Continuous Mass Versus Layered Fascial Closure in Contaminated Emergency Midline Laparotomies: A Prospective Observational Cohort Study.

backgroundEmergency midline laparotomy in a contaminated field carries a high risk of acute fascial dehiscence (burst abdomen) and of late incisional hernia. Recommendations for abdominal wall closure derive largely from elective surgery, and the optimal anatomical closure technique in the emergency contaminated setting remains undefined. This study compared continuous mass closure with continuous layered closure in this population. MATERIALS AND

methodsWe conducted a hospital-based prospective observational cohort study of 340 consecutive adults undergoing emergency midline laparotomy for contaminated intra-abdominal pathology. Patients were allocated to continuous mass closure (n = 172) or continuous layered closure (n = 168) according to the surgical unit to which they were admitted, each unit practicing one technique as its routine. All closures used 2-0 polydioxanone monofilament suture with a suture length to wound length ratio of at least 4:1. The primary outcome was burst abdomen within 30 days. Secondary outcomes were superficial and deep surgical site infection (SSI) and seroma at 30 days, incisional hernia at six, 12, and 24 months, and operative and fascial closure times. Groups were compared using the independent samples t-test or Mann-Whitney U test, the chi-square or Fisher's exact test, multivariable logistic regression, Kaplan-Meier estimation with the log-rank test, and Cox proportional hazards regression.

resultsBaseline characteristics did not differ between groups. Burst abdomen occurred in 10 of 168 layered closure patients (6.0%) and nine of 172 mass closure patients (5.2%), a difference that was not statistically significant (relative risk 1.14, 95% CI 0.47-2.73; p = 0.958); the study had low power for this endpoint at the observed event rate. Seroma was less frequent after mass closure (14/172, 8.1% vs 27/168, 16.1%; p = 0.038). Mass closure was associated with a shorter total operative time (75.77 ± 12.27 vs 95.33 ± 15.92 minutes; p < 0.001) and a shorter fascial closure time (14.80 ± 3.81 vs 24.77 ± 5.29 minutes; p < 0.001). Cumulative incisional hernia at 24 months was 16/172 (9.3%) after mass closure and 28/168 (16.7%) after layered closure. Hernia-free survival differed between groups on log-rank testing (chi-square = 4.235; p = 0.040), and layered closure remained associated with hernia development after adjustment (adjusted hazard ratio 1.860, 95% CI 1.003-3.447; p = 0.049).

conclusionsIn this cohort, continuous mass closure was associated with fewer seromas, shorter operative and closure times, and longer hernia-free survival over 24 months than layered closure, with no difference detected in burst abdomen at 30 days. Because allocation was determined by admitting unit rather than by randomization, these findings describe association rather than causation and require confirmation in a randomized trial.