Emergency midline laparotomy is one of the more common major surgical procedures performed for life-threatening intra-abdominal diseases such as intestinal obstruction, gastrointestinal perforation, peritonitis, abdominal trauma, and intra-abdominal sepsis.[1]

 

Although surgical techniques, perioperative care, and infection control have improved, postoperative wound complications continue to be a major worry, especially after emergency surgery.[2] The most important complications include surgical site infection (SSI) and incisional hernia, which increase hospital stay, healthcare expenditure, reoperation rates, and the incidence of poor functional outcomes.[3] The patients undergoing emergency laparotomy are at a very special risk due to the presence of underlying infection, contamination of the tissues, poor nutritional condition, hemodynamic instability, and late presentation.[4]

 

Thus, precise closure of the abdominal wall is crucial to reduce the postoperative morbidity and maintain abdominal wall integrity for a longer period of time.[5]

The incidence of abdominal wall complications after surgery is still significant. One meta-analysis including over 14,000 patients found that incisional hernia occurred 12.8% of the time in the first two years after performing midline laparotomy, and about one-third of these patients needed surgery to repair the hernia.[5]

 

In addition, the European Hernia Society guidelines found that incisional hernia occurred in 19.4% of patients with postoperative SSI and 6.9% of patients without SSI, reflecting a close link between wound infection and subsequent fascial failure.[6] The results highlight the need to use an appropriate fascial closure method that will minimize both early infectious and late structural complications.[6]

 

There are two methods of closing the abdominal wall after emergency laparotomy: primary fascial closure and retention sutures.[7] The conventional primary fascial closure technique restores abdominal wall integrity by directly opposing the edges of the fascial layer, typically with continuous or interrupted sutures, to minimize tissue trauma.[8] Retention sutures, on the other hand, give extra mechanical reinforcement to the abdominal wall and have been traditionally used in patients at high risk of wound dehiscence.[9] 

 

Primary fascial closure, by contrast, does not involve extending through additional tissues but may be limited by increased intra-abdominal pressure, poor tissue quality, and impaired wound healing. International guidelines focus on careful closure of the fascia, but evidence for the best closure technique in emergency laparotomy patients is scarce.[10]

 

Retention sutures or primary fascial closure is a significant clinical choice to make, especially in the busy Emergency Department setting where laparotomy is a common procedure in patients who present late, with intra-abdominal contamination, and with numerous risk factors for wound healing. While these techniques have been in use in surgical practice, questions remain about the relative efficacy of these procedures on surgical site infection and incisional hernia, and further studies are warranted.

 

Furthermore, institution-specific evidence is crucial as patient factors, indications for surgery, surgical technique, and post-operative management may affect outcomes. The current study compares the rates of surgical site infections and incisional hernias between patients who have undergone primary fascial closure versus retention suture closure after emergency midline laparotomy at Abbottabad International Medical College and Teaching Hospital, Abbottabad, Pakistan.

 

The results could serve as clinically relevant evidence for fascial closure decision-making, optimize postoperative results, and contribute to more secure surgical practice in emergency abdominal surgery.

 

The study was conducted as a prospective comparative observational study at Abbottabad International Medical College and Teaching Hospital, Abbottabad, Pakistan, in the Department of General Surgery. This study was carried out for one year from 1st June, 2025 to 31st May, 2026. The sample size was computed according to the Fleiss formula for two independent proportions, based on a previous study that reported 13.3% of patients undergoing conventional fascial closure while 4.0% of those who received additional retention sutures developed postoperative wound dehiscence.[11] Considering a 90% confidence level, 80% statistical power, 10% level of significance, and a 1:1 allocation ratio, the minimum required sample size was calculated as 250 patients, comprising 125 patients in each group. A non-probability consecutive sampling technique was employed. The study was conducted in the Department of General Surgery, where all eligible patients who were seen were considered for inclusion until the necessary sample size was reached. Two groups with reference to the abdominal fascial closure technique were identified based on the type of technique used. Group A consisted of patients who were treated with primary fascial closure without the use of retention sutures; Group B consisted of patients in whom primary fascial closure was complemented with retention suturing. The study included patients aged 18 years and older of either gender who had undergone midline laparotomy for an acute abdomen including intestinal obstruction, gastrointestinal perforation, peritonitis, abdominal trauma, and other surgical emergencies. Patients were included if they were treated with either primary fascial closure alone or primary closure with retention sutures during the index surgery to achieve definitive fascial closure. Patients with complete perioperative records and with the potential for postoperative follow-up were included. The patients who received elective laparotomy and those under 18 years of age were excluded, as were patients with an incisional hernia at the operative site. Patients undergoing laparoscopic procedures, transverse or paramedian abdominal incisions, open abdomen management, temporary abdominal closure, or abdominal wall reconstruction with prosthetic mesh were also excluded. Patients who had an abdominal wall defect that had to be reconstructed with complex techniques and patients in whom the fascia of the abdominal wall could not be closed during the initial surgery were excluded from the study. After approval of the institutional ethical review committee, patients who were eligible for emergency midline laparotomy were enrolled, and informed consent was obtained from the patients or legally authorized representatives as appropriate. A structured data collection proforma was used to record demographic and clinical data such as age, gender, body mass index, presenting complaints, indication for laparotomy, comorbidities, smoking status, and relevant perioperative risk factors. Operative information collected included indication for surgery, level of intra-abdominal contamination, length of surgery, suture material, and method of closure. Patients were divided into two groups based on the fascial closure technique employed. In group A, the abdominal fascia was closed with conventional primary closure without any securing sutures. In Group B, the abdominal wall was additionally reinforced by the retention sutures at the site of conventional closure of the fascia. The operating surgeon chose the closure technique based on clinical judgment and findings during surgery. The postoperative care of all patients was conducted as per institutional protocol, including proper antibiotic therapy, wound management, postoperative pain management, and surveillance for postoperative complications. Hospitalization and follow-up visits were used to assess surgical wounds for SSI; signs of purulent discharge, localized erythema, swelling, tenderness, and wound breakdown were evaluated. Surgical site infection was evaluated in the 30 days following surgery, based on a set of clinical criteria that align with Centers for Disease Control and Prevention definitions. Incisional hernia was considered as a clinically obvious abdominal wall defect or abdominal wall defect or protrusion at the site of previous laparotomy, which was detected during physical examination and confirmed by ultrasonography if clinically indicated. Patients were evaluated at their routine follow-up appointments, and the presence of surgical site infection and incisional hernia was noted for both groups. All collected information was entered into a standardized proforma while maintaining patient confidentiality. The data collected were entered and analyzed with the software IBM SPSS Statistics version 26.0. Quantitative variables like age, body mass index, length of surgery, and length of hospital stay were reported as mean and standard deviation for normally distributed variables and as median and interquartile range for non-normally distributed variables. Qualitative variables were presented as frequencies and percentages, such as gender, comorbidities, and/or surgical indications, surgical site infection, and incisional hernia. Chi-square test and Fisher's exact test were used to compare the frequencies of surgical site infection and incisional hernia between the two groups. Continuous variables were compared by the independent-samples t-test. Relative risks with 95% confidence intervals were calculated to estimate the association between closure technique and postoperative outcomes. A p-value of less than 0.05 was considered statistically significant