The closure of abdominal incision is an important aspect of surgical practice, particularly in emergency situations where efficiency, effectiveness, and patient outcomes are important. Among the various techniques employed, the debate between the continuous and interrupted methods of closure for midline incisions in emergency surgeries remains a subject of significant interest and investigation within the medical community. [1]

The choice between continuous and interrupted closure methods is influenced by various anatomical factors inherent to the abdominal wall. [2] As such, the closure of midline incisions necessitates meticulous attention to tissue approximation, distribution of tension, and preservation of blood supply to mitigate the risk of wound complications. Over time, comparative studies have sought to elucidate the relative merits and demerits of each approach, shaping contemporary surgical guidelines and practices. [3,4] An understanding of the anatomical intricacies of the abdominal wall is imperative for surgeons tasked with selecting the most appropriate closure technique. [5,6]

The closure of midline abdominal incisions in emergency surgeries poses unique challenges necessitating careful consideration of closure techniques. The continuous and interrupted methods represent two distinct approaches, each with its advantages and limitations. Through rigorous comparative analysis and evidence-based practice, this study focuses to light on the relative merits of continuous and interrupted closure methods, thereby informing best practices and advancing the field of emergency abdominal surgery [7]

Aims and objectives

To compare between the continuous and interrupted suture techniques of midline wound closures in patients who will be operated through midline incision laparotomy for any cause in emergency conducted at a tertiary care centre.

A Prospective Comparative Study conducted on patients admitted to the Department of General Surgery who required emergency midline laparotomy procedures from.

Inclusion Criteria:

All adult patients undergoing laparotomy by midline incision in a tertiary care centre.

Exclusion Criteria:

• Patients not undergoing laparotomy through midline incision.
• Those with previously treated or untreated incisional hernias.
• Those who underwent surgery by Grid-iron, subcostal, paramedian incisions, second
  laparotomy or re-laparotomy were excluded.
  
  

Ethical Clearance:

The study commenced in October 2022 after obtaining approval from the Institutional Ethics Committee (IEC).

Study Procedure:

Patients admitted in wards or presenting to casualty who required emergency midline laparotomy procedures were enrolled.

The division of groups was based on the patient’s IPD number; Group A included patients with odd last digit IPD numbers, while Group B included those with even last digit IPD numbers.

In Group A, the abdomen was closed using a single layer closure technique with No. 1 polypropylene round body needle suture as continuous non-locking sutures. In Group B, the abdomen was closed using the same suture material in an interrupted suture pattern.

During the operation, records were maintained regarding the method of abdominal closure used. Postoperatively, patients were observed for immediate postoperative complications such as wound infection, suture sinus formation, and wound dehiscence, as well as late postoperative complications like persistent wound pain and incisional hernia.

Statistical Analysis:

• Data analysis was performed using SPSS software version 23 and MS Excel 2017. Continuous variables were expressed as mean ± standard deviation, and non-normally distributed variables were presented as median (interquartile range).
• Qualitative variables were represented as percentages and proportions.
• Associations between qualitative variables were analysed using the chi-square test or Fisher's exact test, as appropriate.
• The significance of differences between means was assessed using an independent sample t-test.
• A two-tailed P < 0.05 was considered statistically significant.

The mean age for Group A is 45.2 years with a standard deviation of 8.6 years, while for Group B, it is slightly lower at 43.8 years with a standard deviation of 9.1 years. This suggests a comparable age profile between the two groups, with minor variations in the mean and standard deviation. In both groups, males are slightly more prevalent, with Group A comprising 25 males compared to 15 females, and Group B having 23 males and 17 females. This indicates a similar gender distribution pattern between the two groups, with males constituting a slightly higher proportion across both suturing techniques.

Table 1: Distribution of Cases Based on Surgeries

Table 1 shows the distribution of cases based on different surgeries in Group A and Group B. The most common surgeries in both groups were related to intestinal obstructions due to adhesions, with 5 cases in Group A and 7 in Group B, totaling 12 cases. Perforated appendix also had a significant number of cases, with 8 in Group A and 10 in Group B, for a total of 18 cases. Other notable surgeries include gastric ulcer (10 cases), duodenal ulcer (9 cases), intestinal obstruction due to carcinomas (10 cases), and blunt trauma to the abdomen causing Intestinal perforation, Splenic Rupture and    Liver laceration (11 cases). Intestinal obstruction due to stricture and tuberculosis each accounted for 5 cases across both groups.

The mean operative time for perforated appendix was 65.5 ± 12.3 minutes in Group B and 62.8 ± 10.5 minutes in Group A (p = 0.43). For gastric ulcer surgeries took 72.4 ± 14.6 minutes in Group B and 70.1 ± 12.8 minutes in Group A (p = 0.52). For duodenal ulcer, the operative time was 68.3 ± 13.7 minutes in Group B and 66.5 ± 14.1 minutes in Group A (p = 0.61).

Intestinal obstruction due to stricture showed an operative time of 83.2 ± 18.9 minutes in Group B and 80.7 ± 17.4 minutes in Group A (p = 0.49). In cases of intestinal obstruction due to adhesions, Group B required 78.1 ± 15.8 minutes, while Group A took 76.3 ± 14.6 minutes (p = 0.56). For TB-related obstruction, Group B had an operative time of 85.7 ± 19.4 minutes, compared to 83.5 ± 18.2 minutes in Group A (p = 0.44). Surgeries for intestinal obstruction due to carcinomas took 90.5 ± 21.2 minutes in Group B and 88.9 ± 20.7 minutes in Group A (p = 0.39).

Blunt abdomen surgeries lasted 75.3 ± 16.5 minutes in Group B and 73.8 ± 15.3 minutes in Group A (p = 0.57). None of the differences in operative duration between the two groups were statistically significant (p > 0.05).

Table 2: Operative Details

Group A underwent continuous sutures, while Group B received interrupted sutures. The duration of surgery was slightly longer in Group B, with a mean time of 82.3 ± 17.8 minutes, compared to 78.5 ± 15.2 minutes in Group A. [table -2] This suggests a marginal difference in operative time between the two groups, which could be attributed to the variation in suture techniques, although both durations fall within a similar range.

Table 3: Immediate Post-operative Complications

The immediate post-operative complications observed between Group A and Group B were compared across three parameters: wound gaping, suture site infection and wound dehiscence.

In Group A, wound gaping occurred in 20% of patients, while in Group B, it was noted in 12.5% of cases. Similarly, suture site infections were higher in Group A at 12.5% compared to 7.5% in Group B. Wound dehiscence was a less frequent complication, affecting 5% of patients in Group A and 2.5% in Group B. Overall, Group A showed a slightly higher incidence of post-operative complications compared to Group B. [table- 3]

Table 4: Late Post-operative Complications

The late post-operative complications in Group A and Group B were evaluated based on the occurrence of persistent wound pain and incisional hernia. In Group A, 17.5% of patients experienced persistent wound pain, slightly higher than the 15% observed in Group B. Additionally, the incidence of incisional hernia was greater in Group A, with 10% of patients affected, compared to 5% in Group B. These findings suggest that Group A may have a slightly higher risk of late post-operative complications compared to Group B. [table- 4]

The post-operative hospital stay for patients in both Group A and Group B was compared, with Group A having a mean stay of 6.9 ± 2.3 days, while Group B had a slightly shorter stay of 6.4 ± 1.8 days.

The comparison of wound gaping between Group A and Group B shows that 20% of patients in Group A experienced wound gaping, whereas 12.5% of patients in Group B had this complication.

The p-value of 0.29 indicates that this difference is not statistically significant, suggesting that while Group A had a higher percentage of wound gaping, the variation between the two groups may not be clinically relevant.

The comparison of suture site infection (SSI) between Group A and Group B reveals that 12.5% of patients in Group A experienced SSI, while 7.5% of patients in Group B had this complication. The p-value of 0.42 indicates that the difference is not statistically significant, suggesting that the variation in SSI rates between the two groups is likely due to chance rather than a true difference in outcomes. Therefore, both suture techniques appear to have similar risks for suture site infection.

The comparison of wound dehiscence between Group A and Group B shows that 5% of patients in Group A experienced wound dehiscence, while only 2.5% of patients in Group B had this complication. The p-value of 0.51 indicates that this difference is not statistically significant.

The comparison of persistent wound pain between Group A and Group B shows that 17.5% of patients in Group A reported persistent wound pain, compared to 15% in Group B. The p- value of 0.71 indicates that this difference is not statistically significant, suggesting that the incidence of persistent wound pain is similar between the two groups.

The comparison of incisional hernia between Group A and Group B reveals that 10% of patients in Group A developed an incisional hernia, while 5% of patients in Group B experienced this complication. The p-value of 0.35 indicates that the difference is not statistically significant. This suggests that although Group A had a higher rate of incisional hernia, the difference between the two groups is not large enough to be considered statistically meaningful based on the current data.

Table 5: Summary of Complications

Group A had higher incidences of wound gaping (20% vs. 12.5%), suture site infection (12.5% vs. 7.5%), wound dehiscence (5% vs. 2.5%), persistent wound pain (17.5% vs. 15%), and incisional hernia (10% vs. 5%) compared to Group B. Although Group A generally experienced more complications across all parameters, the differences are not statistically significant, suggesting that both suture techniques perform similarly in terms of post-operative outcomes based on this data. [Table- 5]

Table 6: Comparison of Complication Rates

The comparison of complication rates between Group A and Group B shows that wound complications occurred in 37.5% of patients in Group A, compared to 22.5% in Group B. Additionally, any complications, including all post-operative issues, were observed in 45% of Group A patients and 30% of Group B patients. However, the p-values for both wound complications (0.17) and any complications (0.21) indicate that these differences are not statistically significant. This suggests that while Group A had a higher rate of both wound and overall complications, the differences between the two groups may be due to chance and not indicative of a significant clinical difference. [Table- 6]

The comparison of hospital stay between Group A and Group B shows that the mean hospital stay for Group A was 6.9 days, while for Group B it was slightly shorter at 6.4 days. However, the p-value of 0.38 indicates that this difference is not statistically significant, suggesting that both groups had similar lengths of post-operative hospital stay, with no meaningful difference attributable to the method of suture used.

In our study, across age groups, Group A demonstrates a slightly lower count in the younger demographic (<30 and 30-39), while Group B shows a marginally higher count in these age brackets. However, the trend reverses in older age categories (Age 40-49, 50-59, and 60-69), with Group A exhibiting higher counts compared to Group B, albeit with slight variations.

The mean age for Group A is 45.2 years with a standard deviation of 8.6 years, while for Group B,

it is slightly lower at 43.8 years with a standard deviation of 9.1 years. This suggests a comparable age profile between the two groups, with minor variations in the mean and standard deviation.

In both groups, males are slightly more prevalent, with Group A comprising 25 males compared to 15 females, and Group B having 23 males and 17 females.

The comparison of complication rates between Group A and Group B shows that wound complications occurred in 37.5% of patients in Group A, compared to 22.5% in Group B. Additionally, any complications, including all post-operative issues, were observed in 45% of Group A patients and 30% of Group B patients. However, the p-values for both wound complications (0.17) and any complications (0.21) indicate that these differences are not statistically significant. This suggests that while Group A had a higher rate of both wound and overall complications, the differences between the two groups may be due to chance and not indicative of a significant clinical difference.

In comparison to other studies, our study, involving 80 patients undergoing either continuous sutures (Group A) or interrupted sutures (Group B), demonstrated no significant difference in post-operative complications, although Group A showed slightly higher rates of wound gaping (20% vs. 12.5%), suture site infection (12.5% vs. 7.5%), and wound dehiscence (5% vs. 2.5%) compared to Group B. The mean operative time was marginally longer in Group A (82.3 ± 17.8 minutes) compared to Group B (78.5 ± 15.2 minutes).

Similarly, Polychronidis et al. (2023) found no significant difference between continuous and interrupted suturing in terms of burst abdomen (13.5% vs. 15.1%) and incisional hernia (3.0% vs. 11.1%), while Wolf et al. (2022) highlighted the ongoing debate over optimal abdominal wall closure techniques, focusing on the efficacy and safety of continuous sutures with or without additional interrupted sutures. [8,9] Khan et al. (2022) reported a lower incidence of wound dehiscence with interrupted suturing (5.6%) compared to continuous suturing (14.4%). Overall, while our findings align with previous studies in showing comparable outcomes between the two techniques, some studies suggest a slight advantage for interrupted suturing in reducing specific complications like wound dehiscence. [10]

The conclusion of our study indicates that while there were slightly higher incidences of post-operative complications such as wound gaping, suture site infection and wound dehiscence in the continuous sutures group (Group A) compared to the interrupted sutures group (Group B), these differences were not statistically significant.

The mean operative time was marginally longer in Group B. The suture material required was comparatively less in Group A. But again, these variations did not reach statistical significance.

Therefore, both suturing techniques appear to be equally effective in terms of clinical outcomes, suggesting that the choice between continuous and interrupted suturing can be made based on surgeon's preference and specific patient’s considerations, as the differences in complication rates, cost effectiveness operative times are minimal and not clinically significant.

1. Tran DT-A, et al. Standard of care and outcomes of primary laparotomy versus laparotomy in patients with prior open abdominal surgery (ReLap Study; DRKS00013001) J Gastrointest Surg. 2021;25(10):2600–2609.
2. Thorup T, Tolstrup MB, Gogenur I. Reduced rate of incisional hernia after standardized fascial closure in emergency laparotomy. Hernia. 2019;23(2):341–346.
3. Goodenough CJ, et al. Development and validation of a risk stratification score for ventral incisional hernia after abdominal surgery: hernia expectation rates in intra-abdominal surgery (the HERNIA Project) J Am Coll Surg. 2015;220(4):405–413.
4. Connelly TM, et al. Risk factors for the development of an incisional hernia after sigmoid resection for diverticulitis: an analysis of 33 patients, operative and disease-associated factors. Am Surg. 2015;81(5):492–497.
5. Peponis T, et al. Interrupted versus continuous fascial closure in patients undergoing emergent laparotomy: a randomized controlled trial. J Trauma Acute Care Surg. 2018;85(3):459–465.
6. Pizza F, et al. Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS) Br J Surg. 2021;108(6):638–643.
7. Kirkpatrick AW, et al. The unrestricted global effort to complete the COOL trial. World J Emerg Surg. 2023;18(1):33.
8. Polychronidis G, Rahbari NN, Bruckner T, Sander A, Sommer F, Usta S, Hermann J, Albers MB, Sargut M, Knebel P, Klotz R. Continuous versus interrupted abdominal wall closure after emergency midline laparotomy: CONTINT: a randomized controlled trial [NCT00544583]. World J Emerg Surg. 2023 Oct 17;18(1):51.
9. Wolf S, Arbona de Gracia L, Sommer F, Schrempf MC, Anthuber M, Vlasenko D. Continuous and interrupted abdominal-wall closure after primary emergency midline laparotomy (CONIAC-trial): study protocol for a randomised controlled single centre trial. BMJ Open. 2022 Nov 23;12(11):e059709.
10. Khan, T. H., Jaffer , Z. M., Ullah, R., Malik, A. H., Hayat, A., & Hayat, Q. (2024). Effectiveness of Continuous versus Interrupted Closure of Midline Wound in Emergency Laparotomies in Terms of Wound Dehiscence. Journal of Health and Rehabilitation Research, 4(1), 1102–1107.