Br. J. Surg. Vol. 66 (1979) 278
Abdominal wound closure-the Jenkins’s technique: a registrar’s experience A . LOVE* SUMMARY
Technique
Jenkins’s technique has been used to close 238 abdominal wounds. No dehiscence occurred in this series. It is suggested that this method, which gives strict guidelines on wound closure, is ideal for teaching good technique for wound closure.
The incisions were closed with continuous loop nylon (metric 3.5 Ethilon) o n a 40-mm round-bodied half-circle needle (Ethicon W 740) using suture length to wound length ratios of greater than 4 : 1 and large tissue bites of greater than 1 cm. The wounds were closed in layers whenever possible. Mass closure was used if the layers were obliterated o r if adequate layered bites could not be obtained. Midline incisions were closed in one layer, paramedian incisions were closed in two layers and transverse o r oblique incisions were closed in the layers present at the particular site. The peritoneum was closed separately only if this facilitated the muscle closure by reducing the viscera, otherwise it was included with the deepest muscle layer. The nylon suture was tied with a triple-layer surgeon’s knot and the ends cut flush with the knot to leave no tails.
IN1976Jenkins stated that the burst abdominal wound has a mechanical cause, being the result of suture breaking, knot slipping, the intact suture cutting out of the tissues or protrusion of gut or omentum between the sutures (Jenkins, 1976). These factors were considered to be due to the wound lengthening by as much as 30 per cent if distension occurred. It was suggested that wound disruption can be avoided by using a suture length four times as long as the wound, and by placing non-absorbable sutures at 1-cm intervals and more than 1 cm from the wound edge. To test this hypothesis a prospective study was made of 238 consecutive wound closures in 219 patients. These wound closures were performed by the author, or by another member of the junior staff under supervision, between May 1976 and April 1978. The nature of the operations and the incisions used are shown in Tables I and II. Table I: ANALYSIS OF 238 ABDOMINAL WOUNDS IN 219 PATIENTS ACCORDING TO T H E NATURE OF T H E OPERATIVE PROCEDURE* Nature of ooeration No. Ileum, colon and rectum Biliary and pancreas Upper GI tract Kidney and ureter Arterial Laparotomy only Trauma Bladder Appendix Other
70 60 29 12 10 6
5 4 3 39
* If more than one system was operated upon, the major operation is listed. Table 11: ANALYSIS OF 238 ABDOMINAL WOUNDS I N 219 PATIENTS ACCORDING TO T H E TYPE OF INCISION TvDe of incision No. Transverse 50 Upper paramedian 49 Upper midline 30 Lower paramedian 28 Paramedian 26 Midline 15 Lower midline 14 ‘Kocher’ (left o r right) 13 Oblique 8 5 Pfannenstiel
Results All wounds were reviewed at 6 weeks. No wound dehisced during the period of the study, and at 6 weeks there was no evidence of an incisional hernia. None of the 38 patients who died (17.4 per cent) showed a primary wound failure. Discussion To gain acceptance any new surgical technique must provide good results in the hands of others. Such techniques should be uncomplicated, easily learned and, if possible, universally applicable without special equipment. The ability to close abdominal wounds is a prerequisite for all surgeons in training before other procedures can be undertaken. Surprisingly, few guidelines are given to the trainee, and these cannot be accurately defined. The technique under consideration has the great merit of providing accurate measurements, which can guide the novice. This study confirms the results reported by Jenkins (1977) and shows that the technique can be learnt by the trainee, with good initial results. It would seem that this study supports the hypothesis that bursting of the abdominal wound has a mechanical cause; furthermore, dehiscence can be prevented by overcoming this mechanical cause of wound failure. Acknowledgements I wish to acknowledge the invaluable assistance given to me by Mr R. G. Notley in drafting this paper.
References (1976) The burst abdominal wound: a mechanical approach. Br. J. Surg. 63, 873-876. JENKINS T. P. N. (1977) Burst abdomen-a preventable condition? Br. Med. J. 1, 171-772.
JENKINS T. P. N.
Paper accepted 24 October 1978.
* Surgical Registrar, St Luke’s Hospital and Royal Surrey County Hospital, Guildford. Correspondence to: Princess Alexandra Hospital, Brisbane, Australia.
Abdominal wound closure-the Jenkins’s technique: a registrar’s experience A . LOVE* SUMMARY
Technique
Jenkins’s technique has been used to close 238 abdominal wounds. No dehiscence occurred in this series. It is suggested that this method, which gives strict guidelines on wound closure, is ideal for teaching good technique for wound closure.
The incisions were closed with continuous loop nylon (metric 3.5 Ethilon) o n a 40-mm round-bodied half-circle needle (Ethicon W 740) using suture length to wound length ratios of greater than 4 : 1 and large tissue bites of greater than 1 cm. The wounds were closed in layers whenever possible. Mass closure was used if the layers were obliterated o r if adequate layered bites could not be obtained. Midline incisions were closed in one layer, paramedian incisions were closed in two layers and transverse o r oblique incisions were closed in the layers present at the particular site. The peritoneum was closed separately only if this facilitated the muscle closure by reducing the viscera, otherwise it was included with the deepest muscle layer. The nylon suture was tied with a triple-layer surgeon’s knot and the ends cut flush with the knot to leave no tails.
IN1976Jenkins stated that the burst abdominal wound has a mechanical cause, being the result of suture breaking, knot slipping, the intact suture cutting out of the tissues or protrusion of gut or omentum between the sutures (Jenkins, 1976). These factors were considered to be due to the wound lengthening by as much as 30 per cent if distension occurred. It was suggested that wound disruption can be avoided by using a suture length four times as long as the wound, and by placing non-absorbable sutures at 1-cm intervals and more than 1 cm from the wound edge. To test this hypothesis a prospective study was made of 238 consecutive wound closures in 219 patients. These wound closures were performed by the author, or by another member of the junior staff under supervision, between May 1976 and April 1978. The nature of the operations and the incisions used are shown in Tables I and II. Table I: ANALYSIS OF 238 ABDOMINAL WOUNDS IN 219 PATIENTS ACCORDING TO T H E NATURE OF T H E OPERATIVE PROCEDURE* Nature of ooeration No. Ileum, colon and rectum Biliary and pancreas Upper GI tract Kidney and ureter Arterial Laparotomy only Trauma Bladder Appendix Other
70 60 29 12 10 6
5 4 3 39
* If more than one system was operated upon, the major operation is listed. Table 11: ANALYSIS OF 238 ABDOMINAL WOUNDS I N 219 PATIENTS ACCORDING TO T H E TYPE OF INCISION TvDe of incision No. Transverse 50 Upper paramedian 49 Upper midline 30 Lower paramedian 28 Paramedian 26 Midline 15 Lower midline 14 ‘Kocher’ (left o r right) 13 Oblique 8 5 Pfannenstiel
Results All wounds were reviewed at 6 weeks. No wound dehisced during the period of the study, and at 6 weeks there was no evidence of an incisional hernia. None of the 38 patients who died (17.4 per cent) showed a primary wound failure. Discussion To gain acceptance any new surgical technique must provide good results in the hands of others. Such techniques should be uncomplicated, easily learned and, if possible, universally applicable without special equipment. The ability to close abdominal wounds is a prerequisite for all surgeons in training before other procedures can be undertaken. Surprisingly, few guidelines are given to the trainee, and these cannot be accurately defined. The technique under consideration has the great merit of providing accurate measurements, which can guide the novice. This study confirms the results reported by Jenkins (1977) and shows that the technique can be learnt by the trainee, with good initial results. It would seem that this study supports the hypothesis that bursting of the abdominal wound has a mechanical cause; furthermore, dehiscence can be prevented by overcoming this mechanical cause of wound failure. Acknowledgements I wish to acknowledge the invaluable assistance given to me by Mr R. G. Notley in drafting this paper.
References (1976) The burst abdominal wound: a mechanical approach. Br. J. Surg. 63, 873-876. JENKINS T. P. N. (1977) Burst abdomen-a preventable condition? Br. Med. J. 1, 171-772.
JENKINS T. P. N.
Paper accepted 24 October 1978.
* Surgical Registrar, St Luke’s Hospital and Royal Surrey County Hospital, Guildford. Correspondence to: Princess Alexandra Hospital, Brisbane, Australia.
