A Comparison of Continuous vs. Interrupted Mass Closure of Midline Incisions in Patients with Gynecologic Cancer

Abstract & Commentary

Synopsis: In a randomized comparison, interrupted closure of midline incisions in patients with gynecologic cancer was not superior to the continuous closure for short- and long-term wound security.

Source: Colombo M, et al. Obstet Gynecol 1997;89: 684-689.

Colombo and colleagues randomly compared continuous and interrupted mass closures in 632 patients with gynecologic cancer. The purpose of the study was to address the incidence of deep wound dehiscence and incisional hernia formation after vertical midline laparotomy. Both methods were performed with absorbable material. Of the 614 subjects who were evaluable, 308 underwent a continuous, nonlocking closure with looped polyglyconate suture, and 306 were closed with interrupted polyglycolic acid according to the Smead-Jones technique. Three (1%) patients with the continuous closure and five (1.6%) with the interrupted closure had an abdominal wound infection. One patient whose incision was closed with continuous suturing had a deep wound dehiscence (without evisceration). The follow-up period was six months to three years. No patient had evidence of chronic sinus drainage. Thirty-two (10.4%) of the patients who had the continuous closure and 45 (14.7%) of those who were closed with the interrupted method had evidence of incisional hernia. No hernia developed in any patient with a wound infection. Four (1.3%) hernias after the continuous closure and eight (2.6%) after the interrupted closure required surgical repair because of patient discomfort. Colombo et al conclude that the interrupted closure was not superior to the continous closure for short- and long-term wound security. The continuous method was preferable because it was more cost-efficient and faster.

COMMENT BY DAVID M. GERSHENSON, MD

This study is provocative, but it does not definitively answer the question regarding the optimal wound closure for patients with gynecologic cancer. In this study, the follow-up period was long compared with other similar reports. Only one patient closed with the interrupted method experienced a wound dehiscence. The rates of ventral hernia formation and wound infection did not differ between the two groups. As Colombo et al point out, however, the findings could be the result of a Type II error. To definitively resolve this issue, a study involving almost 1800 patients would be required. Other authors have conducted similar trials that failed to reveal a difference between the continuous and the interrupted methods of wound closure. The ultimate potential outcome in these studies is admirable and in keeping with current outcomes research to maintain or improve quality, while reducing cost or increasing efficiency. Obviously, for busy surgical suites, more rapid closure reduces operating time and allows more cases to be performed. As a gynecologic oncologist operating on patients who may have had multiple surgeries, chemotherapy, or radiation therapy, I have been hesitant to abandon the traditional Smead-Jones wound closure for my patients. But, over the past few years, I have been gently coaxed by my gynecologic oncology fellows to adopt the continuous method of mass closure. Although studies such as this one are not definitive, they do cause me to re-examine my method of wound closure. Of course, the other major issue in this area is the ideal type of suture to employ. Further trials such as this one will hopefully resolve that issue also.