Plate 6

More or less the same steps for closure are carried out whether the incision is midline or transverse. If the peritoneum and linea alba fascia are separate, the fascial edge may be grasped with toothed forceps (Figure 9), exposing the edge of the peritoneum, which is grasped with Kocher's clamps. The closure sutures may be absorbable or nonabsorbable. The technique may use interrupted or continuous sutures that approximate the peritoneum and linea alba either as separate layers or as a combined unified one. If a continuous suture is used, it is technically easier to close from the lower end of the incision upward, particularly if the surgeon stands on the right side of the patient. The suture is anchored in the peritoneum just below on the end of the incision (Figure 10). The needle is passed through the peritoneum and run superiorly in a continuous manner. A medium-width metal ribbon is often placed beneath the peritoneum to ensure a clear zone for suturing and to avoid incorporation of visceral or other structures into the suture line. The placement of the continuous suture is made easier if the assistant crisscrosses the two leading Kocher clamps (Figure 11) to approximate the peritoneum. At the superior end of the incision, the looped and free ends of the suture are knotted together across the line of incision (Figure 12). The type of knot and the number of throws are determined by the characteristics of the suture material.

The linea alba fascia may be closed beginning at either end of the incision. Simple interrupted sutures may be placed (Figure 13) or figure-of-eight sutures (Plate 7, Figure 19) may be used. The sutures are placed about 1 to 2 cm apart whether interrupted or continuous (Figure 14) technique is used.

Alternatively, the linea alba and peritoneum may be closed as a single unified layer with either interrupted or continuous suture. The most expeditious closure may be made with a heavy looped suture on a single needle. The suture material may be either synthetic absorbable or a nonabsorbable in a 0 or #1 size. The suture begins with the transverse placement through the peritoneum and fascia across the lower end of the incision (Figure 15). The needle is then brought through the eye of the loop (Figure 16). Upon tightening, the suture is secured without the need of tying of a knot.

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