and Jyothi G Seshadri2
Most of the gynecological surgeries are either done through a transverse incision or laparoscopically. The closure of transverse incisions and laparoscopic port sites is easy. Transverse incision by nature tends to heal [1]. This is because the blood supply to the wound margins is better when the incision is taken transversely. Also, when a person coughs, sneezes, or vomits, the increased intra-abdominal pressure tends to separate the sutures maximally, around the umbilicus and in the midline. Therefore, small incisions (laparoscopic port sites) and lower abdominal transverse incisions are less likely to gape. However, one must keep in mind that burst abdomen is known to occur even in transverse incisions [2–4]. Incisional hernia is known to occur even in laparoscopic port site incisions. The author has had one experience where the infraumbilical laparoscopic wound had got infected, and on the tenth postoperative day, the rectus sutures had given away. One could see the omentum and the small intestines through the infraumbilical wound. Wound infection around the umbilicus particularly tends to be painful and disfiguring in nature.
However, the challenge of abdominal closure is mainly concerning vertical incision since the complications of wound gape, burst abdomen, and hernia are more commonly associated with it. Obesity, diabetes mellitus, and history of previous chemotherapy and previous radiation to abdomen increase the chances of wound gape. Other systemic factors like anemia, nutritional deficiencies, chronic renal failure, liver failure, prolonged corticosteroid use, all adversely affect wound healing [5–7].
In case of a transverse incision, the author prefers to close the rectus sheath preferably with a nonabsorbable suture followed by subcuticular closure of the skin with an absorbable suture. The peritoneum is not sutured, and the rectus muscle is not sutured even when it has been cut as in case of a Maylard incision. In case of re-suturing of a wound gape, or in cases of primary closure of the wound in obese patients, skin is closed with vertical mattress sutures with a drain in situ. Drain in subcutaneous space is also preferred in all patients with bleeding disorders to prevent collection of blood and serous fluid in the subcutaneous space [8]. Staples can also be used for skin closure, but unlike subcuticular closure, the patient needs to come back after discharge for staple removal, or the patient has to stay in the hospital till the staples are removed.
For laparoscopic surgeries, closure of the rectus sheath in the camera port site is a must, since this is 10 mm and around the umbilicus – the point where there is maximum separating force during coughing, sneezing, straining, vomiting, or any act which increases intra-abdominal pressure.
Hopefully, the earlier chapters of this book have convinced the readers about the fact that a vertical incision sometimes extending above the umbilicus is still required for many situations in modern-day gynecological practice. This is because laparoscopy has a long learning curve and robotic surgeries are not going to be easily accessible to all sections of society anytime soon.
The author prefers to close the vertical incision in layers. The peritoneum is closed with absorbable suture material, followed by the rectus sheath which is closed using a nonabsorbable material. The skin is closed using staplers, and a drain is placed in the subcutaneous space if the subcutaneous fat is thick. The logic behind this method is that in case of mass closure, a single suture is responsible for the integrity of the closure. Should it give way at any one point (let us say due to tissue necrosis or infection), it will result in burst abdomen [9]. But if the abdomen is closed in layers and if the rectus sheath gives way at any point, the closed peritoneum will technically still hold the abdominal wall. It will prevent evisceration and burst abdomen. Peritoneum is a tissue which heals very fast, but it is unlikely to close by itself within a week if bowels are constantly coming in contact with the sutures above or if there is raised intra-abdominal pressure. However, if the risk factors for burst abdomen (cough, abdominal distention due to paralytic ileus, full bladder, straining due to constipation and vomiting, anything that causes increased abdominal pressure) are not controlled in the postoperative period, there is a high risk of burst abdomen irrespective of the type of abdominal closure.
A drain is always placed in the abdomen to keep the intra-abdominal collection low. Following lymphadenectomy, extensive dissection, or in cases of pelvic abscess, there can be significant collection in the peritoneal cavity. The drain serves as a window; should there be a bowel perforation that has been missed, presence of feculent and/or bile-stained drain fluid in the drain output will help in its prompt detection. A drain, by virtue of keeping the collection low, prevents the air-filled intestines from floating and coming in contact with the abdominal sutures above.
The subcutaneous drain keeps the collection in the subcutaneous space low and removes the nidus for infection [8]. Sudden increase in the output of the subcutaneous drain is probably a harbinger of burst abdomen, especially if the drain fluid of pelvic and subcutaneous drains is identical.
In both vertical and transverse incisions, subcutaneous fat is not closed even in very obese patients. Catgut is a suture material that should never be used in any part of abdominal closure. Because of its low cost, it is continued to be used for episiotomy closure in our country, though technically it is not a good choice.
Whenever the author has encountered burst abdomen, the abdomen was immediately closed after thoroughly irrigating the peritoneal cavity with copious amounts of saline and placing a drain in the pouch of Douglas.
The general condition of the patient usually does not permit a layered closure, and it is usually not possible to close the peritoneum because edges are frayed, and they will cut through. In addition, bowels are dilated, and unless general anesthesia is given (the anesthetists might be reluctant since the general condition will be poor in most cases. Most patients will be obese and diabetic and would have undergone a long surgery about a week earlier.), it may not be possible to relax the abdomen. The abdomen is closed using nonabsorbable sutures in an interrupted manner. The sutures are placed one at a time from above and below (taking sutures on the upper end and the lower end of the incision, and gradually coming to the midpoint from both ends). After 2–3 sutures are placed, the assistant places his palm below to depress the bowels while the surgeon lifts the two ends of the suture and ties it. This ensures that a loop of bowel is not entrapped in one of the sutures. After closing the incision from above and below, the last stitch is placed midway, taking care that bites have not been taken through any visceral structure. The reason for taking time-consuming interrupted sutures over continuous sutures to close burst abdomen is that the wound margins are frayed and have poor blood supply; they may cut through unless a good chunk of tissue is taken. So even if one of the interrupted sutures gives way, the rest of the sutures should still be intact provided there is no increase in abdominal pressure postoperatively. It is very important to control cough (think respiratory infection), and vomiting (think electrolyte imbalance—hyponatremia) in the postoperative period [10]. The role of postoperative chest physiotherapy should not be seen as a cursory routine. It helps in expelling chest secretions.
In the postoperative period, anemia, diabetes, hypoproteinemia, and electrolyte imbalance should be aggressively corrected. There should be no hurry to start oral sips, in all cases where there was extensive bowel handling, para-aortic dissection (which can cause delayed return of bowel activity due to handling of hypogastric plexus), and also following closure of burst abdomen. The author prefers to start oral sips only after the patient passes flatus and ensuring that there is no hypokalemia and hyponatremia. Hypokalemia is associated with paralytic ileus which causes distention which is associated with burst abdomen [11]. Hyponatremia is associated with vomiting, which if uncorrected can further worsen hyponatremia.
In addition to taking measures to prevent raised intra-abdominal pressure in the post-operative period, a corset dressing can be applied in obese patients who have a pendulous abdomen that sways from side to side. This helps in stabilizing the panniculus and reduces the stress on the sutures due to the movement of the panniculus. The skin sutures will be subject to separating forces if the thick pad of fat keeps moving; continuous movement will prevent collagen fibers from bridging the wound.
A corset dressing is applied in the following manner. The wound dressing is done in the usual way, and this is followed by applying 2–3 patches of elastic bandage on either flank. Fenestrations are made inside the patches. Roller gauze is applied from fenestration of one side to the other and tied in the middle, taking care that there is enough slack. The patient will find it very difficult to breathe if there is too much of tension.
As compared to an abdominal binder, corset can be applied according to the position of the drains. The gauze can be loosened and retied accordingly. The problem with the use of a binder is that it gets dirty and acts like a fomite. But a corset dressing is discarded and a new dressing applied daily or whenever required. Also, a binder becomes loose in most patients since they also suffer from a poor appetite and lose weight in the postoperative period.
The main disadvantage of the corset is that the some patients develop skin excoriation due to prolonged use of elastic bandage. This however is a temporary problem and resolves quickly.
How to Apply a Corset Dressing (Fig. 12.1a–f)
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