Reduced rate of dehiscence after implementation of a standardized fascial closure technique in patients undergoing emergency laparotomy

Objective: 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. Methods: 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. Results: 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. Conclusion: 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.