Interrupted X-Suture Prevents Burst Abdomen: Analysis of 5 Randomised Controlled Trials from India

Abstract

Burst abdomen is a grave complication of laparotomy. X-suturing has been developed as a new method for reducing risk of burst abdomen. Five randomised controlled trials were conducted comparing X-suture with continuous suture in patients undergoing emergency laparotomy. The analysis of pooled data is presented. Data from five randomised controlled trials were collated. Data on individual patients were obtained from each centre on an Excel database format. A total of 1005 patients undergoing emergency laparotomy were studied. Of these 494 patients were randomised to X-suture arm and 511 to the continuous suture arm. The occurrence of burst abdomen was the main outcome of interest and the suture technique the main predictor of burst. The continuous suture group was considered the reference category. Risk ratio, risk difference, attributable proportion in exposed and prevented fraction in the exposed were calculated. Burst abdomen occurred in 9.31% patients in the X-suture group and in 20.35% patients in the continuous suture group. The risk difference (11%) and relative risk = 0.45 were highly significant (p = 0.0001) with a prevented fraction = 54%. Presence of diabetes, intraperitoneal sepsis, uraemia, and raised serum bilirubin were associated with increased risk of burst abdomen. The risk of burst abdomen can be substantially reduced with the use of X-suture in patients undergoing emergency laparotomy.

Appendix 1: Suturing Technique

The technique of “X”-suturing is described in detail by Srivastava et al. [2] in Indian Journal of Surgery and in the book “Recent Advances in Surgery” edited by Dr Roshan Lall Gupta Number 11 [3].

The first bite is started at 2 cm from cut edge of linea alba with needle entering at point “1” (see Fig. 1). The needle emerges at point “2”on opposite side of wound 4 cm cranially or caudally at 2 cm from edge. Two ends of suture strands are crossed and needle enters at point “3” on a diagonally opposite direction 4 cm away from previous bite and 2 cm from edge. The needle emerges at point “4” diagonal to point “3”. A “right angle” forceps is passed behind the “X” on back of linea alba and two ends of suture are fastened with two double throws alternating with two single throws. The smaller end of suture is next pulled by the “right angle” forceps deep to the linea alba passing behind the “X” like cross of suture. Four more throws are fastened (alternating single and double throws) to complete a secure central reef knot. This central knot fixes the 4 limbs of “X” and acts like a pivot for free movement of four limbs of “X”. The suture ends are held with an artery forceps and suture cut at one centimeter from the knot. The free ends of suture are insinuated between edges of linea alba to prevent any sinus formation. The final result is a “two “X” configurations”—one on surface and other on deeper aspect of linea alba, hence the name “double X suture”. The next X-suture is placed at a distance of 1 cm from the previous one. Any gap between the sutures admitting a finger is reinforced with a simple interrupted suture to prevent any Richter’s hernia of bowel.