ORIGINAL ARTICLE

PROSPECTIVE CLINICAL STUDY: MASS CLOSURE

VERSUS LAYER CLOSURE OF ABDOMINAL WALL
Rajneesh Kumar∗ and Ankur Hastir∗
∗ Department of Surgery, PIMS Punjab Institute of Medical Sciences, Jalandhar, Punjab, India.

ABSTRACT
Background: Most common abdominal wall incisions are midline or paramedian and its closure technique should be
efficient to provide strength for prevention of an incisional hernia and should be a barrier to infection. An incisional
hernia is the most frequent complication as high as 39.9% after abdominal surgery. The integrity of sutured abdominal
wound rests on the balance between suture holding a capacity of tissues and tissue holding capacity of sutures.
Objective: The purpose of the study is to evaluate comparison between the mass closure and layered closure of midline
and paramedian incisions for operative time and postoperative complications after performing single layered closure and
conventional layered closure of laparotomy wounds like a seroma, wound infection, wound gaping, burst an abdomen
and incisional hernia.
Results: Meantime for the closure of laparotomy wound through a midline or Para median incision by single layered
closure technique was 14 minutes, and by the layered closure, the technique was 23 minutes. There was a difference of 9
minutes statistically significant (p=0.001). In postoperative period patients closed by mass closure technique 8 patients
(16%) had postoperative complications in the form of seroma in 2 patients (4%), infection in 3 patients (6%), wound
gaping in 2 patients (4%) and incisional hernia in 1 patient (2%) and no patient had burst abdomen whereas in layered
closure total 16 (32%) patients had complications as seroma in 5 patients (10%), wound infection in 4 patients (8%),
gaping in 4 patients (8%) burst abdomen in 1 patient (2%) and incisional hernia in 2 patients (4%).
Conclusion: Single layered closure technique is better than layered closure in term of operation time and postoperative
complications like a seroma, infection, wound gaping, burst an abdomen and incisional hernia.
KEYWORDS: mass closure, burst abdomen, layered closure, incisional hernia.

HOW TO CITE THIS ARTICLE

Kumar R, Hastir A. Prospective clinical study: mass closure ver-
sus layer closure of abdominal wall. Int J Surg Med. 2017; 3(4):
228-233. doi:10.5455/ijsm.mass-closure-versus-layer-closure-
abdominal-wall

Copyright © 2017 by the Bulgarian Association of Young Surgeons

DOI:10.5455/ijsm.mass-closure-versus-layer-closure-abdominal-wall Introduction
First Received: July 03, 2017
Accepted: July 22, 2017 Abdomen closure is necessary as regards to incision techniques,
Manuscript Associate Editor: George Baytchev (BG) its repair and use of newer suture material matter a lot. The
Editor-in Chief: Ivan Inkov (BG) integrity of sutured abdominal wound depends on a balance
Reviewers: Aldo bove (IT); Avdyl S. Krasniqi (KS); Paulina Vladova (BG) between suture holding a capacity of tissues and tissue hold-
1
Associate Professor, Department of Surgery, PIMS Punjab Institute of Medical
Sciences, Jalandhar, Punjab, India.
ing capacity of sutures [1]. Various clinical trials compared
Email: drrajneeshkumar@ymail.com layered vs mass, abdominal closure. Some studies show more

Rajneesh Kumar et al./ International Journal of Surgery and Medicine (2017) 3(4):228-233
burst abdomen and incisional hernia with layered closure [2, 3,
4] whereas some studies do not show any difference of these
complications [5], but no study demonstrates the advantage of
layered over mass closure. Many of the operations performed by
the general surgeons take place within the abdomen and conse-
quently incision and suturing of abdominal layers are most reg-
ular exercises in operative surgery. The ideal abdominal closure
should be efficient, provide strength and serve as a barrier to in-
fection. It should have low rates of wound dehiscence, infection
and incisional hernia formation and it should be comfortable for
the patient and aesthetic. Use of various combinations of suture
materials for abdomen closure has not brought down the rate of
complications of laparotomy incisions.
Harold Ellis [6] in his text mentioned that his preferred tech-
nique of closure of laparotomy incision is by the mass closure,
using nylon. Until recently, layered closure of abdominal wall is
considered better with more emphasis on closure of peritoneal
layer but animal studies has shown that healing of an incision
takes place by formation of dense fibrous scar that unites the op-
posing face of the laparotomy wound en mass that is the reason
that this method of single layer closure technique (mass closure
technique) has come into vogue [7].
Suture will cut through the tissues if the wound is closed
by using small bites and not enough length of suture is left
in the wound for later wound expansions. A wound length
may increase up to 30% in abdominal distension.So adequate
reserve of suture length in the wound is necessary to allow this
lengthening to occur and to ensure a resulting minimal rise in
tension between the sutures and tissues. Wound disruption
because of cutting out of sutures can be prevented by use of
nonabsorbable continuous sutures at 1 cm intervals and SL: WL
(suture length: wound length) ratio of 4:1 or more (Jenkins rule)
[8].Wound disruption is associated with the use of SL: WL ratio
of 2:1 or less- lower the ratio more is the risk of burst abdominal
wound.
Raw peritoneal defect heals rapidly. In Gilbert [9] and Ellis
[6] study, peritoneal closure in the lateral paramedian incision
wound disruption rate did not alter in both groups in whom
peritoneum was closed with number 1 chromic catgut and in
those whom peritoneum was not closed. However, layer by
layer closure of abdominal incision has a good aesthetic look.
Inclusive of the peritoneum in the suture has no impact on
wound strength, the rate of wound dehiscence and on incisional
hernia; however it may increase the formation of adhesions
[10,11]. There is no much data available about the comparison
of mass closure technique to single layer closure but recently
published European Hernia Society guidelines on abdominal
wall closure recommends a single layer of aponeurosis. [12]
Monofilament sutures nylon or prolene should be used. Loop
suture eliminates all the knots except one [13].
There are certain patient risk factors for a dehiscence and
incisional hernia which includes obesity, malignancy, old age,
smoking, diabetes mellitus, malnutrition, malignancy and use
of steroid [14,15,16].These factors contribute to delayed wound
healing and decreased collagen synthesis. [17,18,19] Despite
advances in surgical techniques and materials, abdominal fascia
closure has remained a procedure that often reflects a surgeon’s
personal preference with reliance on tradition and anecdotal
experience. [20, 21] The present study will evaluate the advan-
tages of single layer closure in comparison with the conventional
layered closure by operative time and postoperative morbidities
such as wound infection, burst abdomen and incisional hernia.
Rajneesh Kumar et al./ International Journal of Surgery and Medicine (2017) 3(4):228-233
Material and Method
Randomly 100 patients admitted in the surgery department of
tertiary care hospital at Punjab Institute of Medical Sciences
(PIMS) Jalandhar, for abdominal surgical procedure needing
either elective or emergency laparotomy. Out of 100 patients, 50
patients were grouped as group 1 as mass closure or single layer
closure technique and remaining 50 by conventional layered
closure as group 2. Patients were followed up to 6 months for
an incisional hernia.
1. Inclusion and exclusion criteria:
Inclusion:
• Patients aged 18-60yrs.
• Patients posted for laparotomy either elective or emergency.
• Patients who had undergone surgery by midline and Para-
median incisions.
• Weight below 80 kg both in male and female.
Exclusion:
• Patients with comorbid conditions like diabetes mellitus,
malnourished, immunocompromised patients, patients on
cancer chemotherapy, immunotherapy and on long-term
steroids.
• Patients where the death occurred within ten days after
surgery.
• Patients who had undergone surgery by Grid-iron and
transverse abdominal incisions.
• Patients who had undergone second laparotomy or re-
laparotomy.
• Patients weight above 80kg both in males and females.
2. Closure of Abdominal Incisions:
In group 1 (single layer mass closure):
1. Midline incision: closure was performed by suturing the
cut edges of the peritoneum and linea alba together, bites
were taken about 1 cm from margins of the cut edges and in-
terval of roughly 1cm with continuous sutures using Ethilon
(Nylon) no. 1.
2. Paramedian incision: the peritoneum, endo-abdominal fas-
cia, posterior layer of rectus sheath, the medial fibres of
rectus abdominis muscle and anterior layer of rectus sheath
were sutured as a single layer. The bites were taken about 1
cm from the cut edges and about 1 cm interval. Continuous
sutures were employed using Nylon No. 1.
In group 2 (conventional layer closure):
1. Midline incision: the peritoneum was closed with Vicryl
or Chromic catgut by continuous sutures, and the linea alba
was closed similarly with Nylon No. 1.
2. Paramedian incision: the peritoneum and posterior layer
of rectus sheath were closed with Vicryl or Chromic catgut
by continuous sutures. The anterior layer of rectus sheath
was closed with No. 1 Nylon by continuous sutures.
The skin was closed with non-absorbable material like
Ethilon using interrupted mattress sutures or staplers in both
groups of patients. Drains were used wherever necessary,
through a separate stab incision. Time taken for the closure
of abdomen was recorded in all cases.
 Postoperative: all the patients received antibiotics suitable
for the case parenterally, usually for 2-3 days and orally for 5-7
days. Antibiotics were continued only whenever indicated after
ten days. The wound was examined on 3rd, 5th, 7th, 9th or 10th
day and the condition of wound noted.
During the postoperative period, the patients were examined
for abdominal distension, vomiting, hiccup and chest infection.
Seroma and wound infection were also noted.
Regular examination of the wounds for signs of wound gap-
ing and burst abdomen was done. Patients were followed up
every month up to 6 months for an incisional hernia.
Seroma: Seroma is a collection of only serous fluid in the
subcutaneous tissue of the laparotomy wound without any evi-
dence of infection. In group 1: 2 patients (4%) who had seroma
were as in group 2: 5 patients (10%) who had a seroma.
Wound infection: Wound infection is considered when there
is an infection in the skin and subcutaneous tissue of the laparo-
tomy wound discharging pus. In group 1 - 3 patients (6%) had
wound infection whereas in group 2 - 4 patients (8%) had wound
infection. Our results were consistent with various studies as
shown in Table: 3.

Table 3 Wound infection.

Results
% age of cases % age of cases
In this study, the age of patients ranged from 18 to 60 years Author/Study with wound infection with wound infection
in both groups with a mean age of 42.8 years in group 1 and
Mass closure Layered closure
41.6 in group 2. Male to female ratio in this study undergoing
Togert et.al [35] 17% 29%
laparotomy was 3:1.
Shukla et.al [36] 0.5% 16.9%
Singh et.al [37] 6.6% 16.6%
Table 1 Type of surgery in patients undergoing laparotomy. Chaudhary & Chaudhary [38] 22.5% 47.5%
Type of surgery Mass closure Layered closure Total Present Study 6% 8%

Elective 28 26 54
Wound gaping: Wound gaping is considered when wound
Emergency 22 24 46 infection reached muscle, and there was a separation of the skin
Total 50 50 100 and wound edges. In group 1- 2 patients (4%) developed wound
gaping, whereas in group 2 - 4 patients (8%) developed gaping.
Our results were consistent with various studies shown in Table:
In this study, 70% of patients had midline abdominal incision,
4.
and 30% had right Para median incision. Nature of abdominal
surgeries performed in patients undergoing laparotomy were
gastric perforations, duodenal perforations, stab abdomen, blunt Table 4 Wound gaping.
trauma abdomen, gasterectomies, gastrostomies, perforated ap-
% age of cases % age of cases
pendix, jejunostomies, cystogastrostomy, colectomies, ileocolic
anastomosis and splenectomies, etc. Author/Study with wound gaping with wound gaping
In this study, the mean time taken for the closure of laparo-
Mass closure Layered closure
tomy wounds, by single layer closure technique was 14min, and
by the conventional layered closure, the technique was 23 min. Togert et.al [35] 0.87% 3.4%
There was a difference of about 9 minutes in the mean time Shukla et.al [36] 2% 13%
between the two methods used which was statistically signifi-
cant (p=0.001), indicating that the time needed for single layer Singh et.al [37] 0% 10%
closure procedure was significantly less than that required for Present study 4% 8%
conventional layered technique.

Burst abdomen: Burst abdomen was considered when there

Table 2 Time taken for closure of laparotomy wounds. was a separation of all layers including peritoneum with or
Time was taken (min) Single layer Conventional layered Total
without protrusion of viscera out of laparotomy wound. In
group 1, burst abdomen occurred in no patient (0%) whereas
10-15 10 0 10 in group 2 burst abdomen occurred in 1 patients (2%). Jenkins
15-20 23 2 25 et al. have stressed the importance of suture length to suture
20-25 16 14 30
wound length in the prevention of burst abdomen. He advocated
30% lengthening of the wound in postoperative period due
25-30 1 23 24 to abdominal distension and wound oedema, etc. Hence, he
30-35 0 10 10 advocated usage of the suture of at least four times length of the
35-40 0 1 1
length of the wound (SL: WL 4:1) for mass closure technique.
We also followed the same principle in our study, and there was
40-45 50 50 100 no incidence of burst abdomen in this group. Our results were
consistent with various studies shown in Table: 5.
Postoperative complications: In single layer closure group, An incisional hernia: an incisional hernia was considered
total eight patients (16%) and in general layered closure group, to be present when a protruding swelling was noticed, and a
16 patients (32%) had postoperative complications like a seroma, fascial defect was palpable in the wound during postoperative
wound infection, wound gaping, burst an abdomen and inci- follow up of the patient, in the supine position, lifting legs, and
sional hernia. head raising test or expansile impulse on coughing. One patient

Rajneesh Kumar et al./ International Journal of Surgery and Medicine (2017) 3(4):228-233
 wire closure with interrupted mass far-near sutures incorporat-
Table 5 Burst abdomen. ing all layers, apart from the skin.
% age of cases % age of cases An incisional hernia occurs due to wound complications
Author/Study with burst abdomen with burst abdomen such as seroma, wound infection and faulty closure technique
Mass closure Layered closure [23].Mass closure method reduces the time required for closure
of incision and incidence of wound dehiscence and the incidence
Higgnis et.al [28] 0.7% 6.7%
of an incisional hernia [24].An incisional hernia is a frequent com-
Bucknall et.al [14] 0.8% 3.8%
plication of abdominal wall closure with a reported incidence
Jones et.al [22] 0% 3.9% of between 5% and 15% following vertical midline incisions at
Chaudhary & Chaudhary [38] 0% 3.75% one-year follow-up [25, 26, 27].
Present study 0% 2% Ellis had reported a decrease in evidence of an incisional her-
nia with mass closure technique [6].This is consistent with our
studies, where in one case of an incisional hernia in mass closure
(2%) in group 1 had an incisional hernia whereas in group 2 an and 2 cases of layered closure had an incisional hernia, compa-
incisional hernia occurred in 2 patient (4%). An incisional hernia rable to international reported incidence. Recently published
is closely related to suture technique. Ellis reported a decrease two meta-analyses confirmed that mass closure is responsible
in the incidence of an incisional hernia with mass closure, which for the statistically significant reduction in hernia formation and
is consistent with our study [6].However, Bucknall et al. [4] wound dehiscence [26, 27].
reported no significant difference in the incidence of incisional In 1970, Dudley observed ischemic necrosis about a suture is
hernias. Singh et al. [23] reported no case of an incisional her- the outcome of revascularizing of the bite and continued pres-
nia in mass closure and 6.6% in conventional layered closure. sure exerted by any distractive force at the suture-tissue interface.
Single layer closure had reduced operative time than conven- In mass closure, a deep bite of tissue provides more cushioning
effect and therefore less strangulation of tissue. In various stud-
ies of layered and mass closure techniques incidence of wound
Table 6 An incisional hernia. dehiscence and burst, the abdomen was less with mass closure
% age of cases % age of cases mass closure technique. In our study no case of burst abdomen
in mass closure group where as one case of burst abdomen
with an incisional with an incisional occurred in layered closure. The results of our study were sta-
Author/Study
hernia hernia tistically similar to those of Hygnis et al. [28] and Bucknall et
al. [4]. For mass closure of abdominal, commonly used threads
Mass closure Layered closure are monofilaments like No. 1 Nylon or Prolene, and with these
Shukla et.al [36] 0% 3% threads chances of stitch, sinus is there because of knots at start
and end. To prevent this complication always bury the knot [29].
Singh et.al [37] 0% 6.6% In our both groups there was no incidence of sinus formation,
Present study 2% 4% as we buried knots in all cases.
The ideal amount of tension should be placed on closing
suture remains unknown due to lack of research. One study by
tional layered closure, and hence, prevents anaesthetic hazards,
Mayer et al. revealed greater tension on suture line increased
reduces the cost of anaesthetic agents and saves the time of the
the rate of wound infection compared with lower suture line
surgeon. The incidence of postoperative complications like a
tension [30].
seroma wound infection, wound gaping, burst an abdomen and
As demonstrated experimentally by Jenkins that the length
incisional hernia is comparatively less in single layer closure
of a midline laparotomy incision can increase up to 30% in the
technique. Detection of seroma and its management in postop-
postoperative period in association with several factors that a
erative period prevents the occurrence of wound infection. Use
suture length- to- wound ratio should be 4:1.[8,31,32] In case
of newer antibiotics and better suture materials has reduced the
of emergency, time is a major factor, Spencer in his study ob-
rate of wound infection.
served significantly reduced the time required for mass closure
as compared to layered closure [33]. In our study mean time
Discussion taken for the closure of laparotomy wounds was 14 minutes
The techniques for closure of midline and Paramedian incisions by the mass closure and was 23 minutes by the conventional
varied over the time with the improvement of surgical equip- layered closure. Single layer closure took 9 minutes lesser than
ment and method. The ideal wound closure provides strength layered closure. In Banerjee and Chatterjee study, single layer
and barrier to infection. In the present study, the aim was to took 10 minutes more minor than layered closure [34].Reduction
compare laparotomy wound closure technique which prevents in operative time prevents anaesthetic hazards, reduces the cost
postoperative complications like wound infection, wound gap- of anaesthetic agent and save the time of surgeon.
ing, burst an abdomen and incisional hernia. Rucinski et al. in their meta-analysis study for the closure
Smead, a resident to Finney in Baltimore, first used the “far- of abdominal midline fascia compared absorbable and non-
near” stitch in 1900, in America named as “Smead-Jones Tech- absorbable sutures found no significant difference in postop-
nique”. In 1941, Jones and associates [22] reported a burst ab- erative wound infection, dehiscence and incisional hernia [27].
domen rate of 11% when incisions were sutured with two layers Wound infection rate in various studies for Togart was 17% and
of catgut, and 7% when sutured with catgut for peritoneum and 29%, Shukla et al. was 0.5% and 16.9%, Singh et al. also was
interrupted steel wire for the anterior rectus sheath. However, 6.6% and 16.6% and for Chowdhury was 22.5% and 47.5% in sin-
only one burst abdomen occurred in 81 operations after steel gle layer closure and conventional layered closure respectively

Rajneesh Kumar et al./ International Journal of Surgery and Medicine (2017) 3(4):228-233
[35, 36, 37, 38]. In our study, the incidence of wound infection
was 6% in single layer closure and 8% in conventional layered
closure. Use of newer antibiotics and better suture materials has
probably decreased the rate of wound infection.
Conclusion
Reducing local wound complications and incisional hernia for-
mation after abdominal wound closure remains a persistent chal-
lenge. Mass closure technique is preferred technique than lay-
ered closure in term of consumption of time and also in term of
incidence of postoperative complications like a seroma, wound
infection, wound gaping, burst an abdomen and incisional her-
nia. Hence, single layer closure technique is better than the
conventional layered closure of laparotomy wounds.
Authors’ Statements
Competing Interests
Written informed consent was obtained from the patient for
publication of this case report and any accompanying images.
There were no financial support or relationships between the
authors and any organization or professional bodies that could
pose any conflict of interests.
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