‘The figure-of-8 through-and-through monofilament abdominal wound closure with wound splints: Elimination of evisceration in poor-risk wounds over 25 years Clarence Dennis, M.D., Ph.D., and Edip Aka, M.D.,+ Brooklyn, N. Y. The method of through-and-through abdominal wall closure for poor-risk wounds reported in 1953 has been re-evaluated after 18 more years of use. It has proved in our experience the only method entirely free of postclosure evisceration and has been uncomplicated by significant or chronic suppuration, skin cutting and resultant postoperative pain, or intestinal fistulization. Success appears attributable to mechanically secure approximation without strangulation, elimination of dead space in the wound, and minimization of foreign suture material in the line of approximation. From the State University of New York, Downstate Medical Center* CLEAN SOUND HEALING of the ab- dominal wall after intra-abdominal operative procedures is a cardinal index of good surgi- cal care. The technical factors involved in success- ful wound healing are many, but those of especially accepted importance are: (1) minimization of bacterial contamination, (2) good hemostasis, (3) approximation without strangulation, (4) minimization of residual foreign material, (5) minimization of dam- age to tissues, and (6) obliteration of dead space. The importance of obliteration of dead Accepted for publication July 18, 1972. Reprint requests: Dr. Clarence Dennis, Chief, Medical Devices Applications Program, National Heart and Lung Institute, National Institutes of Health, Bethesda, Md. 20014, *Cases reported here were operated upon at the Kings County Hospital, St. John’s Episcopal Hospital, Jewish Hospital of Brooklyn, State University Hospital, Long Island College Hospital, Brooklyn Veteran’s Administra- tion Hospital, and the Maimonides Hospital of Brooklyn. fDeceased June 30, 1965. Vol. 73, No. 2, pp. 171-175 space was quantitated by Condie and Fergu- son.1 They deliberately contaminated ab- dominal wounds in dogs and found a space- obliterating pattern of closure to reduce the incidence of infection from 11 out of 12 in the conventionally closed wounds to 3 out of 12 in the experimental ones. Furthermore, they reported that monofilament closures were strikingly effective in reducing the in- fection rate as compared to closures with braided sutures of silk or Dacron. This is in agreement with the report of Elek and Conen* that the burial of silk sutures in man enhances the virulence of contaminating staphylococci by a factor of 10,000. Cognizant of these principles but in ad- vance of these specific studies, Dennis, Nel- son, and Ankner? reported a method of closure in 1953 which was intended to ap- proximate the fascial and muscle layers and skin, to bury a minimum of suture material at the line of approximation, to utilize a monofilament suture, and to obliterate the dead space in the wound. February, 1973 SURGERY 171 172 Dennis and Aka | MONOFILAMENT wt ~— SUTURE PLASTIC SPLINT Fig. 1. Figure-of-8 through-and-through monofila- ment abdominal wall closure with wound splints. METHOD The details of the closure method are indi- cated in Fig. 1. This is a redrawing of the original illustration, redone for the purpose of emphasizing avoidance of bowstringing of suture material and thus the hazard of small bowel perforation therefrom. Wound closure with figure-of-8 monofila- ment sutures and wound splints is now ac- complished with 0.016 or 0.018 inch steel wire, or other inelastic monofilament suture of high tensile strength, such as No. 2 Tev- dek. When the time comes for closure, wound towels are removed and the skin about the wound is reprepared with antiseptic solution. Sutures are placed 2 cm. apart, first in the musculofascial structures 2 cm. back from the line of incision. In so doing, a bite of posterior fascia or rectus sheath and _peri- toneum is taken on each side (see Fig. 1). The large round Mayo needle used for this is removed, and hemostatic forceps are ap- plied to the suture ends to permit progression of placement of sutures in this layer. Large trocar needles are now applied for passage of each end of each suture through the subcu- taneous tissue and skin of the opposite side of the wound. A length of wound splint is selected which Surgery February 1973 Table I. Fate of closures employing figure-of-8 through-and-through sutures of No. 25 stainless steel with wound splints* | No. As supplement to standard closure: Uneventful sound healing 29 Infection followed by sound healing 4 Failure of healing of all wounds, with 1 maintenance of closure by wires; death at one week Wound normal at early death from cause 3 other than wound Total 37 As sole security of closure: Uneventful sound healing 14 Infection followed by sound healing 2 Dehiscence, cellulitis of abdominal wall, 1 death at 2 months Fecal fistula, carcinomatosis; bowel torn 1 at operation, death late Failure of healing, maintenance of closure 2 by wires; death from other cause Total 20 Grand total 57 *Reproduced with permission from Dennis, Nelson, and Ankner: Surg. Forum IV:, 601, 1953. is appropriate to approximate all layers with- out unduly pulling on the skin. Prior to drawing snug each of these sutures over the selected splint, the area between it and that just tied is explored with a finger, and, if necessary to avoid herniation between figure- of-8 sutures, a simple fine approximation suture of peritoneum and posterior fascia is placed and tied. Snugging up the musculofascial layers and tying over the splints commonly completes the closure, although inaccuracies in place- ment occasionally must be corrected by three or four fine silk sutures or adhesive strips to approximate the skin precisely. In case the monofilament suture is steel wire of the diameters indicated, it is more convenient simply to twist the wires than to tie knots. This has proved entirely adequate. Routinely, the fine accessory skin stitches or adhesive strips are removed in one week, and the figure-of-8 sutures and splints are removed 18 to 21 days after closure, longer if the patient has been on heavy steroid therapy, has low serum protein levels, has carcinomatosis, or has other reason to sug- Volume 73 Number 2 Abdominal wound closure: Elimination of evisceration 173 Table I. Types of cases—Each closure incident listed but once Patients | Deaths Crohn’s disease or idiopathic ulcerative colitis Shock from gastrointestinal bleeding Cancer with metastases or carcinomatosis Diabetes and/or obesity Peritonitis, pancreatitis, or pus in wound at time of closure Prednisone, more than 30 mg. per day Cancer in the senile Chronic biliary obstruction Suppurative cholangitis Intestinal obstruction with unrelieved distension Intestinal obstruction, carcinomatosis Chronic cardiopulmonary insufficiency and hernia Hemolytic hypersplenism Recent infection in reopened wound Diverticulitis and abscess, primary resection and anastomosis Wound dehiscences: Peritonitis, wound infection. and high intestinal fistula Diabetes and high steroids Uncomplicated Remarks 8 0 3 2 Pneumonia in both, one after renal failure 5 0 6 1 Pancreatitis after gastrectomy 4 0 3 0 2 0 2 0 2 0 1 0 1 ! Carcinomatosis, pulmonary emboli 1 0 ! 1 Diffuse bleeding I 0 1 0 1 1 High fistula 1 1 Pulmonary embolus 1 0 gest impairment of wound healing, Ordi- narily this suture removal is done on an out- patient basis. RESULTS The authors have personally used or supervised use of this closure on 103 oc- casions. Of these, 57 are in the report of Dennis, Nelson, and Ankner? (Table I), and the remainder are from personal experience since 1953 (Tables II and IIIT). The method has almost always been reserved for situations in which wound difficulty by conventional closure was considered highly likely. The splint closure has proved reliable in the presence of severe distension in the early postoperative period (e.g., acquired adult megacolon), in the presence of violent thrashing about during recovery from anes- thesia, and in the presence of massive steroid therapy associated with failure of other wounds to heal in the same patient. The method has permitted the authors to proceed confidently despite such usually ac- cepted contraindications as unexpected in- cision into abscesses on the way through the abdominal wall, most often on entering through old incisions. It has permitted closure of abdominal incisions made for drainage of Table II. Fate of wounds closed with figure-of-8 monofilament sutures and wound splints No. No. of wound closures (not previously 46 reported) No. of eviscerations 0 Failure to heal, but apposition held by closure 1 Wound infection in clean expectancy wound 1 No. cleanly healed in face of visible contami- 7 nation at time of closure No. of late hernias 0 intra-abdominal abscesses; here clean pri- mary healing has been repeatedly observed in that portion closed with splints, limiting the area of secondary healing to that corner of the wound left open for egress of Penrose or tubular drains. It has permitted primary healing in explorations for purulent peri- tonitis as well. In these latter cases and in those with purulent intraperitoneal collec- tions, it has been usual to lavage the abdo- men for an hour with a dilute solution of broad-spectrum antibiotic in Ringer’s solu- tion, leaving an intravenous type of catheter through a puncture wound in the upper abdomen for continuing infusion of anti- biotic, and a sump drain in a lower quadrant for evacuation. 174. Dennis and Aka Finally, the splint method has been used in situations in which re-exploration of the abdomen has appeared in order within the first day or two after the original closure. Here simple untwisting of the wire and anchoring of the wire ends by hemostats has permitted such re-exploration more expedi- tiously and safely than by other methods. The wire sutures, already in place, are simply drawn snug again and twisted over wound splints for closure at the end of the re- exploration. The fate of these closures is indicated in Table III. COMMENT The use of wound splints and monofila- ment figure-of-8 sutures for closure in situa- tions of poor-risk wounds has been standard procedure at Kings County Hospital for 20 years and has been widely adopted in several of the other hospitals listed. A survey too inaccurate to justify attempts to quantitate indicates the number of such closures at Kings County Hospital and State University Hospital to have been in excess of 1,500. Review of the record books of all the surgical services reveals no instance of evisceration after such closure. Our Record Rooms’ cross- listings unfortunately do not include the types of closure employed, and furthermore the Department of Hospitals of the City of New York has had the policy of destroying charts after seven years, so that these data are for the most part not retrievable. The mechanical inadequacy of retention sutures without splints has been expounded by several authors, among them Price® and Taylor and Jontz.* This inadequacy is not significantly lessened by use of “booties” and is compounded by painful and unsightly cutting of the skin by the sutures. The wound splint method described in 1953 has been adapted by Taylor and Jontz (1) to include a unit splint the length of the wound and (2) to avoid entry of the suture into the peritoneal cavity. The longi- tudinal splint was adopted because of a re- ported tendency under tension “to twist around longitudinally.” We have been care- ful to place the full length of each of the Surgery February 1973 figure-of-8 sutures in a plane perpendicular to the long axis of the wound, and suggest this as the reason for our failure to observe this difficulty. As to fear of cutting bowel by bow-string- ing intraperitoneal portions of the figure-of-8 sutures, Taylor and Jontz* report an instance, and we have scen an instance in totally buried wire closure in other hands elsewhere. We have not seen this complication in our own experience and observation with the splint closure nor has it come to light at Kings County Hospital or State University Hospital. We had nonetheless respected the possibility and chosen toa catch the wound edges with the figure-of-8 suture in the mid- 50’s after seeing the tragedy noted above with totally buried steel sutures. We concur in the opinion of Taylor and Jontz that pre- cautions should be taken but prefer passage through-and-through at the holding ex- tremes of the suture loop because of the greater certainty of engaging the posterior rectus sheath or posterior fascia and taking advantage of the strength of these structures. In 1963, 1964, and 1965 we studied varia- tions in technique which might simplify the tedious closure as described. Polypropylene monofilament sutures were employed for a time*; the. elasticity appeared to us, as an elastic closure had appeared to Taylor and Jontz, to be accompanied by rapid loosening and the need for frequent re-tying to main- tain the desired tension. Surgaloy suture was employed in some cases, but too often became so anchored as to make removal impossible. We have seen no untoward effects from division of such anchored sutures under tension at skin level when withdrawal is impossible, but prefer to remove the figure- of-8 sutures altogether, and therefore do not use braided wire. Reverdin needles were employed for a time. The procedure of closure was ex- pedited, but the added trauma led to bleed- ing which in turn raised concern about the possibility of secondary infection. The same problem arises if cutting edge needles are employed. Use of a round Mayo needle is *Kindly made available to us by Dr. Francis Usher. Volume 73 Number 2 straightforward except in the skin; the change to a trocar needle for the skin is time-con- suming, but passage of the needle produces little bleeding and is expeditiously accom- plished.* The oaken splints reported in 1953 have been replaced by color-coded splints, of 5, 6, 7, and 8 cm. lengths, made of autoclavable plastic and which can be re-used if desired.+ The length of splint to use is based upon a balance of the estimated maximum momen- tary musculofascial pull of 7.5 Kg. per figure-of-8 suture and a suture pressure to be placed upon the splint sufficient to ob- literate the subcutaneous dead space with- out cutaneous pain or skin necrosis. The actual dimensions employed suggest these momentary tensions to be well tolerated, and the pressures developed by the splint upon the skin during coughing or struggling dur- ing recovery from anesthesia leave no lasting ill effect. These pressures may be as much as 300 Gm. per square centimeter under the splint if the transit of the suture through the subcutaneous fatty and areolar tissue is three times the thickness of that layer. In practice, this is the ratio employed, although the splint is usually of the maximum length which does not impinge upon the groin or costal margin, or fail to conform to body curvature in small patients. Placement of the suture through the sub- cutaneous tissue and skin must be thought- fully accomplished to avoid necrosis-produc- ing lateral pressure by the suture upon the friable areolar tissue. Choice of length of splint must consider the skin as well as the musculofascial tension already noted. In practice, the skin distance from suture exit to suture exit can be curtailed 25 percent by proper choice of length of splint. Greater curtailment leads to gradual skin cutting; this does not impair security of fascial closure, but it causes distress and leads to suppura- tive drainage from the suture exits. When this has occurred, the suture exits have *Swedged-on trocar needle 0.016 inch steel sutures are to be made available by Ethicon, Inc., Atherton, Calif. 94026. t+Kindly manufactured and provided by Dr. Leonard Kurtz of the Deknatel Company. Splints are to be made available by the Pilling Co., Philadelphia, Pa. Abdominal wound closure: Elimination of evisceration 175 healed quickly after removal of the sutures. Uneasiness has been expressed by those new to the technique concerning the discom- fort of removal of the wire sutures. If the wire is well cleansed and cut close to the skin while under traction so that the cut end is straight, the discomfort is rarely dis- turbing to the patient. There are situations in which it is good practice to re-explore the abdomen within a day or two for security of determination of the viability of intestine left behind. Such is the case after reduction of midgut volvulus in the newborn and in the elderly patient with partial ileac resection for mesenteric venous thrombosis. Under such circumstances, it is suggested that the wound splint closure might simplify the re-inspection enough to be life-saving. As previously reported by Howes and Harvey® in several tissues and by Fast, Nel- son, and Dennist in the abdominal wall of the rabbit, most (80 percent) of the ulti- mately achieved tensile strength across the wound is gained in the first 15 days. The occasional unexpected failure of a normal pace of strength gain has led us to delay suture removal until 18 to 21 days, par- ticularly in instances in which poor healing had already been demonstrated. REFERENCES 1. Condie, J. D., and Ferguson, D. J.: Experi- mental wound infections; infection versus sur- gical technique, SurcERY 50: 367, 1961. 2. Dennis, C., Nelson, C. A., and Ankner, F. J.: Utilization of wound splints and through-and- through figure-of-8 sutures of stainless-steel wire for abdominal closure in the presence of poor wound expectancy, Surg. Forum IV: 601, 1953. 3. Elek, S. D., and Conen, P. E.: The virulence of Staphylococcus pyogenes for man, Br. J. Exp. Pathol. 38: 573, 1957. 4, Fast, J., Nelson, C. A., and Dennis, C.: Rate of gain in strength in sutured abdominal wall wounds, Surg. Gynecol. Obstet. 84: 685, 1947. 5. Howes, E. L., and Harvey, S. C.: Tissue re- sponse to catgut absorption, silk, and wound healing, Int. J. Med. Surg. 43: 225, 1930. 6. Price, P. B.: Stress, strain, and sutures, Ann. Surg. 128: 408, 1948. 7. Taylor, F. W., and Jontz, J. D.: Fixed figure- of-8 type of retention sutures, Surg. Gynecol. Obstet. 109: 378, 1959.