Ten Commandments of Safe and Optimum Abdominal Wall Closure
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We read with great interest the article by Chintamani et al., regarding the ten commandments of safe and optimum closure of abdominal wall . We would like to commend the author for choosing an appropriate title as it lays down once and for all the ten important rules of abdominal wall closure. We find these rules almost synonymous with the commandments that God gave to Moses in terms of validity and utility.
Taking into account that this is an area of considerable variation, one feels fortunate as a surgical resident to have an access to learning one correct way of doing it by reading this article. In mass closure of abdomen, only the rectus sheath is closed continuously (without locking), preferably using a non- or delayed-absorbable monofilament suture and following Jenkin’s law, as mentioned in the article.
This technique offers many advantages. In emergency, time is the key and the described method allows the fastest way to close abdomen. While making the incision, one cuts at linea alba, as rightly mentioned in the article. This is not only because linea alba is relatively avascular but it also permits the surgeon to explore both the sides of the abdomen with equal ease, although in infants or growing children transverse incisions are preferred.
The author has not only described step by step the correct technique of closing the abdomen but has also explained the physiological basis for the same. Also, it does not matter whether the abdomen is closed from above downwards or below upwards; however, most surgeons prefer to close from above downwards. There is no rule related to this aspect as if the surgeon is on the right side of the patient; it is only natural for one to close from above downwards. The first bite should be inside-out and then outside-in so that the knot is not protruding outwards and pocking the skin from beneath. The described optimal closure is easy to follow, time saving, and cost-effective.
The current focus should be on obtaining widespread adoption of the described commandments of safe and optimum abdominal wall closure for better patient outcome.
A recent study revealed that only 10% of the surgical residents know the correct suture-to-wound length ratio and only 40% are familiar with literature on the proper technique of abdominal closure . If the commandments are followed in spirit, each resident would be able to learn a standardized way of abdominal wall closure, that is easy to learn and teach thus preventing complications like wound dehiscence incisional hernias that continue to be a challenge.
Therefore, education regarding one correct way of doing safe and optimum abdominal wall closure needs to be re-inforced.
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Conflict of Interest
The authors declare that they have no conflict of interest.