Abdominal wound dehiscence defined as post-operative wound separation that involves all the layers of abdomen wall. Dehiscence of an abdominal wound may be partial or complete. It is partial when one or more layers have separated, but either the skin or the peritoneum remains intact. When it is complete, all the layers of abdominal wall have burst apart and this may or may not be associated evisceration [1].

Surgical wound dehiscence carries with it a substantial morbidity as well as mortality. Historically, wound dehiscence up to 10% was reported, contemporary series estimates an incidence between 1 and 3% [2,3]. Mortality associated with dehiscence has been estimated at 10-30%.4 The mean time for wound dehiscence is 8-10 days after operation [4,5].

Wound dehiscence is related to the technique of closure of the abdomen. Number of studies has been conducted to evaluate a bewildering variety of closure technique and suture materials [6,7].

Many patients undergoing emergency laparotomy suffer from one of these comorbid condition which are detrimental to healing [8]. In this scenario interrupted suturing has been found to give good strength and have less incidence of wound dehiscence [9].

There are many studies in the literature comparing various methods of wound closure, with conflicting results. Unfortunately, the types of safe and effective abdominal closure vary, leaving the surgeons wondering which closure is superior.

Since there are conflicting results in literature, the present study was done to find the incidence of wound dehiscence after closure of midline abdominal wound by Interrupted X suture with polydioxanone No 1 (PDS) suture. 

Aims and objective

To find out the rate of abdominal wound dehiscence by using Interrupted X suture technique in closure of rectus sheath after midline laparotomies.

Source of Data

This study was conducted on 100 patients undergoing midline laparotomy in the Department of General Surgery, Indira Gandhi Medical College, Shimla from June 2018 to December 2019. Patients were selected who require midline laparotomy either as emergency or elective procedure.

Inclusion Criteria

• Patients aged 18-75 years, requiring laparotomy

• Gender: Both male and female.

• Patients who require surgery with midline incision either as emergency or elective procedure.

• All patients giving written informed consent for enrollment in study.

Exclusion Criteria

• Patients below 18 years and above 75 years.

• Patients aged 18-75 years with immuno-compromised state, on chemotherapy/immunotherapy, long term steroids.

• Patients who died within 10 days following midline laparotomy

• Patients undergoing Re-Laparotomy.

Study Design

It was an institutional based Cross Sectional study

Study Procedure

Closure of midline abdominal wound by Interrupted X suturing technique with polydioxanone No 1 (PDS) suture. 

Method of Collection of Data

Pre-Operative Evaluation

The patients were assessed preoperatively with clinical history, physical examination, biochemical and radiological evaluations. A detailed Performa was filled with the following details:

• Details of patient age, sex, address, CR No., Date of Admission, Date of discharge.

•  Brief History

•  General Physical Examination

• Details of Operative Procedure

•  Date of surgery 

• Operation

• Indication

• Findings

• Closure Technique

Patients included in the study undergone following investigations:

• Complete Haemogram: Haemoglobin (HB), Total Leucocyte Count (TLC), Differential Leucocyte count (DLC), Platelet Count.

•  LFT and Serum Proteins.

•  Renal Function Test: Blood Urea, Serum Creatinine.

• Serum Electrolytes: Sodium (Na+), Potassium (K+), Chloride (Cl-).

• Chest X-Ray (PA View)

•  Abdomen X-Ray (AP View in Erect and Supine Position)

• Ultrasound Abdomen/CT

• Electrocardiography (ECG)

Intra-Operative Technique

After parts painted and draped, midline incision was given and abdomen was opened in layers. Once the pathology dealt, abdominal drains placed rectus sheath was closed by Interrupted X suture technique by PDS 1-0 suture. 

Suture Material

PDS 1-0 Round body was used in the study.

Technique of Continuous closure

Interrupted X-Closure: Interrupted X-closure performed using PDS 1-0 RB as large bite being taken outside as 2 cm from the cut edge of linea alba. The needle emerged on other side from inside out diagonally 2 cm from the edge and 4 cm above or below the first bite. This strand subsequently crossed or looped around the free end of suture and continued outside in diagonally at 90o to the first diagonal. The two end tied just tight enough to approximate the edge of linea alba taking care not to include omentum or bowel between the edges. This created two X like crosses- one on the surface and another deep to linea alba. The next X- suture placed 1 cm away from the previous one. Henceforth, in a 14 cm long wound, 3 X-sutures was applied.

Post-Operative evaluation:

In post-operative period, patients examined daily, kept nil per oral and on par-enteral fluids till bowel recover and assessed for the following parameters:

• Cough

• Discharge

• Abdominal Distension

•  Drain output

• Wound Gaping

• Wound Dehiscence

• Anemia

Broad Spectrum antibiotic coverage was given and changed as per culture sensitivity of wound discharge. Daily dressing was done. In asymptomatic patients with no wound infection, gaping and wound dehiscence, skin sutures removed on 10th post-operative day. 

Figure 1: PDS No 1 Round Body suture

Follow Up 

Regular follow up done up-to 7th,10th and 14th day. During follow up above mentioned parameters assessed.

Statistical Analysis

The statistical analysis of the data was done at the end of the study using appropriate statistical tests depending upon the variables. Quantitative data was presented as mean and range as appropriate. For normally distributed data, mean was compared using T-test. For discrete categorical data, number and percentage were calculated. Chi-Square tests or Fisher’s exact tests were applied for categorical data. All statistical tests were two sided. A p value of <0.05 was considered to indicate statistical significance. Analysis was conducted using Epi-Info version 7.2.3.1.
 

Figure 2: Interrupted X-Suture Technique

The study was conducted in the Department of General Surgery, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh from June 2018 to December 2019. A total of 100 patients were included in the study. The patients underwent closure of rectus sheath with conventional continuous closure technique 

Figure 3: Gender Distribution of Study Participants

In this study there were 89 (89%) males and 11 (11%) females. (Figure 3) The age of the patients varied from 18–75 years with a mean age of 45.65 years and SD ± 14.93. In current study the common indication of midline laparotomy was hollow viscus perforation and D1 perforation i.e perforated duodenal ulcer was the most common indication. (Table 1).

Table 1: Indication of Midline Laparotomy

It was observed that out of total 100 patients who underwent continuous closure technique, 6 (6%) patient developed wound dehiscence. (Figure 4)

Figure 4: Incidence of wound dehiscence

Maximum wound dehiscence occurred in the age group of 36-55 years & 46-55 age group 2(33.33%) each. (Table2) (Figure 5)

Figure 5: Age Group distribution of Wound dehiscence

Table 2: Age Group distribution of Wound dehiscence

The present study was performed at Indira Gandhi Medical College & Hospital, Shimla, HP, to find the rate of abdominal wound dehiscence in Interrupted X suture technique for abdominal wall closure in midline laparotomy. 

In this study there were 89 (89% )males and 11 (11%) females. The age of the patients varied from 18–75 years with a mean age of 45.65 years and SD ± 14.93. In current study the common indication of midline laparotomy was hollow viscus perforation and D1 perforation i.e perforated duodenal ulcer was the most common indication. It was observed that out of total 100 patients who underwent Interrupted X closure technique, 6 (6%) patient developed wound dehiscence. Maximum wound dehiscence occurred in the age group of 36-55 years & 46-55 age group 2(33.33%) each.

In 2017, Kuldip Singh Ahi et al [10] conducted a prospective randomized study of conventional continuous versus Interrupted-X type versus Hughes Far and Near interrupted abdominal fascial closure in surgical patients to prevent burst abdomen. They took 90 patients, 19 (21%) of 90 patients develop burst in the post-operative period. 11 (36.7%) of 30 patients in continuous arm developed burst, 4 out of 30 (13.3%) patient in Interrupted-X arm and 4 out of 30 (13.3%) patients in Huges Far and Near arm developed burst abdomen. On statistical analysis it is found significant (p=0.011) and the results obtained in the current study were comparable to this study.

In 2018,Shashikala V et al [11] conducted a prospective comparative study between continous and X interrupted suture in emergency laparotomies. A total of 60 patients undergoing emergency midline lapartomy for secondary peritonitis were considered for the study, 30 of whom underwent closure of abdominal wall with continous sutures and the other 30 with X-interrupted suture. The wound dehiscence rate was 26.67% (8 out of 30) for continous group versus 6.67% (2 out of 30) for the interrupted group. This difference was statistically significant showing results similar to those obtained in the current study.

One of the most important factor in preventing post-operative complications is the technique of laparotomy wound closure. Technical errors like poorly placed incision, wrong suture selection, unsatisfactory closure technique can lead to complications like wound hematoma, surgical site infection and gaping, wound dehiscence, evisceration, incisional hernia, hypertrophic scar. The main aim of a surgeon is to prevent all said complications by opting better technique and suture material.

The present study reported quite low incidence of wound dehiscence after using Interrupted X Suture Technique in Midline Laparotomy. Patients with age group of 36-55 years found to have highest incidence of abdominal wound dehiscence. Most of wound dehiscence occurred from 5th to 10th post-operative day. Using interrupted X suture technique in sheath closure, wound dehiscence can be prevented up to quite an extent.

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11. Shashikala, V., et al. “A comparative study between continuous and X-interrupted sutures in emergency midline laparotomies.” International Surgery Journal, vol. 5, no. 5, April 2018, pp. 1753–1757