Prevention of Hernia in Long Midline Abdominal Incisions: An Opinion Paper

Background: Laboratory and clinical data have shown that small (0.5-1.0 cm) bites of a running suture closely spaced (0.5 cm) and only through midline fascia results in the lowest incidence of incisional hernia. Methods: Laboratory and clinical manuscripts were used to formulate a goal for optimal closure of a long midline abdominal incision. Using these conclusions as a starting point, surgical technology to achieve an optimal wound closure was formulated. Results: A fixed retractor must be placed prior to performing an abdominal incision. Skin traction sutures elevate the skin and subcutaneous tissue to make a fascial incision directly through the linea alba. Peritoneum and preperitoneal fat beneath the posterior rectus sheath are resected. Separations of the anterior and posterior rectus sheath are repaired prior to fascial closure. A running suture of closely spaced small bites is used to bring the fascial edges together. Maintaining fascial exposure with the skin traction sutures facilitates accurate placement of fascia only sutures. Conclusions: Revised surgical techniques for opening and closing a long midline abdominal incision will minimize the incidence of incisional hernia.