared to group A. Our findings regarding burst abdomen are in concordance with the study of Kumar et al21. They reported 8 cases of burst abdomen in the continuous suture group whereas only one burst abdomen in interrupted X-sutures group. The relative risk in interrupted X-sutures group for burst abdomen was 0.127.

Similarly, another study by Srivastava et al9 reported one burst abdomen (out of 46) in the X-sutures and 8 cases of burst abdomen (out of 54) in the continuous group. Agarwal et al20 conducted a study and reported 5 cases of burst abdomen in X-suturing compared to 19 in continuous suturing groups, which indicates that interrupted suturing was related with significant reduction in risk of burst abdomen compared with continuous closure. Similar to our findings another study conducted at Rawalpindi (Pakistan) reported 01 (2.5%) case with burst abdomen operated in emergency for acute abdomen by using interrupted X-technique of closure and 4 (10%) burst abdomen cases using continuous technique, no statistical difference was observed among the two groups22. However, in the West, many randomized trials have reported equal wound complication rates following the use of interrupted or continuous monofilament fascial closure23-25.

There are several factors such as cough, wound infection intraperitoneal sepsis and uremia which can increase burst. In such situations and condition we need to apply most effective suturing method to prevent burst.

CONCLUSION

Frequency of post-operative burst abdomen was low in patients undergoing interrupted X-suturing technique compared to continuous suturing technique for the closure of midline laparotomy wound. Therefore, interrupted X-suturing technique for midline laparotomy closure in emergency cases was found better than continuous closure technique.

RECOMMENDATIONS

We recommend that this technique of interrupted X-sutures should be practiced and adopted by our surgeons in emergency laparotomies so that complication of burst abdomen can be minimized.

REFERENCES

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19. Kumar P, Chaubey D, Sahu SS, Shashi K, Mundu M, Baxla RJ. Comparative study of continuous versus interrupted X-type abdominal fascial closure in reference to burst abdomen. Int J Sci Study 2014; 2.

20. Agarwal CS, Tiawari P, Mishra S, Rao A, Hadke NS, Adikhari S et al. Interrupted abdominal closure prevents burst: randomized controlled trial comparing interrupted X and conventional continuous closure in surgical and gynecological patients. Indian J Surg 2014; 76: 270-6.

21. Kumar N, Choudhary N, Sherawat RC, Hussain I, Gupta S, Om P. A prospective study to compare the suture technique (continuous versus interrupted) in prevention of burst abdomen. IOSR J Dent Med Sci 2015; 14:129-32.

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24. McNeill PM, Surgerman HJ. Continuous absorbable vs. interrupted nonabsorbable fascial closure: a prospective, randomized comparison. Arch Surg 1986; 121:821-3.

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Publication:Journal of Postgraduate Medical Institute
Article Type:Report
Geographic Code:9PAKI
Date:Dec 31, 2018
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