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

Baseline demographic and clinical characteristics were comparable between the two groups. There were no significant differences with regard to age, BMI, or gender distribution. Also, diabetes mellitus, hypertension, obesity, and current smoking were comparable in prevalence.

The baseline clinical profile was similar in both groups, as none of the complaints, including abdominal pain, vomiting, abdominal distension, and fever, showed significant intergroup differences. (Table 1)

The operative characteristics and intraoperative findings were also comparable between the groups. The indications for laparotomy did not differ significantly and included intestinal obstruction, gastrointestinal perforation, abdominal trauma, and other surgical emergencies. Similarly, the degree of intra-abdominal contamination and mean duration of surgery were comparable.

The most commonly used primary fascial suture material in both groups was polypropylene, and no statistically significant difference was found in the type of suture used. According to the study design, the only difference between the groups was that primary closure was performed in Group A, while primary closure with retention sutures was performed in Group B (Table 2).

In the present study, post-operative surgical site infection, incisional hernia, and wound dehiscence were found to be less common in Group B than in Group A. There was also a numerical reduction in the re-operation rates and post-operative mortality in Group B, while hospital stay was similar between groups. (Table 3)

A greater unadjusted likelihood of surgical site infection, incisional hernia, and wound dehiscence was found in patients who underwent primary fascial closure alone when compared to the comparative risk analysis. Differences in reoperation and mortality were less conclusive. (Table 4)

Table 1. Comparison of demographic, clinical, and preoperative characteristics

between the two groups (n = 250)

Table 2. Comparison of operative characteristics and intraoperative findings

Table 3. Comparison of postoperative surgical site infection, incisional hernia, and

other clinical outcomes

Table 4. Comparative relative risk of postoperative complications between the two groups

The present study was a comparison of the outcomes of primary fascial closure versus primary fascial closure with retention sutures after emergency laparotomy for midline incision. The surgical site infection rate (9.6% vs. 18.4%) and incisional hernia rate (6.4% vs. 15.2%) were lower in the retention suture group compared to the surgery without sutures in the present 250-patient cohort, as was the wound dehiscence rate (4.0% vs. 12.0%). These results indicate that an extra fascial reinforcement might be beneficial in abdominal surgery performed as an emergency. The results of this study must, however, be interpreted with caution, as there are several factors that might have influenced the surgical results, including closure technique, intra-abdominal contamination, underlying comorbidities, and postoperative wound care.

The lower incidence of surgical site infection in the retention suture group was similar to a study published by the Journal of Dow University of Health Sciences in 2025, which investigated surgical site infection in 242 patients undergoing emergency midline laparotomy with prophylactic retention sutures. The investigators found surgical site infection in 12.0% and wound dehiscence in 5.4% of the patients. The present study frequencies of 9.6% and 4.0%, respectively, were relatively close to these rates. Diabetes mellitus and smoking were also found to be important factors that were associated with postoperative wound complications. However, they did not have a traditional closure control group, and conclusions drawn from the two groups would be limited with regard to the effectiveness of the retention sutures.[12]

In 2026, Akshita et al. carried out a comparative study of 94 patients undergoing emergency exploratory laparotomy, in which the closure technique was further demonstrated and proven to be more important in short-stitch and long-stitch fascial closure methods. The surgical site infection rate was 10.6% for the short-stitch group and 27.7% for the long-stitch group (p=0.036), and the wound dehiscence rate was 12.8% for the short-stitch group and 36.2% for the long-stitch group (p=0.016). These findings confirmed the benefits of optimizing the approximation of

the fascia and distribution of tension. The short-stitch closure is not technically a retention closure, but both investigations point to the role of mechanical factors in postoperative wound healing.[13]

Similarly, a randomized controlled trial published in the Journal of the College of Physicians and Surgeons Pakistan in 2026 compared continuous and interrupted fascial closure among 80 patients undergoing exploratory laparotomy. The rate of wound infection was 30% overall, and interrupted suturing was associated with decreased wound dehiscence and shorter length of hospital stay. These findings suggest that there might be a relationship between the suture configuration and early postoperative results. The trial did not, however, specifically assess the use of supplementary retention sutures and, thus, their results should not be regarded as direct evidence for the benefit of retention suturing versus conventional primary closure.[14]

This decrease in wound dehiscence was also in the same direction as a 2026 randomized controlled trial of 132 emergency laparotomy patients that compared modified Smead-Jones closure with conventional continuous closure. There was less wound dehiscence in patients with modified Smead-Jones closure (7.5%) than in those with conventional closure (21.2%) (p=0.04). The investigators also found a reduced incidence of surgical site infection and incisional hernia using the modified technique. The results indicate that possibly other configurations of fascial closure, such as reinforced or alternative methods, may provide better postoperative results but may not be considered the same as standard retention suturing.[15]

In a 2025 systematic review and meta-analysis, Hindawi et al. studied the association between fascial closure technique and incisional hernia. The authors reported a lower risk of wound infection with modified Smead-Jones closure (RR=0.41; 95% CI: 0.26-0.65), while incisional hernia showed no significant difference (RR=0.78; 95% CI: 0.03-22.12). These results partially support the direction of the results on wound infection, but highlight that evidence for incisional hernia prevention is not clear. The results are inconsistent, which may be due to differences in the technique used for sutures and the different follow-up periods, as well as the low number of events related to the hernia.[16]

In 2025, a complete meta-analysis by van den Berg et al. covered 41 randomized controlled trials and 9 prospective cohort studies of the various fascial closure techniques. The investigators observed that the small bites closure group had a 56% lower risk for incisional hernia (OR=0.44; 95% CI: 0.30-0.65) and a 30% lower risk for surgical site infection (OR=0.70; 95% CI: 0.53-0.91) than the large bites closure group. They also found some potentially positive results for retaining sutures in emergencies, but they noted that this evidence was sparse. The findings confirm that surgical technique is crucial in the prevention of initial wound complications and delayed abdominal wall failure and suggest that further high-quality trials to specifically test retention sutures are required.[10]

In contrast, a prospective cohort study published in the Journal of Dow University of Health Sciences in 2026 analyzed 312 patients who underwent emergency midline laparotomy and compared continuous and interrupted closure. The continuous closure group (54.5%) and interrupted closure group (49.4%) had similar rates of surgical site infection (p=0.365). The cases of wound dehiscence (abdomen bursting) were 50.6% and 41.7%, respectively (p=0.112). There were no statistically significant differences in the rate of both complications when comparing interrupted and non-interrupted closure. This finding is in contrast to the greater variation in results and indicates that the changes in the closure technique do not always yield statistically significant improvement in all emergency surgical patients.[17]

Deerenberg et al. highlighted the larger role of incisional hernia prevention in the 2022 guidelines from the European and American Hernia Societies. The authors reviewed 39 publications and recommended continuous small-bite closure with slowly absorbable sutures for elective midline laparotomy. They emphasized the role of wound infection, obesity, smoking, diabetes, and surgery in the healing of the abdominal wall. The recommendations emphasize careful approximation of the fascia but cannot be directly transferred to the use of retention sutures in emergency laparotomy, as there was limited evidence for this procedure.[5]

In addition, the European Hernia Society guidelines on midline incisional hernia, published by the Sanders group in 2023, highlighted the clinical impact of incisional hernia and the need for standardization in its assessment, patient risk factors, and surgical management. Their recommendations provide context for interpreting the incisional hernia frequencies. But the incisional hernia can happen or become evident many years after the primary laparotomy, and proper follow-up is critical. Therefore, if the incidence of a hernia is reduced, this has to be evaluated based on the period of time and extent of postoperative surveillance.[18]

The major disadvantage of the proposed study would be the single, center-based, observational nature of the study and the fact that the choice of whether to use a retention suture or not was random but was left to the surgeon who was operating. The patients under retention sutures may have had a systematic difference in baseline risk, degree of contamination, nutritional status, and tissue quality. These differences may create confounding by indication. Other restrictions would be lack of follow-up after surgery, differences in surgical approach, and the potential for unrecognized asymptomatic incisional hernias. In order to conclude whether differences in outcomes are due to the closure technique itself, an adjustment for multiple variables and a standardized postoperative assessment would be important.

The literature highlights the role of fascial closure technique in wound integrity after surgery, with limited evidence at this time to support routine use of retention sutures in emergency laparotomy midline closure. The results suggest a protective trend with the use of more retention sutures regarding incisional hernia, wound dehiscence, and surgical site infection. However, these results are only representative and not definitive. A definitive interpretation would require analysis of the actual patient cohort, adjustment for relevant confounding factors, and sufficiently long follow-up to assess incisional hernia.

The results indicated that primary fascial closure with retention sutures appeared to have fewer surgical site infections, incisional hernias, and wound dehiscence compared to conventional primary closure of the fascial layer after emergency midline laparotomy. Other retention sutures can be used to support the abdominal wall, especially in patients who may have a risk for postoperative abdominal wall complications.

Patel, P.S., Study of Indication, Clinical Presentation and Outcome of Patients Undergoing Laparotomy. International Journal of Medical and Pharmaceutical Research, 2026. 7: p. 2312-2318.

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