What does three-layer suturing include?

Three-Layer Suturing Definition and Components

Three-layer suturing refers to a layered closure technique where the surgical incision is closed with more than one separate layer of fascial closure, typically involving closure of the peritoneum, fascial/muscle layers, and skin as distinct layers. 1

Technical Definition

According to the World Society of Emergency Surgery (2023), layered closure is defined as closing the incision with more than one separate layer of fascial closure, where each anatomical layer is sutured independently. 1

Traditional Three-Layer Components Include:

1. Deep layer (Peritoneum/Fascia): Closure of the peritoneal layer and/or deep fascial structures 1

2. Middle layer (Muscle/Fascia): Separate closure of the muscular and fascial layers of the abdominal wall 1

3. Superficial layer (Skin/Subcutaneous): Final closure of subcutaneous tissue and skin 1

Important Clinical Context: This Technique Is NOT Recommended

The World Society of Emergency Surgery (2023) explicitly recommends AGAINST layered closure in favor of mass closure for abdominal wall incisions. 1

Why Layered Closure Is Discouraged:

• No clinical benefit: Moderate-quality evidence shows no difference between mass closure versus layered closure in terms of incisional hernia rates or wound complications 1

• Increased operative time: Layered closure takes significantly longer to perform, which is particularly problematic in emergency surgery settings 1

• Peritoneal closure specifically contraindicated: Strong recommendation (1B) against separate peritoneal closure, as it adds operative time without any short-term or long-term benefit 1

Preferred Alternative: Mass Closure

Mass closure is the recommended technique, where all layers of the abdominal wall (except skin) are included in a single suture bite. 1, 2

• Faster to perform 1, 2
• Equivalent outcomes for hernia and wound complications 1
• Should use continuous suture technique with 4:1 suture-to-wound length ratio 1, 2
• Small bite technique (5mm from edge, 5mm between stitches) preferred 2

Exception: Obstetric/Perineal Repairs

In obstetric surgery, three-layer closure remains standard for second-degree perineal lacerations and episiotomies, involving: 1

1. Vaginal epithelium and muscularis 1
2. Perineal body musculature and rectovaginal fascia 1
3. Perineal skin (preferably continuous subcuticular technique) 1

Common Pitfall to Avoid:

Do not confuse historical three-layer abdominal closure techniques with modern evidence-based practice. The term "three-layer suturing" represents an outdated approach for abdominal wall closure that has been superseded by mass closure based on superior efficiency without compromising outcomes. 1, 2