title: Reduced Rate of Dehiscence After Implementation of a Standardized Fascial Closure Technique in Patients Undergoing Emergency Laparotomy.
abstract: In elective surgery, it is well documented that a midline laparotomy should be closed with a slowly absorbable monofilament suture material in a continuous technique, in a ratio of at least 4 : 1. The evidence concerning the suture material or suturing technique in the emergency setting is lacking. We aimed to investigate whether this technique would reduce the rate of dehiscence.
  
  
  
  A standardized procedure of closing the midline laparotomy by using a "small steps" technique of continuous suturing with a slowly absorbable (polydioxanone) suture material in a wound-suture ratio of minimum 1 : 4 was introduced in June 2014. All patients scheduled for any gastrointestinal emergency midline laparotomy were included until October 2015. Pre-, intra-, and postoperative data were registered. All emergency laparotomies performed from 2009 to 2013 served as reference. Chi-squared tests and multivariate Cox regression analysis were performed.
  
  
  
  We included 494 patients from 2014 to 2015 and 1079 patients from our historical cohort for comparison. All patients had a midline laparotomy in an emergency setting. The rate of dehiscence was reduced from 6.6% to 3.8%, P = 0.03 comparing year 2009 to 2013 with 2014 to 2015. Factors associated with dehiscence were male gender [hazard ratio (HR) 2.8, 95% confidence interval (95% CI) (1.8-4.4), P < 0.001], performance status ≥3 [HR 2.1, 95% CI (1.2-3.7), P = 0.006], cirrhosis [HR 3.8, 95% CI (1.5-9.5), P = 0.004], and retention sutures [HR 2.8, 95% CI (1.6-4.9), P < 0.000]. The 30-day mortality rate was 18.4% in the standardized group vs 22.4% in 2009 to 2013, P = 0.057 and 90-day mortality 24.2% vs 30.4%, P = 0.008.
  
  
  
  The standardized procedure of closing the midline laparotomy by using a "small steps" technique of continuous suturing with a slowly absorbable (polydioxanone) suture material reduces the rate of fascial dehiscence.
authors.affiliation: *Department of Gastrointestinal Surgery, Copenhagen University Hospital, Herlev, Denmark†Zealand University Hospital. Dept. Surgery, Center for Surgical Science, Copenhagen University, Koege, Denmark.
authors.forename: Mai-Britt
authors.initials: MB
authors.lastname: Tolstrup
authors.forename: Sara Kehlet
authors.initials: SK
authors.lastname: Watt
authors.forename: Ismail
authors.initials: I
authors.lastname: Gögenur
mesh_terms: D058107:Abdominal Wound Closure Techniques / Q000009:adverse effects; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D016208:Databases, Factual; D003718:Denmark; D004630:Emergencies; D000071938:Fasciotomy / Q000379:methods*; D005260:Female; D006785:Hospitals, University; D006801:Humans; D015994:Incidence; D007813:Laparotomy / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018570:Risk Assessment; D012737:Sex Factors; D013529:Surgical Wound Dehiscence / Q000453:epidemiology* / Q000517:prevention & control; D015996:Survival Rate; D013536:Suture Techniques; D013537:Sutures; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology*