Recommendations on Abdominal Wall Closure Techniques

Definition and Components of Three‑Layer Suturing

Three‑layer suturing is a layered closure method that separately approximates the peritoneum (or deep fascia), the muscular/fascial layers, and the skin/subcutaneous tissue of an abdominal incision. 1, 2, 3
The World Society of Emergency Surgery (2023) defines layered closure as closing the incision with more than one distinct fascial layer, each sutured independently. 4, 1
Deep layer: closure of the peritoneal and/or deep fascial structures. 1, 2
Middle layer: separate closure of the abdominal wall muscle and fascia. 4, 3
Superficial layer: final closure of subcutaneous tissue and skin. 1, 3

The World Society of Emergency Surgery (2023) recommends against layered closure and favors mass closure for abdominal wall incisions. 4, 1, 2
Moderate‑quality evidence shows no difference in incisional hernia rates or wound complications between mass closure and layered closure. 4, 1, 2 (moderate quality)
Layered closure significantly increases operative time, which is especially problematic in emergency surgery settings. 4, 3
A strong recommendation (Grade 1B) advises against separate peritoneal closure because it adds operative time without short‑ or long‑term benefit. 1, 2, 3

Mass closure is the preferred method: all abdominal wall layers (except skin) are incorporated in a single suture bite. 4, 1
Mass closure is faster to perform than layered closure. 4, 3
Outcomes for incisional hernia and wound complications are equivalent between mass closure and layered closure. 1, 2
The technique should use a continuous suture with a 4 : 1 suture‑to‑wound length ratio. 4, 1
A small‑bite approach (≈5 mm from the wound edge and 5 mm between stitches) is preferred for optimal tissue handling. 5

In obstetric surgery, a three‑layer closure remains the standard for second‑degree perineal lacerations and episiotomies. 6
The layers are:

All facts are derived from cited guideline statements and evidence summaries; patient‑specific details have been generalized.