ECLAPTE: Effective Closure of LAParoTomy in Emergency—2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings

WSES · 2023 · international

Source and licence

Authors: Simone Frassini, Lorenzo Cobianchi, Paola Fugazzola et al.
Title: ECLAPTE: Effective Closure of LAParoTomy in Emergency—2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings
Journal: World Journal of Emergency Surgery : WJES, 2023
DOI: 10.1186/s13017-023-00511-w
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC10373269

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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Methods

I.1 When urgent access to the peritoneal cavity is required, we recommend midline laparotomy because it is faster and allows the best approach to the abdomen. When clinical circumstances allow, we suggest avoiding a midline incision for an alternative incision2A
I.2 We recommend AGAINST midline incision as the extraction site when laparoscopic interventions are performed1A
The current evidence does not suggest any difference in the incidence of incisional hernia or dehiscence between continuous or interrupted sutures for fascial closure. However, the time taken for fascial closure is less with continuous closure. Therefore, we suggest a continuous suture technique of the midline abdominal wall incision in emergency settings2A
We recommend AGAINST separate closure of the peritoneum during the abdominal wall closure of emergency laparotomy1B
For closure of abdominal midline incision in emergency surgery, no difference between mass closure or layered closure was observed in terms of incisional hernia and wound complications: we suggest mass closure because it is faster than layered closure which might be highly important when emergency surgery is performed2B
We recommend a suture-to-wound length ratio (SL/WL) of at least 4:1 for continuous closure of midline abdominal wall incisions in emergency surgery1B
We suggest the closure of the midline laparotomy with a ‘small bite’ technique to prevent incisional hernia and wound complications in emergency surgery cases although the evidence stems from elective surgery cases2C
There is currently no evidence to suggest that absorbable or non-absorbable sutures are better in terms of incisional hernia or surgical site infections. Absorbable sutures may decrease pain; therefore, we suggest slowly absorbable sutures for the closure of emergency laparotomy2C
When using an absorbable suture for the closure of midline incisions in the emergency setting, we suggest choosing a slowly absorbable material2A
We recommend a monofilament suture material (slowly absorbable monofilament suture) in the closure of midline laparotomies in the emergency setting as they may decrease the incidence of incisional hernia1A
We recommend an antimicrobial-coated suture for the fascial closure of abdominal laparotomy in cases of clean-, clean-contaminated, and contaminated fields when it is available in the emergency setting1B
There is currently no high-quality evidence literature to suggest that retention sutures decrease the incidence of wound dehiscence in patients undergoing emergency laparotomies. The panel did not reach consensus as to whether retention sutures should be used routinely in laparotomy closures in the emergency setting The panel did not reach an agreement of at least 80%, and consequently, this statement cannot be considered as an indication in the current guidelines
There are very limited data about a blunt tapered or sharp needle in closing different layers of emergency laparotomies. Therefore, no recommendations can be made, and further studies are needed to clarify this concept
To decrease surgical site infection occurrence after emergency surgery, we suggest prophylactic wound irrigation in clean, clean-contaminated, and contaminated fields of the surgery. We recommend not to use antibiotic irrigation.2C
Povidone–iodine wound irrigation has been associated with lower SSI rates, but recent data suggest that this consideration should be reconsidered. We recommend future prospective high-quality trials to clarify this point2C
There is currently no evidence supporting the routine use of subcutaneous drains. Therefore, we suggest AGAINST the routine use of subcutaneous drains after emergency laparotomy2A
There is currently no evidence to support or refute delayed laparotomy closure: because of the high risk of SSIs, we suggest surgeons should consider DCS of surgical wounds compared to primary closure in case of contaminated and dirty incisions with purulent contamination2B
When delayed closure of surgical incision is performed, we recommend a revision between two and five days postoperatively1B
No recommendation about postoperative physical restriction after open abdominal surgery can be made due to the lack of evidence, and further trials are necessary
In patients undergoing primary closure after emergency laparotomy with high risk for surgical site infections, we recommend prophylactic incisional NPWT dressing on the closed skin1A
No recommendation about a specific type of incisional NPWT dressing can be made due to the lack of evidence
We suggest the use of prophylactic mesh augmentation in the closure of midline laparotomies in emergency settings to decrease the risk of incisional hernia (2B) The panel did not reach an agreement of at least 80%, and consequently, this statement will not be considered as a recommendation in the current guidelines
We suggest considering prophylactic mesh augmentation, particularly in patients with an increased risk of incisional hernia development2B
In light of current evidence, for prophylactic mesh augmentation no specific type of mesh can be recommended. There is uncertainty about the type, position, or the type of fixation that should be used when prophylactic mesh augmentation is performed after emergency laparotomy. Evidence about mesh positioning is heterogeneous: onlay mesh position and retromuscular position are both recommended, even in emergency surgery, but future perspectives are needed to clarify the role of other types of meshes—absorbable and biological, for example, as well as other mesh placement positions2C
Trocar-site hernia rates increase when trocars of 10 mm or larger are used and when trocars are introduced midline. We recommend using the smaller trocar size appropriate for the procedure and on an off-midline location when possible2C
Trocar-site hernia may increase when bladed trocars are used. Surgeons may consider using non-bladed trocars when available2C
We suggest closing the fascial defect caused by the trocar placement when trocars of 10 mm or of larger sizes are used2C
We recommend conventional laparoscopic procedures over single incision laparoscopic surgery (SILS) due to a higher risk of incisional hernia with the SILS technique1B
When SILS is performed, surgeons might consider meticulous fascia closure to decrease the risk of incisional hernia formation2C

Section 5

We suggest the use of prophylactic mesh augmentation in the closure of midline laparotomies in emergency settings to decrease the risk of incisional hernia2B

Abstract

Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy.

Contents of the original publication

The section headings of the original.

Background
Methods
Results
Introductory section
Section 1
Section 2
Section 3
Section 4
Section 5
Section 6
Conclusions

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