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Study Protocol

A Comparative Study between Intermittent Smead Jones Rectus Closure and Continuous Rectus Closure in Midline Laparotomy Wound

[version 1; peer review: awaiting peer review]
Maulik Maheshwari
https://orcid.org/0009-0007-4578-2279
1, Imran Ali khan1
Maulik Maheshwari
https://orcid.org/0009-0007-4578-2279
1, Imran Ali khan1
PUBLISHED 25 Apr 2024
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS AWAITING PEER REVIEW

This article is included in the Datta Meghe Institute of Higher Education and Research collection.

Abstract

This comparative study delves into the efficacy and impact of two primary closure techniques, intermittent Smead Jones rectus closure, and continuous rectus closure, on midline laparotomy wound management. Aimed at offering evidence-based guidance to surgeons, this investigation encompasses a prospective observational study involving 98 patients aged ≥18 undergoing midline exploratory laparotomy at Acharya Vinoba Bhave Rural Hospital Sawangi. Divided into two groups—intermittent S-J closure and continuous closure—the study will meticulously assess wound parameters and complications, notably focusing on wound dehiscence, burst abdomen, and incisional hernia repair rates. Spanning from February 2023 to May 2025, the research aims to scrutinize statistical outcomes using SPSS and MS Excel, seeking to provide critical insights into these closure techniques’ comparative effectiveness. Despite its limitations, including a relatively small sample size and an observational nature without interventions, this study aspires to contribute valuable data that can aid surgeons in optimizing closure methods for midline laparotomy wounds, thereby enhancing postoperative outcomes and patient care.

Keywords

Intermittent Smead Jones closure, continuous rectus closure, midline laparotomy, wound dehiscence, burst abdomen, incisional hernia, surgical techniques, postoperative outcomes

Corresponding author: Maulik Maheshwari
Competing interests: No competing interests were disclosed.
Grant information: The author(s) declared that no grants were involved in supporting this work.
Copyright:  © 2024 Maheshwari M and khan IA. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Maheshwari M and khan IA. A Comparative Study between Intermittent Smead Jones Rectus Closure and Continuous Rectus Closure in Midline Laparotomy Wound [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:391 (https://doi.org/10.12688/f1000research.147103.1) First published: 25 Apr 2024, 13:391 (https://doi.org/10.12688/f1000research.147103.1) Latest published: 25 Apr 2024, 13:391 (https://doi.org/10.12688/f1000research.147103.1)

Introduction

Surgical techniques for midline laparotomy wound closure play a pivotal role in postoperative outcomes, particularly concerning wound complications and recovery. Amid the diverse closure methods, the debate continues regarding the optimal technique to reduce complications and enhance patient recovery.1 This thesis presents a comprehensive investigation into two primary closure approaches: intermittent Smead Jones rectus closure and continuous rectus closure, aiming to provide a comparative analysis of their efficacy, safety, and impact on midline laparotomy wound healing.

Midline laparotomy incisions are extensively utilized in various abdominal surgeries, yet complications such as wound dehiscence, incisional hernias, and burst abdomen remain significant concerns post-surgery.2 The closure technique employed can profoundly influence the incidence of these complications, prompting an ongoing quest for an optimal closure method that minimizes such risks and contributes to better patient outcomes.3

The intermittent Smead Jones rectus closure technique, characterized by its interrupted sutures pattern, and the continuous rectus closure technique, marked by uninterrupted closure, stand as two prominent approaches in abdominal wound closure strategies.4 The continuous method of closure has various benefits, including rapid closure with fewer knots, which lowers the likelihood of sinus formation. This studyendeavors to scrutinize and juxtapose these methods, examining their respective advantages, disadvantages, and overall impact on midline laparotomy wound management.

This investigation aims to provide critical insights into the comparative effectiveness of these closure techniques in midline laparotomy wounds, contributing valuable data to the existing body of surgical knowledge. By analyzing clinical outcomes, wound healing parameters, and the incidence of complications associated with each closure method, this study endeavors to offer evidence-based recommendations that may guide surgeons in selecting the most optimal closure technique for midline laparotomy wounds.

Aim

To compare the efficacy and outcomes of intermittent Smead-Jones rectus closure versus continuous rectus closure techniques in managing midline laparotomy wounds.

Objective

  • 1. To evaluate the effectiveness of the Smead-Jones closure technique concerning wound dehiscence and burst abdomen.

  • 2. To examine the effectiveness of the continuous closure technique concerning incisional hernia repair.

Methods

Study design

This research will employ a prospective cross-sectional observational study design, allowing for the collection of data and observation of naturally occurring phenomena without intervention.

Study population

The study will include 96 patients aged ≥ 18 years who require midline exploratory laparotomy.

Study setting

The study will be conducted at Acharya Vinoba Bhave Rural Hospital Sawangi, Wardha, which offers well-equipped facilities, providing an ideal environment for the investigation.

Duration of study

The study, spanning from February 2023 to May 2025, will provide a two-year duration allowing for comprehensive data analysis and a thorough exploration of the research objectives.

Inclusion criteria

  • • Patients more than 18 years of age.

  • • All patients that require midline exploratory laparotomy; either emergency or elective.

Exclusion criteria

  • • Pregnancy

  • • Patients not willing for the study

  • • Patients requiring 2 ormoresurgeries through the same incision withinthe period initial 30 postoperative days.

Sample size5

n={z1,√[2P(1−P)]+z2,√[P1(1−P1)+P2(1−P2)]}2(P1–P2)2

Building on the investigation led by Chirag B. Aghara, et al.,6 the determination of the required sample size in our study centered on postoperative outcomes and wound infection, recognized as crucial elements. The ratio was observed to be 24% in the case group and 56% in the control group. In our present analysis, determining the minimum sample size involved two primary criteria: patients aged >18 years and those who underwent emergency laparotomy through a midline incision with subsequent wound infection.

Utilizing the aforementioned formula, for the entirety of our study, we will include a total of 96 patients. These 96 samples will be randomly divided into two groups, resulting in the collection of 48 samples in each group (Table 1).

Table 1. Sample size calculation parameters.

P1Probability of variable in sample-1 (Value <1.0)0.24
P2Probability of variable in sample-2 (Value <1.0)0.56
PArthmetic average of P1 & P20.4
AHAlternate hypothesis ONE sided (1), or TWO sided? (2)2
1-αSet level of confidence (value<1.0). Usual values 0.95;0.990.95
1-βSet level of power of test (value<1.0). Usual values 0.8;0.90.9
Z1Z value associated with set level of alpha (One sided)1.959963985
Z2Z value associated with set level of beta1.281551566
n1Minimum sample size48
n2Minimum sample size48

Sample size - 96 patients

Group A - intermittent S-J closure 48 TEST

Group B - continuous closure 48 CONTROL

All patients will be included following the inclusion and exclusion criteria.

Data documentation and statistical analysis will done with JASP is released under a GNU Affero GPL v3 license, which is an open-source license that free and MS Excel.

Data collection process and method

Patients will be randomly allotted into two groups and will alternatively be undergoing Smead Jones intermittent closure and continuous rectus closure.

Postoperatively patients will be accessed for 7-10 days as an inpatient and watched for any burst abdomen.

The patient will be followed up after 6 weeks, 3 months, and watched for incisional hernia.

Plan for analysis

This Cross-sectional, comparative study will be conducted after the approval of the Ethics Committee Department of Medical Education, Jawaharlal Nehru Medical Sciences, Deemed University, Sawangi (Meghe). The outcomes will be recorded and analyzed at the end of the study using a statistical package for social science (SPSS).

Discussion

The investigation into intermittent Smead Jones rectus closure and continuous rectus closure techniques in midline laparotomy wounds serves as a critical endeavor toward evaluating the efficacy of these closure methods. The findings of this study contribute to the existing body of knowledge regarding abdominal wound closure strategies, particularly focusing on midline laparotomy incisions and their associated complications.

The comparative analysis between intermittent Smead Jones and continuous rectus closures revealed valuable insights into their respective advantages and disadvantages. The intermittent closure technique, characterized by interrupted sutures, offers a distinct pattern compared to the uninterrupted closure of the continuous technique. Notably, the continuous closure showed benefits including rapid closure with fewer knots, potentially reducing the risk of sinus formation. However, it’s essential to acknowledge that each method has its unique features, and the choice of closure technique may depend on various patient-specific factors and surgeon preferences.

The study’s focus on wound complications such as wound dehiscence, incisional hernias, and burst abdomen post-surgery sheds light on the critical importance of selecting an appropriate closure method. Abdominal wound dehiscence or a burst abdomen is a significant concern after emergency midline laparotomy, causing considerable sickness and death. Preventive actions are necessary as this condition can result in severe consequences such as pain, mental distress, infections, financial burdens, and the need for additional surgeries (reoperation) due to organ protrusion through the wound (evisceration). Addressing wound dehiscence is crucial to reducing patient suffering and complications, emphasizing the importance of finding effective measures to prevent such occurrences following midline laparotomy.7–9

The study has several limitations that warrant consideration. The relatively small sample size of 96 patients might restrict the generalizability of findings to a broader population. Its observational nature without intervention limits establishing direct cause-and-effect relationships between closure techniques and postoperative complications. Moreover, the possibility of unaccounted confounding variables influencing outcomes highlights the necessity for further research and analysis. Caution is advised when extending these findings to broader clinical practice or different patient groups due to these limitations.

Implications and generalizability

The study’s findings offer valuable insights into choosing optimal closure techniques for midline laparotomy wounds, potentially reducing complications and improving patient recovery. However, caution is needed when applying these findings widely due to the study’s limited sample size and observational nature. Further research involving larger and diverse patient groups is necessary to strengthen the applicability of these findings to different surgical scenarios and improve their real-world impact in clinical practice.

Ethical considerations

The Institutional Ethics Committee of Datta Meghe Institute of Higher Education and Research (DU) has approved the study protocol with approval number DMIHER (DU)/IEC/2024/182 on date 01/02/2024. Before commencing the study, we will obtain written informed consent from all participants, providing them with a comprehensive explanation of the study’s objectives.

Dissemination

This study protocol will be published in an indexed journal.

Study status

The study has yet to start.

Data availability

No data are associated with this article.

Extended data

Figshare: STROBE checklist for A COMPARATIVE STUDY BETWEEN INTERMITTENT SMEAD JONES RECTUS CLOSURE AND CONTINUOUS RECTUS CLOSURE IN MIDLINE LAPAROTOMY WOUND. https://doi.org/10.6084/m9.figshare.24972075.v1. 10

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

References

  • 1.  Chalya PL, et al.: Abdominal fascia closure following elective midline laparotomy: a surgical experience at a tertiary care hospital in Tanzania. BMC. Res. Notes. 2015; 8(1): 1–9. Publisher Full Text
  • 2.  Hempel S, et al.: Wound complications after primary and repeated midline, transverse and modified Makuuchi incision: A single-center experience in 696 patients. Medicine. 2021; 100(20): e25989. PubMed Abstract | Publisher Full Text | Free Full Text
  • 3.  Patel SV, Paskar DD, Nelson RL, et al.: Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications. Cochrane Database Syst. Rev. 2017; 2017(11): CD005661. Published 2017 Nov 3. PubMed Abstract | Publisher Full Text | Free Full Text
  • 4.  Iswarya D: A Comparative study between Intermittent Smead Jones Rectus Closure and Continuous Rectus Closure in Midline Laparotomy Wound, Diss. Chennai: Stanley Medical College; 2021.
  • 5.  Patikar S: In text book of community medicine.Bhalwar R, editor. Dept of Community Medicine. 1st Ed.New Delhi: AFMC Pune. Publ. WHO India Office; 2009.
  • 6.  Aghara C, Rajyaguru A, Bhatt J: Prospective comparative study of modified Smead Jones versus conventional continuous method of fascial closure in emergency midline laparotomy. Int. Surg. J. 2020; 7: 3713. Publisher Full Text
  • 7.  Gislason H, Gronbech JE, Soreide O: Burst abdomen and incisional hernia after major gastrointestinal operations-comparison of three closure techniques. Eur. J. Surg. 1995; 161: 349–354. PubMed Abstract
  • 8.  Riou JP, Cohen JR, Johnson H: Factors influencing wound dehiscence. Am. J. Surg. 1992; 163: 324–330. Publisher Full Text
  • 9.  Sørensen LT, Hemmingsen U, Kallehave F, et al.: Risk factors for tissue and wound complications in gastrointestinal surgery. Ann. Surg. 2005; 241(4): 654–658. PubMed Abstract | Publisher Full Text | Free Full Text
  • 10.  Maheshwari M: STROBE-cross-sectional_checklist for A COMPARATIVE STUDY BETWEEN INTERMITTENT SMEAD JONES RECTUS CLOSURE AND CONTINUOUS RECTUS CLOSURE IN MIDLINE LAPAROTOMY WOUND. figshare. Online resource. 2024. Publisher Full Text

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Maheshwari M and khan IA. A Comparative Study between Intermittent Smead Jones Rectus Closure and Continuous Rectus Closure in Midline Laparotomy Wound [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:391 (https://doi.org/10.12688/f1000research.147103.1)
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