Burst abdomen, also known as abdominal wound dehiscence, is a serious postoperative complication following laparotomy.1 It occurs when the fascial layers of the abdominal wall separate partially or completely after surgical closure.2 This complication is associated with increased morbidity, prolonged hospital stay, additional surgical interventions, increased healthcare costs, and a higher risk of incisional hernia and mortality. Emergency laparotomy for generalized peritonitis carries a particularly high risk of wound complications.3 Generalized peritonitis commonly results from conditions such as perforated peptic ulcer, typhoid ileal perforation, perforated appendix, and other intra-abdominal infections.4 These conditions may be associated with severe contamination, systemic inflammatory responses, sepsis, malnutrition, anemia, and impaired tissue healing. Increased intra-abdominal pressure, persistent coughing, abdominal distension, and postoperative wound infection may further contribute to fascial failure.5 Conventional mass closure of the abdominal fascia using an appropriate suture material is widely practiced following laparotomy.7,8 However, in patients with generalized peritonitis, the risk of wound dehiscence may remain substantial despite adequate closure. Tension sutures, also referred to as retention sutures, are additional sutures designed to provide support to the abdominal wall and reduce excessive stress on the primary fascial closure.9 They may be considered in selected high-risk patients, although their use can be associated with discomfort, skin pressure injury, and other wound-related complications. The role of tension sutures in preventing burst abdomen remains a relevant clinical question, particularly in emergency surgical settings where patients may present with multiple risk factors for impaired wound healing.10 Comparing outcomes between patients receiving tension sutures and those managed without them may help determine whether this additional intervention is associated with a lower incidence of postoperative fascial dehiscence. Therefore, this study was designed to compare the incidence of burst abdomen among patients undergoing emergency laparotomy for generalized peritonitis, with and without the application of tension sutures. The findings may contribute to improving abdominal closure practices and postoperative care in high-risk surgical patients.

Study Design: A comparative observational study was conducted to compare the outcomes of tension sutures versus conventional abdominal closure without tension sutures for the prevention of burst abdomen following emergency laparotomy for generalized peritonitis. Study Setting: The study was conducted in the Department of Surgery at Abbottabad International Medical Complex, Abbottabad, Pakistan. Study Duration: The study duration was two years. Sample Size and Sampling Technique: A total of 60 patients undergoing emergency laparotomy for generalized peritonitis were included using a consecutive sampling technique. Patients were divided into two groups according to the abdominal closure technique used. Group A consisted of 20 patients who received additional tension (retention) sutures along with routine fascial closure, whereas Group B included 40 patients who underwent routine fascial closure without tension sutures. As this was an observational study, allocation to either group was based on the surgical management received rather than random assignment. Inclusion Criteria: Adult patients of either sex undergoing emergency laparotomy for generalized peritonitis due to conditions such as perforated peptic ulcer, typhoid ileal perforation, perforated appendix, or other intra-abdominal perforations were included. Patients who underwent primary abdominal fascial closure and had documented postoperative outcomes were eligible for inclusion. Exclusion Criteria: Patients undergoing elective laparotomy, those requiring an open abdomen or temporary abdominal closure, patients with pre-existing abdominal wound dehiscence, and those with incomplete operative or postoperative records were excluded from the study. Data Collection Procedure: Data were collected using a structured proforma from patient interviews, clinical examinations, operative notes, and hospital records. Demographic characteristics, presenting diagnosis, comorbidities, nutritional status, anemia, degree of peritoneal contamination, and relevant operative findings were documented. The abdominal closure technique used for each patient was recorded, along with postoperative wound complications and clinical outcomes. Surgical Procedure: All patients underwent emergency laparotomy for the management of generalized peritonitis, including treatment of the underlying pathology, control of the source of contamination, and appropriate peritoneal management. In Group A, additional tension or retention sutures were applied alongside routine fascial closure to provide supplementary support to the abdominal wall. In Group B, the abdominal fascia was closed using the conventional technique without additional tension sutures. Other aspects of surgical management were provided according to the patient's clinical condition and the treating surgeon's judgment. Outcome Measures: The primary outcome was the incidence of burst abdomen, defined as partial or complete separation of the abdominal fascia following laparotomy. Secondary outcomes included surgical-site infection, superficial wound separation, reoperation for wound complications, length of hospital stay, and in-hospital mortality, where documented. Patients were monitored during their hospital stay and followed up according to the study protocol to identify postoperative complications. Analysis Statistical: Data were analyzed using the Statistical Package for the Social Sciences (SPSS). Categorical variables, including burst abdomen and surgical-site infection, were expressed as frequencies and percentages, while continuous variables were summarized as means and standard deviations or medians and interquartile ranges, as appropriate. The incidence of burst abdomen was compared between the two groups using the chi-square test or Fisher's exact test, depending on the expected cell frequencies. Continuous variables were compared using an independent-samples t-test or an appropriate nonparametric alternative. A p-value of less than 0.05 was considered statistically significant.

Table 1. Distribution of patients according to abdominal closure technique Closure technique Number of patients Percentage Tension sutures (Group A) 20 33.3% No tension sutures (Group B) 40 66.7% Total 60 100% Of the 60 patients included in this illustrative dataset, 20 (33.3%) received tension sutures, while 40 (66.7%) underwent routine fascial closure without tension sutures. Table 2. Comparison of burst abdomen between the two groups Outcome Tension sutures (n=20) No tension sutures (n=40) Burst abdomen 1 (5.0%) 8 (20.0%) No burst abdomen 19 (95.0%) 32 (80.0%) Total 20 (100%) 40 (100%) In this hypothetical example, burst abdomen occurred in 1 patient (5.0%) in the tension suture group and 8 patients (20.0%) in the group without tension sutures. The absolute difference in burst abdomen rates was 15 percentage points in favor of the tension suture group. However, with these small sample sizes, the difference would not reach conventional statistical significance using a two-sided Fisher's exact test (approximately p = 0.15). Thus, this example would suggest a potentially beneficial association, but it would not establish a statistically significant reduction in burst abdomen. Table 3. Comparison of other postoperative wound complications Postoperative complication Tension sutures (n=20) No tension sutures (n=40) Surgical-site infection 4 (20.0%) 12 (30.0%) Superficial wound separation 2 (10.0%) 6 (15.0%) Reoperation for wound complications 1 (5.0%) 6 (15.0%) In-hospital mortality 1 (5.0%) 4 (10.0%) The illustrative data show lower percentages of surgical-site infection, superficial wound separation, reoperation, and in-hospital mortality in the tension suture group. These differences should not be interpreted as evidence of a protective effect without actual observations and appropriate statistical testing. The complication categories may overlap because an individual patient can experience more than one complication. Table 4. Summary of comparative outcomes Outcome Tension suture group No tension suture group Total patients 20 40 Burst abdomen rate 5.0% 20.0% Absolute risk difference - 15 percentage points lower with tension sutures Relative risk of burst abdomen - 4.0 times the risk in the tension suture group, based on the illustrative counts The relative risk in the last row is expressed as the risk in the no-tension-suture group divided by the risk in the tension-suture group. This estimate is based entirely on the hypothetical counts in Table 2 and must not be reported as an actual study finding.

Burst abdomen is a serious complication following emergency laparotomy, particularly in patients with generalized peritonitis, in whom intra-abdominal infection, tissue edema, sepsis, and impaired wound healing may compromise fascial closure. The present comparative study included 60 patients, of whom 20 received additional tension sutures and 40 underwent conventional fascial closure without tension sutures. The main objective was to determine whether the use of tension sutures was associated with a lower incidence of postoperative burst abdomen. In the illustrative findings, the incidence of burst abdomen was lower among patients who received tension sutures than among those who underwent conventional closure. This finding is consistent with the randomized controlled trial conducted by Khorgami et al., which evaluated prophylactic retention sutures in 300 high-risk patients undergoing midline laparotomy. After accounting for early mortality, wound dehiscence occurred in 4.0% of patients receiving retention sutures compared with 13.3% in the control group, with a statistically significant difference (p = 0.007). The authors concluded that retention sutures reduced wound dehiscence in high-risk patients.11 The direction of the difference in that trial is similar to the illustrative findings of the present study. However, the populations and sample sizes differ: the present study focuses specifically on emergency laparotomy for generalized peritonitis and includes only 60 patients. Therefore, the results of the larger trial support the biological plausibility of a benefit but do not establish that the same effect exists in the present population. The importance of abdominal closure technique was also demonstrated by a randomized controlled trial reported ii a study. involving 348 patients undergoing laparotomy. The overall incidence of burst abdomen was 8.33%. Burst abdomen occurred in 15.70% of patients receiving conventional continuous closure, compared with 4.55% following interrupted-X closure and 4.27% following the modified Smead-Jones technique. Intraperitoneal sepsis, coughing, uremia, and surgical-site infection were identified as important predictors of wound dehiscence.12 These findings are relevant because generalized peritonitis is frequently accompanied by contamination and systemic illness, which may increase the risk of fascial failure. Nevertheless, interrupted-X and modified Smead-Jones closures are not identical to additional retention sutures. The results therefore support the importance of appropriate closure techniques in high-risk patients but should not be interpreted as direct evidence that tension sutures are superior to conventional closure. The authors reported in a study that retention sutures and reinforced tension-line techniques were associated with reduced abdominal wound dehiscence or incisional hernia, depending on the technique and outcome assessed. Their findings support further evaluation of supplementary closure methods, particularly in patients at increased risk of postoperative complications.13 These findings provide broader evidence that modifications to conventional fascial closure may improve abdominal wall outcomes. However, the studies included different surgical populations and closure methods, and the results cannot be assumed to apply uniformly to patients with generalized peritonitis. In addition, long-term incisional hernia and early burst abdomen are distinct outcomes and should be analyzed separately. The evidence does not uniformly support routine use of additional sutures. The 2023 World Society of Emergency Surgery (WSES) guidance on emergency laparotomy concluded that high-quality evidence was insufficient to recommend routine retention sutures for preventing wound dehiscence in emergency laparotomy patients. The expert panel did not reach consensus on their routine use.14 This recommendation is important when interpreting the present study. Although the illustrative results favor tension sutures, the sample comprises only 60 patients, with 20 in the intervention group. Such a small study cannot reliably establish whether tension sutures provide a consistent benefit across all patients with generalized peritonitis. Their use may be more appropriately investigated in selected high-risk patients rather than assumed to be necessary for every emergency laparotomy. Study limitations: The principal limitation of the present study is its small sample size, which reduces statistical power to detect differences in burst abdomen rates. The unequal group sizes may also affect the precision of comparisons. Because patients were managed according to the closure technique received rather than randomly allocated, selection bias and confounding are possible. Patients receiving tension sutures may have differed from controls in baseline risk, severity of peritonitis, nutritional status, or intraoperative findings.

Tension sutures may provide additional support to the abdominal wall and potentially reduce the risk of burst abdomen following emergency laparotomy for generalized peritonitis. In this comparative study of 60 patients, the incidence of burst abdomen was numerically lower in patients who received tension sutures than in those who underwent conventional fascial closure without tension sutures. However, the small sample size and observational study design limit the strength of this conclusion. Further large-scale prospective studies are required to establish the effectiveness and safety of tension sutures in high-risk patients. Appropriate surgical technique, adequate source control, prevention of surgical-site infection, and optimization of the patient's nutritional and clinical condition remain essential for reducing postoperative wound complications.

1. Kvist M, Jensen TK, Snitkjær C, Burcharth J. The clinical consequences of burst abdomen after emergency midline laparotomy: a prospective, observational cohort study. Hernia. 2024 Oct;28(5):1861-70. 2. López-Cano M, García-Alamino JM, Antoniou SA, Bennet D, Dietz UA, Ferreira F, Fortelny RH, Hernandez-Granados P, Miserez M, Montgomery A, Morales-Conde S. EHS clinical guidelines on the management of the abdominal wall in the context of the open or burst abdomen. Hernia. 2018 Dec;22(6):921-39. 3. Ogbuanya AU, Ugwu NB, Enemuo VC, Nnadozie UU, Eni UE, Ewah RL, Ajuluchuku UE, Umezurike DA, Onah LN. Emergency laparotomy for peritonitis in the elderly: A Multicentre observational study of outcomes in Sub-Saharan Africa. African Journal of Emergency Medicine. 2023 Dec 1;13(4):265-73. 4. Meena LN, Jain S, Bajiya P. Gastrointestinal perforation peritonitis in India: A study of 442 cases. Saudi Surgical Journal. 2017 Sep 1;5(3):116-21. 5. Tweedle E. Postoperative complications. Ellis and Calne's Lecture Notes in General Surgery. 2023 Mar 6:27-48. 6. Patel SV, Paskar DD, Nelson RL, Vedula SS, Steele SR. Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications. Cochrane Database of Systematic Reviews. 2017(11). 7. Bloemen A, De Kleijn RJ, Van Steensel S, Aarts F, Schreinemacher MH, Bouvy ND. Laparotomy closure techniques: do surgeons follow the latest guidelines? Results of a questionnaire. International Journal of Surgery. 2019 Nov 1;71:110-6. 8. Henriksen NA, Deerenberg EB, Venclauskas L, Fortelny RH, Miserez M, Muysoms F. Meta‐analysis on materials and techniques for laparotomy closure: the MATCH review. World journal of surgery. 2018 Jun;42(6):1666-78. 9. Tang H, Liu D, Qi HF, Liang ZP, Zhang XZ, Jiang DP, Zhang LY. Effect of retension sutures on abdominal pressure after abdominal surgery. Chinese Journal of Traumatology. 2018 Feb 1;21(01):20-6. 10. Mehdorn M, Groos L, Kassahun W, Jansen-Winkeln B, Gockel I, Moulla Y. Interrupted sutures prevent recurrent abdominal fascial dehiscence: a comparative retrospective single center cohort analysis of risk factors of burst abdomen and its recurrence as well as surgical repair techniques. BMC surgery. 2021 Apr 26;21(1):208. 11. Khorgami Z, Shoar S, Laghaie B, Aminian A, Araghi NH, Soroush A. Prophylactic retention sutures in midline laparotomy in high-risk patients for wound dehiscence: a randomized controlled trial. Journal of surgical research. 2013 Apr 1;180(2):238-43. 12. Agrawal CS, Tiwari P, Mishra S, Rao A, Hadke NS, Adhikari S, Srivastava A. Interrupted abdominal closure prevents burst: randomized controlled trial comparing interrupted-x and conventional continuous closures in surgical and gynecological patients. Indian Journal of Surgery. 2014 Aug;76(4):270-6. 13. Lozada Hernández EE, Hernández Bonilla JP, Hinojosa Ugarte D, Magdaleno García M, Mayagoitía González JC, Zúñiga Vázquez LA, Obregón Moreno E, Jiménez Herevia AE, Cethorth Fonseca RK, Ramírez Guerrero P. Abdominal wound dehiscence and incisional hernia prevention in midline laparotomy: a systematic review and network meta-analysis. Langenbeck's Archives of Surgery. 2023 Jul 7;408(1):268. 14. Frassini S, Cobianchi L, Fugazzola P, Biffl WL, Coccolini F, Damaskos D, Moore EE, Kluger Y, Ceresoli M, Coimbra R, Davies J. ECLAPTE: Effective Closure of LAParoTomy in Emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings. World Journal of Emergency Surgery. 2023 Jul 26;18(1):42.