Plate 8

Following closure of the peritoneum and the linea alba, Scarpa's fascia may be approximated with 3/0 absorbable suture. Many feel this lessens the subcutaneous dead space within the fat (Figure 28). In thin patients, this suture may be placed in an inverted manner (as shown), with the knot at the bottom of the loop. However, in most patients, these sutures are placed upright with the knot on top.

The skin may be closed with interrupted fine 3/0 or 4/0 nonabsorbable sutures using a curved cutting needle (Figure 29). The skin edge is elevated with forceps in such a manner that the needle is introduced perpendicular to the skin on the one side and exits perpendicularly on the opposite. The sutures are spaced such that the distance between them is approximately equal to their width. This creates a pleasing uniform pattern. As the individual sutures are tied, the skin will rise, creating a slight ridge. When all sutures are tied, they are held in the surgeon's left hand and then sequentially cut with the scissors (Figure 30). Some surgeons prefer an interrupted vertical mattress suture for skin closure. The vertical mattress suture is especially well suited for circumstances where the skin edges do not lie in level approximation. The skin is grasped with the toothed forceps. A wide lateral base is created as the needle enters the skin about 1 cm or so lateral to the cut edge (Figure 31). The opposite skin edge is then grasped with forceps and the needle brought through in a symmetric manner (Figure 32). A careful approximation of the skin edges at equal levels is accomplished by a returning small bite that is approximately a millimeter or two from the skin edge and only a millimeter or two deep. A symmetric bite on the proximal skin edge completes the stitch (Figure 33). This stitch is tied loosely, producing a gentle ridge effect (Figure 34).

The skin may also be closed with interrupted fine 4/0 or 5/0 synthetic absorbable subcuticular sutures. With this method, the suture must lie in the deepest layers of the corium. The skin edge is grasped with toothed forceps and the suture is placed by either the continuous or interrupted horizontal mattress technique. Multiple interrupted sutures are preferred for short incisions, whereas continuous sutures are more suitable for incisions that are more than a few centimeters long. In this technique, small horizontal bites are taken in opposite sides of the skin margins (Figures 35 and 36). When the knot is tied, a perfect approximation occurs (Figure 37). After tying, the sutures are cut as close to the knot as possible. Thereafter, the skin is cleaned of the preparative antiseptic solution and a benzoin-like skin protector is applied. When this becomes tacky, porous adhesive paper tapes are applied transversely (Figure 38). This relieves tension in the incision and provides a simple covering.

Conversely, some surgeons use metal staples for skin closure. Their advantage is speed of application (Figure 39) and ease of removal (Figure 40). Special care must be taken, however, to approximate carefully the everted skin margins with a pair of fine-toothed forceps. The stapling instrument should not press into the skin. A gentle light application will result in the desired mounding up that keeps the two skin edges in good approximation. Some prefer to place these staples widely and use the adhesive paper tapes between them. Finally, a covering gauze dressing is necessary so as to absorb the small amount of serum and blood that evacuates in the postoperative period. In general, staples should be removed sooner rather than later as they penetrate the skin and can result in localized inflammations.