Observations on opening and closing the abdominal incision for cytoreductive surgery using a self-retaining retractor to reduce the incidence of incisional hernia.

BACKGROUND

Cytoreductive surgery for resection of peritoneal metastases requires an incision from the xyphoid process to the pubic rami. Laboratory and clinical data from randomized trials have shown that small (0.5-1.0 cm) bites of a running suture closely spaced (0.5 cm) through an isolated midline fascia results in the lowest incidence of incisional hernia.

METHODS

Manuscripts were used to formulate criteria for optimal closure of a long midline abdominal incision. Using these conclusions as a starting point, surgical technology to achieve an optimal wound closure were formulated.

RESULTS

A fixed retractor was placed prior to performing an abdominal incision. Skin traction sutures elevate the skin and subcutaneous tissue to facilitate fascial incision directly through the linea alba. Peritoneum and preperitoneal fat beneath the posterior rectus sheath are resected. Separations of the anterior and posterior rectus sheath are repaired prior to fascial closure. When closing the incision, a running suture of closely spaced small bites is used to bring the fascial edges together in the absence of excess tension. During closure of the fascia exposure of the linea alba with the skin traction sutures facilitates accurate placement of fascia only sutures.

CONCLUSIONS

Optimal exposure of abdominal wall structures while opening and closing a long midline abdominal incision will minimize the incidence of incisional hernia. A fixed retractor and skin traction sutures are required.