Layered Closure Versus Retention Closure Technique for the Abdominal Wall in Midline Laparotomy: A Longitudinal Cohort Study

Introduction: Midline laparotomy wound is closed in layers co-opting the various layers separately from historical times; however various methods of closure had come into vogue in the recent years. One such is the single layer mass closure technique, in which all the layers of the abdominal wall are closed in single layer, except for the skin and subcutaneous tissue. Yet another method described is the retention closure technique incorporating all layers including skin and subcutaneous tissue are closed in a single layer. Aim: To compare the postoperative wound complications in layered closure with retention closure technique in midline laparotomy. Materials and Methods: This was a longitudinal cohort study done on 57 consecutive patients who underwent midline laparotomy on an elective or emergency basis over a 12 months period from January 2014 to January 2015 in the Department of General Surgery at Mahatma Gandhi Medical College and Research Institute, Puducherry, India. They were divided in to two groups depending on the closure type, layered closure (Group A) and retention closure (Group B) depending on the operating surgeon: retention closure was done in a single surgical unit and layered closure was done in rest of the respective units. Patients were followed up meticulously and immediate postoperative complications were recorded up to four weeks. Statistical analysis was carried out using SPSS version 19.0 (IBM SPSS, US) software with regression modules installed. Chi-square test and t-test were used to analyse the data. Results: In Group A there was 30 patients while in Group B there were 27 patients. In layered closure technique out 30 patients 12 (40%) patients developed wound infection, 1 (3.3%) patient developed partial dehiscence, and 2 (6.6%) patients developed complete dehiscence. In retention closure technique out of 27 patients only 5 (18.5%) patients developed wound infection, 3 (11%) patients developed partial dehiscence and none of them had complete dehiscence in this group. There was significant association between wound complications and patients with uraemia and hypoalbuminemia. Out of 12 uremic patients 8 (66%) developed wound infection (p-value=0.002), 2 (16.7%) patients developed partial dehiscence and 2 (16.7%) patients developed complete dehiscence (p-value=0.06). In patients who had hypoalbuminemia, out of seven patients, 5 (71.4%) patients had wound infection and 2 (28.6%) patients did not have wound infection (p-value=0.01). Four (57.1%) patients had partial dehiscence and 2 (28.6%) had complete dehiscence only 1 (14.3%) patient did not have any dehiscence (p-value=0.001). Conclusion: Retention closure has some advantages over layered closure in preventing wound infections and burst abdomen. Various risk factors are associated with postoperative wound complications, among which hypoalbuminemia and uraemia have a strong association.