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Physiologic tension of the abdominal wall

  • 2023 SAGES Oral
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Tension-free abdominal closure is a primary tenet of laparotomy. But this concept neglects the baseline tension of the abdominal wall. Ideally, abdominal closure should be tailored to restore native physiologic tension. We sought to quantify the tension needed to re-establish the linea alba in patients undergoing exploratory laparotomy.

Methods

Patients without ventral hernias undergoing laparotomy at a single institution were enrolled from December 2021 to September 2022. Patients who had undergone prior laparotomy were included. Exclusion criteria included prior incisional hernia repair, presence of an ostomy, large-volume ascites, and large intra-abdominal tumors. After laparotomy, a sterilizable tensiometer measured the quantitative tension needed to bring the fascial edge to the midline. Outcomes included the force needed to bring the fascial edge to the midline and the association of BMI, incision length, and prior lateral incisions on abdominal wall tension.

Results

This study included 86 patients, for a total of 172 measurements (right and left for each patient). Median patient BMI was 26.4 kg/m2 (IQR 22.9;31.5), and median incision length was 17.0 cm (IQR 14;20). Mean tension needed to bring the myofascial edge to the midline was 0.97 lbs. (SD 1.03). Mixed-effect multivariable regression modeling found that increasing BMI and greater incision length were associated with higher abdominal wall tension (coefficient 0.04, 95% CI [0.01,0.07]; p = 0.004, coefficient 0.04, 95% CI [0.01,0.07]; p = 0.006, respectively).

Conclusion

In patients undergoing laparotomy, the tension needed to re-establish the linea alba is approximately 1.94 lbs. A quantitative understanding of baseline abdominal wall tension may help surgeons tailor abdominal closure in complex scenarios, including ventral hernia repairs and open or burst abdomens.

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Acknowledgements

Thank you to Sebastian Bakalarczyk of the CCF Mechanical Prototype Department for designing, manufacturing, and assembling the tensiometers.

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Authors and Affiliations

  1. Center for Abdominal Core Health, Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A10-429, Cleveland, OH, 44195, USA

    Benjamin T. Miller, Ryan C. Ellis & Michael J. Rosen

  2. Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

    R. Matthew Walsh, Daniel Joyce & Robert Simon

  3. Center for Urologic Cancer, Glickman Urological & Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

    Nima Almassi, Byron Lee & Samuel Haywood

  4. Department of Gynecologic Oncology, Ob/Gyn & Women’s Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

    Robert DeBernardo & Lindsey Beffa

  5. Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

    Scott Steele

  6. Department of Statistics, Cleveland Clinic Foundation, Cleveland, OH, USA

    Chao Tu

Authors
  1. Benjamin T. Miller
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  2. Ryan C. Ellis
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  3. R. Matthew Walsh
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  6. Nima Almassi
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  7. Byron Lee
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  8. Robert DeBernardo
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  9. Scott Steele
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  10. Samuel Haywood
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  11. Lindsey Beffa
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  12. Chao Tu
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  13. Michael J. Rosen
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Corresponding author

Correspondence to Benjamin T. Miller.

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Disclosures

Michael J. Rosen receives salary support as medical director of the Abdominal Core Health Quality Collaborative and is a board member of Ariste Medical with stock options. Chao Tu, Benjamin T. Miller, Ryan C. Ellis, R. Matthew Walsh, Robert Simon, Daniel Joyce, Nima Almassi, Byron Lee, Samuel Haywood, Robert DeBernardo, Lindsey Beffa, and Scott R. Steele have no conflicts of interest or financial ties to disclose.

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Miller, B.T., Ellis, R.C., Walsh, R.M. et al. Physiologic tension of the abdominal wall. Surg Endosc 37, 9347–9350 (2023). https://doi.org/10.1007/s00464-023-10346-w

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  • DOI: https://doi.org/10.1007/s00464-023-10346-w

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