Key content
Selection of any incision must be highly individualised.
Numerous options of skin closure have become available and it is
paramount to choose the method tailored to each patient and
surgical procedure.
The ideal wound closure device should be easy to use, painless,
provide good cosmesis and be cost-effective.
This article reviews the traditional closure materials as well as
some materials that have recently become available, such as staples
and glue.
Use of electrosurgery on the skin.
Learning objectives
To review the medical literature on this subject.
To outline the anatomical and technical aspects that influence the
choice of incisions and sutures.
To assess the safety aspects, risks and the appropriate use of various
closure techniques.
Ethical issues
Is it ethical to allow the selection of an incision dictated by
patient choice to preserve cosmesis if it may compromise the
surgical approach?
Is it ethical to subject high-risk women to laparotomy for
diagnostic or therapeutic purposes when laparoscopic
management has demonstrated benefits?
Keywords: closure / electrosurgery / incision / laparoscopy / suture
Introduction
Skin preparation
Abdominal incisions
Advantages and disadvantages of transverse incisions
Advantages:
best cosmetic results
less painful
less interference with postoperative respirations
greater strengtha
Disadvantages:
more time-consuming
more haemorrhagic
compromised ability to explore upper abdominal cavity
division of multiple layers of fascia and muscle and nerves, may
result in potential spaces with haematoma or seroma
Advantages and disadvantages of vertical incisions
Advantages:
excellent exposure
easily extendable
median incision is least haemorrhagic
minimum nerve damage
rapid entry into abdomen and pelvis with median incision
Disadvantages:
wound dehiscence and hernia may be more frequent5
poorer cosmetic results
higher infection rates, haemorrhage and operative time with
paramedian incision
Principles of suturing skin incisions
The primary function of suture is to maintain tissue approximation
during healing
Debridement of skin edges should be done if necessary
Avoidance of direct tissue trauma helps ensure best outcomes
Clean passage of the needle following the arc is imperative
Skin sutures that blanch the underlying skin are too tight
Skin edges must just touch each other
Conclusion
As scientific evidence accumulates to refute traditional
dogma, surgical techniques have undergone significant
changes. Surgeons should now be able to create and close
abdominal wounds based on scientific evidence rather than
on the dictum of ‘Do what I always do’.