Peritoneal closure after lateral paramedian incision

The lateral paramedian incision has been advocated as the strongest incision for abdominal surgery. We have evaluated this incision and tested the necessity for closing the deep peritoneal layer by a prospective randomized trial. All 206 patients undergoing laparotomy in the Surgical Unit in 1984, both elective and emergency cases, were included. In patients undergoing laparotomy through unscarred tissue, a lateral paramedian incision was performed and they were randomized to have either the peritoneum closed (n = 77) or left open (n = 75). Patients in whom the laparotomy was performed through a previous incision (n = 51) and those in whom the abdomen had to be opened urgently (n = 3) were excluded from the trial but studied separately (n = 54). The rectus sheath was closed with monofilament nylon in all cases. Patients were assessed for wound integrity during the immediate postoperative period and at 1, 3, 6 and 12 months after operation. So far the patients have been followed up for between 1 and 2 years and follow-up is continuing as in some cases incisional hernia may not be detected until several years after operation. There have been no cases of burst abdomen. No incisional hernias have developed in patients in whom a lateral paramedian incision was performed and the peritoneum was closed, and one incisional hernia has occurred in the patients in whom the peritoneum was left open. Seven incisional hernias have occurred in patients excluded from the trial of the lateral paramedian incision (13 per cent). We conclude that the lateral paramedian incision successfully abolishes the burst abdomen and that incisional hernia is rare. It is not necessary to close the peritoneum with this incision.