Emergency exploratory laparotomy is associated with significant risk for morbidity and mortality. Often, these complications are related to fascial dehiscence and surgical site infections (SSIs).1–3 The presence of these factors can substantially increase risk for long-term complications, future incisional hernia, prolonged hospital stay, increased hospital costs, and mortality.4–6 In fact, it is reported that up to 500,000 laparotomy-induced incisional hernias are seen annually in the United States and produce a significant burden of costs and morbidity even decades after the index laparotomy.7

While most published data are from elective cases, not every laparotomy has the luxury of a nonurgent status and preoperative planning and optimization. Emergency laparotomy is a high-risk procedure that may be associated with a 10% to 15% rate of fascial dehiscence and SSIs, but some report these compilations occurring as high as 45% of the time.8 Thus, prevention of dehiscence and local infectious complications remains a topic of academic and clinical importance. Data from elective cases demonstrate the benefit of laparotomy closure using slowly absorbable monofilament suture in a continuous fashion with a 4:1 wound-length ratio.7,9–11 Initial data in nontrauma emergency laparotomy seem to support a similar strategy.8,12 However, the type of slowly absorbable monofilament suture may also have a significant impact, as triclosan-coated barbed (TCB) suture was recently evaluated for dehiscence and SSI prevention in emergency laparotomy patients.13 In this prospective, randomized multicenter trial, Ruiz-Tovar et al.13 found that TCB suture reduces the incidence of SSI and acute evisceration compared with standard fascial closure with triclosan-coated polydioxanone (PDS) looped suture and noncoated PDS looped suture in emergency nontrauma laparotomy.

Unfortunately, these reports have limitations, including the fact that they do not include trauma laparotomy, they have small sample sizes, and traumatic patient factors do not necessarily make the extrapolation across scenarios simple. In addition, most previous studies exclude patients with the presence of midline hernia, previous laparotomy, or previous dehiscence—all factors that may be present in trauma cases. In addition, traumatic laparotomy may be performed using a “damage-control” strategy that delays the final fascial closure. Damage-control scenarios are performed under less-than-ideal circumstances and may already be set up for less than stellar wound outcomes following closure, especially when as the timing to closure is prolonged.14 The benefit of TCB suture in prevention of SSI and dehiscence in emergency laparotomy warrants further investigation of TCB in midline laparotomy closure following both nontrauma and trauma scenarios.

The aim of this investigation is to compare the use of TCB suture with conventional nonbarbed, PDS suture in the closure of abdominal fascia in patients undergoing emergent laparotomy for trauma or emergent general surgery conditions on local wound complications including fascial dehiscence and SSIs. Based upon previous data,13 we hypothesize that rates of abdominal fascial dehiscence will be lower in laparotomies closed with TCB.

After undergoing local institutional review board approval, a prospectively collected observational study was performed on patients undergoing emergent laparotomy at an American College of Surgeons Level 1 trauma center over a 1-year period using the appropriate STROBE guidelines for observational studies (Supplemental Digital Content, Supplementary Data 1, https://links.lww.com/TA/D718). Inclusion criteria included adult patients undergoing emergent midline laparotomy for either trauma or emergency general surgery with primary fascial closure during the same hospital admission. Patients were excluded if they were younger than 18 years, had a history of immunocompromise (determined by the presence of a documented immunodeficiency or immunosuppressive medication present at time of hospital admission), presented with a known nosocomial infection, or were deceased or lost to follow-up during the first 30 days following the index laparotomy.

The type of suture used was determined by the surgeon of record. Before the study, four surgeons were known to prioritize TCB in fascial closures. However, throughout the course of the collection period, all surgeons had experience with both TCB and PDS fascial closures. While not specifically recorded, the standard practice among the included surgeons is to close the facial wounds by using continuous 0.5 cm by 0.5 cm fascial bites in a 4:1 wound-length ratio. The standard group practice for fascial closure is to use either two no. 1 looped PDS suture in running fashion or two no. 1 TCB sutures (Stratafix; Ethicon Inc., Cincinnati, Ohio) on a CT or CT-1 needle in running fashion. The PDS sutures are run from each end of the incision and tied at the midpoint using at least seven knots. The TCB sutures are run from each end of the incision and then run for an additional two to three bites to overlap each other and lock the suture without the need for any knot tying. Patients were evaluated based upon the type of suture used at the initial fascial closure, TCB versus PDS.

Incisional SSI's were defined according to the Centers for Disease Control criteria of the documented presence of at least one of the following features: purulent drainage, positive culture, pain, tenderness, redness, and swelling.15 Superficial SSI was defined as a documented infection of the skin where the incision was made. Deep SSI was defined as documented evidence of the local muscle and/or surrounding tissues beneath the incision. Organ space SSI was defined as a documented infection in an area of the body other than skin, muscle, and surrounding tissue that was involved in the surgery.

Fascial dehiscence was defined as any documented evidence of fascial separation seen on physical examination or imaging. Evisceration was defined as any evidence of intra-abdominal contents protruding through the fascial defect seen on local examination or imaging.

Extracted clinical variables included demographic data (age, sex, body mass index [BMI], comorbidities, preoperative diagnosis, mechanism of injury, and Injury Severity Score), procedural data (operative procedures performed, presence of associated injuries, blood product utilization, damage-control laparotomy, temporary abdominal closure, and timing of facial closure [if not performed during index laparotomy]), and postoperative occurrences (superficial SSI, deep SSI, organ site infection, dehiscence, evisceration, fascial necrosis, need for unplanned abdominal reoperation, acute kidney injury, acute respiratory distress syndrome, bacteremia, sepsis, myocardial infarction, presence of postoperative steroids, presence of postoperative negative pressure wound therapy, need for prolonged [>7 days] postoperative antibiotics, and length of stay).

The primary outcome was fascial dehiscence. Secondary outcomes were SSIs and evisceration.

Statistical analysis was performed SPSS version 29 (IBM Corp., Chicago, IL) with statistical significance set at p value of <0.05. Continuous variables were reported as the median (interquartile range), and categorical variables were reported as n (%). Univariate analysis compared the parameters between study groups using Mann-Whitney U test for continuous variables and Pearson χ2 or Fisher's exact test for categorical variables, as appropriate. Multivariable logistic regression was used to identify clinically relevant independent factors associated with a fascial dehiscence.

Two hundred ninety-eight patients underwent emergency laparotomy during the study time, 92 of which either died or were lost to follow-up before 30 days. Of the 206 patients meeting the inclusion criteria, 73 (35%) were closed with TCB, while 133 (65%) were closed with PDS. There were no differences in age, sex, BMI, or comorbidities between groups (Table 1). Trauma was the most common reason for laparotomy in both groups (TCB, 74% vs. PDS, 72%; p = 0.782). The majority of cases involved hollow viscus organs, with the small bowel being the most intervened-upon organ (46%). Rates of hollow viscus and solid organ injuries were similar across both groups.

Significantly fewer incisional events were seen in the TCB groups compared with the PDS group (13.5% vs. 25%, p = 0.037) (Fig. 1). Regarding local complications, SSI occurred in 19% of cases, with no difference seen between groups (11% vs. 21.1%, p = 0.68). Of these, rates of superficial SSI and deep SSI were also similar between the TCB and PDS groups. However, fascial dehiscence was less frequently seen in the TCB group (4.1% vs. 13.5%, p = 0.032). No difference was seen in systemic complications.

Rates of local complications following emergency laparotomy separated by fascial suture utilization.

Secondary analysis was performed on patients separated by reason for laparotomy. The outcomes of laparotomy performed for trauma can be found in Table 2. Seventy percent of cases were performed for a penetrating mechanism, and damage-control laparotomy with temporary wound closure during the index laparotomy was performed in 35% of operations. The injuries were similar, with the exception of more colorectal procedures performed in the TCB group (51% vs. 33%, p = 0.031). Systemic complications were similar between groups. Despite the disparity in colorectal procedures, there was no appreciated difference in SSI or fascial dehiscence when the trauma laparotomy was closed with TCB versus PDS (13 vs. 22.9, p = 0.138; 10.4% vs. 3.7%, p = 0.213, respectively).

Fifty-six included laparotomy closures were performed for emergency general surgery indications (Table 2). Of these, more patients underwent a staged laparotomy with damage-control surgery in the TCB group (15.8% vs. 0%, p < 0.05). Despite this,