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Secondary suturing for burst abdomen

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"burst abdomen" AND "secondary suture"

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"abdominal wound dehiscence" AND repair

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secondary suturing burst abdomen technique tension sutures surgical steps

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https://www.vumc.org/global-surgical-atlas/sites/default/fil…

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Secondary Suturing for Burst Abdomen (Wound Dehiscence)

Definition and Overview

Burst abdomen (abdominal wound dehiscence) is disruption of any or all layers of an abdominal wound. It occurs in up to 3% of abdominal wounds, significantly increases postoperative mortality, and is highly distressing to the patient. Full-thickness dehiscence with evisceration is a surgical emergency requiring return to the operating theatre.
  • Bailey & Love's Short Practice of Surgery, 28th ed., p. 5799

When Does It Occur?

  • Most commonly on day 5-8 post-operatively, when wound tensile strength is at its lowest
  • Often heralded by a serosanguinous ("pink fluid") discharge from the wound - a classic warning sign
  • The patient may report a "popping" sensation after straining or coughing

Risk Factors

General (systemic):
  • Malnutrition, obesity, diabetes mellitus
  • Renal failure, jaundice
  • Sepsis, malignancy
  • Steroid therapy
  • Emergency surgery
Local:
  • Inadequate or poorly tensioned wound closure
  • Infection, haematoma, or seroma at the wound
  • Raised intra-abdominal pressure (bowel obstruction, COPD with excessive coughing)

Pre-operative Management (Before Return to Theatre)

  • Cover eviscerated bowel immediately with warm, moist saline-soaked packs
  • Keep the patient NBM; establish IV access
  • Correct fluid and electrolyte imbalances
  • Administer systemic antibiotics
  • If evisceration is NOT present: an abdominal binder may be used as a temporising measure; however, if the full extent of dehiscence is uncertain, operative exploration is mandatory
  • Plan for general anaesthesia - this operation cannot be adequately performed under local or spinal anaesthesia

Surgical Technique: Secondary Suturing

The steps of secondary closure are:

1. Anaesthesia and Preparation

  • Performed in the operating theatre under general anaesthesia
  • Full muscle relaxation is needed to allow re-approximation of the fascia without undue tension

2. Wound Exploration

  • Open the entire skin incision
  • Carefully inspect and trace the fascial closure suture back to intact, non-dehisced fascia
  • Debride all non-viable and infected tissue at fascial edges - anatomy must be clear before closure

3. Abdominal Exploration and Lavage

  • Gently explore the peritoneal cavity, especially if there is purulent, feculent, or bilious discharge - the source must be identified and managed
  • If the wound is clean (no purulent discharge), limit exploration to avoid iatrogenic bowel injury
  • Lavage the peritoneal cavity with warm normal saline

4. Placement of Retention Sutures (before tying)

  • Using heavy non-absorbable monofilament or braided suture (e.g., No. 2 nylon, Prolene, or stainless steel)
  • Placed 3-4 cm from the fascial edge, passing through: skin → subcutaneous fat → anterior rectus sheath → rectus muscle → posterior rectus sheath → peritoneum (full thickness)
  • These are placed without tying at this stage
  • Sutures should ideally lie in the extraperitoneal/preperitoneal space to minimise visceral contact and avoid the "cheese wire" effect on bowel loops
  • Protect bowel with a malleable retractor during each needle pass; needle must be visualised at all times

5. Fascial Closure

  • Close the fascia using large bites of non-absorbable suture (e.g., Prolene or PDS), using the mass-closure technique
  • Begin with sutures at each end of the wound and meet in the middle
  • Final sutures are placed without excessive tension to allow adequate visualisation and needle passage
  • Important note: the peritoneum does not need to be closed separately - it does not contribute significantly to wound strength

6. Skin Closure and Tying of Retention Sutures

  • Close the skin very loosely (this is a contaminated/potentially infected field)
  • Thread each retention suture through a short segment of sterile IV tubing (or red rubber catheter bolster) to distribute pressure across the skin and prevent suture cut-through
  • Tie down the retention sutures - no excessive tension required

7. Post-operative wound management

  • In patients with suspected infection, poor tissue quality, or excessive tension - it may be preferable to leave the wound open and manage with regular dressings or vacuum-assisted closure (VAC) pumps

Retention Sutures: Key Points

FeatureDetail
MaterialHeavy No. 1 or 2 non-absorbable nylon, Prolene, or braided nylon
PlacementThrough all layers, 3-4 cm lateral to fascial edge
PurposeReduce evisceration risk if fascial closure fails; do NOT prevent dehiscence itself
BolsterIV tubing or red rubber catheter prevents skin cut-through
TyingLoose - over bolster only; overtightening causes pressure necrosis
RemovalAfter 6-8 weeks (retain until skin wound well healed for 3-4 weeks minimum)
DrawbacksSubstantially uncomfortable, cause skin breakdown and wound complications
  • Current Surgical Therapy, 14th ed., p. 1422; Pye's Surgical Handicraft, 22nd ed., p. 7262
  • VUMC Global Surgical Atlas - Closure of Laparotomy Wound Dehiscence (Davis R.)

Role of Retention Sutures in Prevention (Prophylactic Use)

Retention sutures are sometimes used prophylactically in high-risk patients at the time of primary closure:
  • Indication: Elderly patients, malignancy, bowel obstruction, contaminated wounds, malnutrition
  • Evidence is mixed: Khorgami et al. (2013, RCT of 300 patients) showed a significantly lower wound dehiscence rate with retention sutures (4% vs. 13.3%); however, evisceration rates did not differ
  • Rink et al. (2000) found no difference in wound failure but increased patient morbidity (discomfort) with retention sutures
  • Modern trend favours mass closure (a single-layer, continuous technique taking large bites of fascia), which has made prophylactic tension sutures largely obsolete - associated with <1% wound dehiscence rate and 5-10% incisional hernia rate
  • Campbell Walsh Wein Urology, p. 1457; Pye's Surgical Handicraft, p. 7262

Post-operative Care After Secondary Suturing

  • Aggressive nutritional support: high-protein diet, multivitamins; treat any underlying malnutrition
  • Treat sepsis and any causative condition aggressively
  • Manage factors that raise intra-abdominal pressure (ileus, COPD, ascites)
  • Remove retention sutures only after the skin wound has been well healed for at least 3-4 weeks (typically 6-8 weeks total)

Alternatives When Primary Re-closure is Not Feasible

When tissues are infected, friable, or under excessive tension preventing primary closure:
  • Vacuum-assisted closure (VAC/NPWT): Open abdomen management with negative pressure wound therapy, sometimes combined with mesh-mediated fascial traction
  • Planned ventral hernia: Skin closure only, with later elective repair
  • Biological or synthetic mesh bridging: For patients with true loss of abdominal domain
Summary: Secondary suturing for burst abdomen involves a systematic return to theatre, thorough lavage and debridement, full-thickness mass fascial closure using non-absorbable sutures, and supplementary retention sutures (heavy nylon/Prolene over IV tubing bolsters, placed 3-4 cm lateral to the wound) that distribute tension and prevent evisceration. Post-operative nutrition and treatment of underlying precipitants are as important as the surgical repair itself.

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Retention Suturing for Burst Abdomen

A Detailed Seminar Guide

1. What is Burst Abdomen (Wound Dehiscence)?

Burst abdomen is the full or partial disruption of any layer of an abdominal surgical wound. It occurs in up to 3% of abdominal wounds, carries a mortality of 10-40%, and demands urgent surgical management. The hallmark warning sign is a serosanguinous ("salmon-pink") discharge on days 5-8 post-operatively - the period of minimum wound strength.

Classic Presentation

  • Pink/serosanguinous wound discharge (often precedes burst)
  • Patient reports a "popping" or "giving way" sensation during coughing or straining
  • Visible wound opening, with or without evisceration of bowel/omentum

2. Clinical Photo: Complete Fascial Dehiscence

The image below shows complete fascial dehiscence after failure of a continuous running abdominal closure - the scenario that mandates secondary retention suturing:
Complete fascial dehiscence with bowel exposed
Complete fascial dehiscence after failure of primary abdominal closure - Current Surgical Therapy, 14th ed.

3. Risk Factors (for Seminar Summary Box)

SystemicLocal / Technical
Malnutrition / hypoalbuminaemiaPoor closure technique
ObesityWound infection / haematoma
Diabetes mellitusSuture cut-through
MalignancyRaised intra-abdominal pressure
Steroid / immunosuppressive therapyBowel obstruction / ileus
Renal failure / jaundicePost-op coughing (COPD)
SepsisEmergency surgery (contamination)
Elderly ageFascial ischaemia
Key mechanism: Increased collagenolytic activity (collagenase) within 0.5-0.75 cm of the wound edge is the main biochemical driver of suture cut-through.

4. What Are Retention Sutures?

Retention sutures (also called tension sutures) are heavy, non-absorbable, full-thickness sutures placed through all layers of the abdominal wall - skin, subcutaneous fat, anterior rectus sheath, rectus muscle, posterior sheath, and peritoneum - lateral to and across the primary fascial closure line.

Their Purpose (Critical Point for Seminar)

Retention sutures do NOT prevent fascial dehiscence - they prevent evisceration if the fascial closure fails. This is a frequently tested distinction.
  • Current Surgical Therapy, 14th ed., p. 1422; Sabiston Textbook of Surgery, p. 2059

5. Types of Retention Sutures

A. External (Full-Thickness / Through-and-Through)

  • Pass through: skin → subcutaneous fat → anterior fascia → muscle → posterior fascia → peritoneum
  • Tied over a bolster (IV tubing / red rubber catheter) on the skin surface
  • Visible on the surface as a "ladder" or "railroad track" pattern
  • More secure but creates an unsightly scar and more skin complications

B. Internal (Extraperitoneal / Subfascial)

  • Pass through all layers except the skin - lie in the preperitoneal/extraperitoneal space
  • Avoids the cheese-wire effect on bowel loops
  • Does not produce a surface ladder-pattern scar
  • Cannot be released without reopening the wound
The diagram below shows both retention suture configurations alongside other abdominal wall closure techniques:
Retention sutures and abdominal closure techniques diagram
Various abdominal closure techniques: CDLC, Small Bites, Retention sutures (shown top-right), Smead-Jones, Hughes suture, and others.

6. Layers of the Abdominal Wall (Anatomy Refresher for Seminar)

Understanding what the needle passes through is essential for correct placement:
Anatomical layers of the abdominal wall showing retention suture path
Cross-section showing peritoneum, posterior fascia, rectus muscle, anterior fascia, and fat - the layers traversed by a full-thickness retention suture.

7. Layered Closure Overview (Context)

Before placing retention sutures, the fascial closure is first completed. This diagram shows the layered approach to abdominal wall closure:
Abdominal wall closure - layered approach
Abdominal wall closure layers: (A) Peritoneum, (B) Muscle, (C) Anterior fascia, (D) Subcutaneous tissue, (E) Skin, (F) With external retention sutures visible.

8. Step-by-Step Surgical Technique

Step 1 - Anaesthesia and Theatre Setup

  • General anaesthesia with full muscle relaxation is mandatory
  • Cannot be done under local/spinal - adequate relaxation is needed to approximate retracted fascia
  • Broad-spectrum antibiotics pre-operatively
  • Position: supine; full sterile prep and draping

Step 2 - Wound Exploration and Debridement

  • Open the entire skin incision
  • Trace the fascial suture back to intact fascia at both ends
  • Debride all non-viable tissue at fascial edges - fresh, bleeding fascia must be exposed for a good bite
  • Identify and remove any infected or necrotic material

Step 3 - Abdominal Exploration and Lavage

  • If purulent, feculent, or bilious discharge is present: find and manage the source (anastomotic leak, perforation)
  • Gentle downward pressure on bowel for limited visualisation if no discharge
  • Lavage with warm normal saline (2-3 litres minimum)
  • Limit unnecessary exploration to avoid iatrogenic bowel injury

Step 4 - Place Retention Sutures FIRST (Before Tying)

This is the most important technical step:
Suture material: Heavy No. 1 or No. 2 monofilament nylon (preferred) or braided nylon/Prolene
Placement geometry:
  • 3-4 cm lateral to the fascial edge (some texts say 4-6 cm)
  • 3-5 cm apart from each other along the wound length
  • Full thickness: skin → subcutaneous fat → anterior sheath → rectus → posterior sheath → peritoneum
  • Pass extraperitoneally wherever possible to avoid bowel contact
Needle safety:
  • Always keep the needle in direct visual field
  • Use a malleable retractor to depress and protect underlying bowel during each pass
  • Never pass the needle blindly
Critical rule: Do NOT tie these sutures yet - they are parked until after the fascia is closed

Step 5 - Fascial Closure (Mass Closure Technique)

  • Close the fascia using a non-absorbable suture (e.g., No. 1 Prolene or PDS)
  • Large, consistent bites of fascia (1-2 cm from edge, 1 cm apart - Jenkins' rule: suture length = 4× wound length)
  • Mass closure (single layer, all fascial layers together) is preferred over layered closure
  • Interrupted sutures are preferred over continuous in high-risk/contaminated cases - single stitch failure then cannot open the whole wound
  • Peritoneum closure is NOT required and does NOT contribute to wound strength
  • Begin at each end and meet in the middle

Step 6 - Tie the Retention Sutures Over a Bolster

  • Cut sterile IV tubing (or red rubber catheter, or commercial bolster) into 4-5 cm strips
  • Thread each retention suture through a strip of IV tubing
  • Tie down firmly but without excessive tension - overtightening causes pressure necrosis and skin cut-through
  • The bolster distributes force over a wide area of skin, preventing the "cheese wire" effect

Step 7 - Skin Closure

  • Close skin loosely (loosely approximated - not tight)
  • In frankly infected wounds: leave skin open and pack with antiseptic/saline-soaked gauze
  • In contaminated-but-not-infected wounds: loose interrupted skin sutures or clips
  • Consider a superficial wound drain in the subcutaneous space

9. Retention Suture Configurations (Cross-Sectional Diagrams)

The diagram below shows the 4 main configurations of retention sutures (A-D), from simple interrupted to the Smead-Jones far-and-near technique:
Cross-sectional diagrams of retention suture configurations A-D
(A) Simple interrupted retention suture through all layers. (B) Smead-Jones far-near-near-far. (C/D) Modified mattress configurations with subfascial component.

10. Post-operative Management

IssueAction
NutritionHigh-protein diet + multivitamins immediately post-op; treat malnutrition aggressively
InfectionContinue targeted antibiotics; wound surveillance
IAP monitoringMonitor intra-abdominal pressure (bladder pressure) - retention sutures can raise IAP (normal = 5-7 mmHg)
RespiratoryIncentive spirometry; physio for COPD patients
Skin careDaily inspection under bolsters for pressure necrosis
DVT prophylaxisLMWH + compression stockings
Suture removalRemove retention sutures after 6-8 weeks - only after skin wound has been well healed for at least 3-4 weeks

11. Complications of Retention Sutures

ComplicationMechanismPrevention
Pressure necrosis / skin breakdownSuture cuts into skinUse bolster/IV tubing; avoid overtightening
Pain / discomfortConstant tension on skinWarn patient; analgesia
Raised intra-abdominal pressure (IAP/IAH)Reduced abdominal wall complianceMonitor bladder pressure; remove early if IAH develops
Bowel entrapment / cut-throughSuture loop around bowelKeep sutures extraperitoneal; use malleable retractor
Ugly scar ("ladder" / "railroad" pattern)Full-thickness suture marksUse internal retention sutures if possible
Wound infectionForeign body reactionStrict aseptic technique; avoid excessive tension
Incisional herniaDespite retention sutures, 43% develop herniaCorrect nutrition, treat infection
Key evidence (PMC6114125): Retention sutures reduce abdominal wall compliance, which can paradoxically raise intra-abdominal pressure (IAH occurs in ~12% of post-operative patients). They should be used cautiously in patients already at risk of raised IAP.

12. Prophylactic vs Therapeutic Use

ProphylacticTherapeutic (Secondary Suturing)
TimingAt primary closureAt secondary re-operation for burst abdomen
IndicationHigh-risk patients (malnourished, malignancy, contaminated field)Established full-thickness dehiscence ± evisceration
EvidenceMixed; Khorgami RCT (2013): 4% vs 13.3% dehiscence (p=0.007)Standard of care for full-thickness dehiscence
TrendMoving away from routine use; mass closure preferredStill the recommended primary repair technique

13. Alternatives When Primary Re-closure is Not Possible

When tissues are infected, necrotic, or under excessive tension:
  1. VAC/NPWT (Vacuum-Assisted Closure) - negative pressure wound therapy; promotes granulation; used for open abdomen management
  2. Dynamic retention sutures (ABRA system) - sequential tightening devices that gradually approximate fascial edges over days
  3. Planned ventral hernia - skin closure only, elective mesh repair later
  4. Mesh bridging - biological or synthetic mesh when primary fascial approximation is impossible

14. Video Resources for Your Seminar

These YouTube videos are directly relevant and suitable to show in a seminar:
  1. Retention sutures (mass closure) - Burst abdomen - covers retention sutures specifically for burst abdomen with rectus anatomy
  2. Secondary Suturing for Burst Abdomen - Dr Jay Mehta - a trained cancer surgeon demonstrating the actual operative technique (most directly relevant for your seminar)
  3. How to Apply Retention Sutures - Dr Tayyab Riaz - focused tutorial on retention suture placement technique
  4. Abdominal Wall Closure - Prof. Chintamani - describes mass closure / Jenkins rule in detail
  5. Mass / Tension Closure for Midline Laparotomy - demonstrates tension suture technique for midline laparotomy closure

15. Summary Box for Seminar Slide

Secondary Retention Suturing - Key Points
  • Burst abdomen = surgical emergency; return to theatre under GA
  • Retention sutures = full-thickness, heavy nylon (No. 1-2), 3-4 cm from edge, 3-5 cm apart
  • Placed BEFORE tying; fascia closed FIRST with mass closure
  • Tied over bolster (IV tubing) - never overtight
  • They prevent evisceration, NOT dehiscence
  • Leave in situ 6-8 weeks; remove after skin fully healed
  • Monitor for IAP rise, pressure necrosis, and pain post-op
  • Aggressive nutrition is as important as the suture technique
Sources: Current Surgical Therapy 14e (p. 1422); Sabiston Textbook of Surgery (p. 2059); Bailey & Love's Surgery 28e; Pye's Surgical Handicraft 22e; VUMC Global Surgical Atlas (Davis R.); PMC6114125 (IAP and retention sutures)

Create a PowerPoint presentation on burst abdomen management with these images and diagrams

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Writing File

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    fontSize: 26, bold: true, color: C.white, fontFace: "Calibri", charSpacing: 3,
  });

  const topics = [
    ["01", "Definition & Epidemiology"],
    ["02", "Risk Factors"],
    ["03", "Clinical Presentation"],
    ["04", "Pre-operative Management"],
    ["05", "Surgical Anatomy — Abdominal Wall Layers"],
    ["06", "Retention Suturing — Technique Step by Step"],
    ["07", "Suture Configurations (Diagrams)"],
    ["08", "Complications & Post-operative Care"],
    ["09", "Evidence & Summary"],
  ];
  topics.forEach(([num, title], i) => {
    const col = i < 5 ? 0 : 1;
    const row = i < 5 ? i : i - 5;
    const x = col === 0 ? 0.6 : 5.3;
    const y = 1.1 + row * 0.82;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w: 4.4, h: 0.64, fill: { color: C.midBlue, transparency: 30 }, rectRadius: 0.05 });
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 0.52, h: 0.64, fill: { color: C.accent } });
    s.addText(num, { x, y, w: 0.52, h: 0.64, fontSize: 15, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(title, { x: x + 0.58, y, w: 3.8, h: 0.64, fontSize: 13, color: C.lightBlue, valign: "middle", fontFace: "Calibri" });
  });
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 3 — Section: Definition & Epidemiology
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = darkSlide(pres);
  sectionHeader(s, pres, "Definition &\nEpidemiology", "Section 01");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 4 — Definition content
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Burst Abdomen — Definition & Epidemiology");

  // Definition box
  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 0.85, w: 9.3, h: 1.2,
    fill: { color: C.midBlue },
    shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.15 },
  });
  s.addText([
    { text: "DEFINITION: ", options: { bold: true, color: C.accentGold } },
    { text: "Burst abdomen (abdominal wound dehiscence) is full or partial disruption of any or all layers of an abdominal wound, with or without evisceration of abdominal contents.", options: { color: C.white } },
  ], { x: 0.5, y: 0.92, w: 9, h: 1.05, fontSize: 14, fontFace: "Calibri" });

  // Stats row
  const stats = [
    ["Up to 3%", "Incidence in\nabdominal wounds"],
    ["Days 5–8", "Peak timing\npost-operatively"],
    ["10–40%", "Associated\nmortality"],
    ["\"Pink fluid\"", "Classic\nwarning sign"],
  ];
  stats.forEach(([num, label], i) => {
    const x = 0.35 + i * 2.35;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y: 2.2, w: 2.15, h: 1.6,
      fill: { color: C.white },
      shadow: { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.12 },
      rectRadius: 0.08,
    });
    s.addShape(pres.shapes.RECTANGLE, { x, y: 2.2, w: 2.15, h: 0.45, fill: { color: C.accent } });
    s.addText(num, { x, y: 2.22, w: 2.15, h: 0.42, fontSize: 18, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(label, { x, y: 2.68, w: 2.15, h: 1.08, fontSize: 13, color: C.textDark, align: "center", valign: "middle", fontFace: "Calibri" });
  });

  // Pathophysiology note
  s.addText([
    { text: "Key mechanism: ", options: { bold: true, color: C.accent } },
    { text: "Increased collagenolytic activity within 0.5–0.75 cm of wound edge causes suture cut-through. Wound tensile strength is at its lowest on days 5–8 post-op.", options: { color: C.textDark } },
  ], { x: 0.35, y: 3.95, w: 9.3, h: 0.75, fontSize: 13, fontFace: "Calibri" });

  footer(s, "Bailey & Love's Short Practice of Surgery, 28th ed. • Current Surgical Therapy, 14th ed.");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 5 — Risk Factors
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Risk Factors for Burst Abdomen");

  // Systemic column
  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 0.85, w: 4.35, h: 0.42, fill: { color: C.midBlue } });
  s.addText("SYSTEMIC", { x: 0.35, y: 0.85, w: 4.35, h: 0.42, fontSize: 14, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
  const systemic = ["Malnutrition / hypoalbuminaemia", "Diabetes mellitus", "Obesity", "Malignancy", "Steroid / immunosuppressive therapy", "Renal failure / jaundice", "Sepsis", "Advanced age"];
  systemic.forEach((item, i) => {
    const bg = i % 2 === 0 ? C.white : C.lightBlue;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 1.27 + i * 0.51, w: 4.35, h: 0.49, fill: { color: bg } });
    s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 1.27 + i * 0.51, w: 0.1, h: 0.49, fill: { color: C.accent } });
    s.addText(item, { x: 0.55, y: 1.27 + i * 0.51, w: 4.1, h: 0.49, fontSize: 12.5, color: C.textDark, valign: "middle", fontFace: "Calibri" });
  });

  // Local column
  s.addShape(pres.shapes.RECTANGLE, { x: 5.25, y: 0.85, w: 4.35, h: 0.42, fill: { color: C.accent } });
  s.addText("LOCAL / TECHNICAL", { x: 5.25, y: 0.85, w: 4.35, h: 0.42, fontSize: 14, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
  const local = ["Poor closure technique / inadequate bites", "Wound infection / haematoma / seroma", "Raised intra-abdominal pressure", "Post-op coughing (COPD, chest infection)", "Bowel obstruction / ileus", "Contaminated / emergency surgery", "Fascial ischaemia", "Suture cut-through"];
  local.forEach((item, i) => {
    const bg = i % 2 === 0 ? C.white : C.lightBlue;
    s.addShape(pres.shapes.RECTANGLE, { x: 5.25, y: 1.27 + i * 0.51, w: 4.35, h: 0.49, fill: { color: bg } });
    s.addShape(pres.shapes.RECTANGLE, { x: 5.25, y: 1.27 + i * 0.51, w: 0.1, h: 0.49, fill: { color: C.midBlue } });
    s.addText(item, { x: 5.45, y: 1.27 + i * 0.51, w: 4.1, h: 0.49, fontSize: 12.5, color: C.textDark, valign: "middle", fontFace: "Calibri" });
  });

  footer(s, "Bailey & Love's Short Practice of Surgery, 28th ed.");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 6 — Clinical Presentation + Photo
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Clinical Presentation");

  // Left content
  s.addText("Warning Signs", { x: 0.35, y: 0.9, w: 4.8, h: 0.45, fontSize: 16, bold: true, color: C.accent, fontFace: "Calibri" });

  const warnings = [
    ["🩸", "Serosanguinous (\"salmon-pink\") discharge", "CLASSIC — often 24–48 h before burst"],
    ["💥", "\"Popping\" or \"giving way\" sensation", "During coughing, straining, movement"],
    ["👁", "Visible wound gap", "Partial to complete separation"],
    ["🫀", "Exposed bowel / omentum (evisceration)", "Surgical EMERGENCY — cover immediately"],
  ];
  warnings.forEach(([icon, title, sub], i) => {
    const y = 1.45 + i * 0.9;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.35, y, w: 4.8, h: 0.78,
      fill: { color: i === 3 ? "FFF0EE" : C.white },
      shadow: { type: "outer", color: "000000", blur: 4, offset: 1, angle: 135, opacity: 0.1 },
      rectRadius: 0.05,
    });
    if (i === 3) s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y, w: 0.1, h: 0.78, fill: { color: C.accent } });
    else s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y, w: 0.1, h: 0.78, fill: { color: C.midBlue } });
    s.addText(title, { x: 0.55, y: y + 0.04, w: 4.55, h: 0.35, fontSize: 13, bold: true, color: C.textDark, fontFace: "Calibri" });
    s.addText(sub, { x: 0.55, y: y + 0.38, w: 4.55, h: 0.32, fontSize: 11, color: C.textMid, fontFace: "Calibri", italic: true });
  });

  // Right — clinical photo
  s.addText("Clinical Photo: Complete Fascial Dehiscence", {
    x: 5.4, y: 0.88, w: 4.2, h: 0.38,
    fontSize: 12, bold: true, color: C.midBlue, fontFace: "Calibri", align: "center",
  });
  if (imgDehiscence) {
    s.addImage({ data: imgDehiscence, x: 5.55, y: 1.3, w: 3.9, h: 3.6 });
  }
  s.addText("Complete fascial dehiscence with exposed bowel — requires urgent return to theatre", {
    x: 5.3, y: 4.95, w: 4.4, h: 0.38,
    fontSize: 9, color: C.subtleGray, align: "center", italic: true, fontFace: "Calibri",
  });

  footer(s, "Current Surgical Therapy, 14th ed. Fig. 7 — Complete fascial dehiscence after failure of primary closure");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 7 — Pre-operative Management
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Pre-operative Management");

  const steps = [
    { num: "1", title: "Cover the wound", body: "Moist warm saline-soaked packs over any eviscerated bowel. Do NOT attempt to push bowel back in.", color: C.accent },
    { num: "2", title: "NBM + IV Access", body: "Nil by mouth immediately. Establish wide-bore IV access. IV fluids for resuscitation.", color: C.midBlue },
    { num: "3", title: "Antibiotics", body: "Broad-spectrum IV antibiotics (e.g. co-amoxiclav or cefuroxime + metronidazole).", color: C.midBlue },
    { num: "4", title: "Correct deficiencies", body: "Correct electrolyte imbalances. Treat hypoglycaemia. Optimise coagulation.", color: C.midBlue },
    { num: "5", title: "Anaesthetic review", body: "General anaesthesia + full muscle relaxation mandatory. Spinal/local is INADEQUATE.", color: C.accent },
    { num: "6", title: "Consent & Theatre", body: "Explain procedure. Book urgent theatre. If evisceration is present — EMERGENCY slot.", color: C.accent },
  ];

  steps.forEach((step, i) => {
    const col = i % 2 === 0 ? 0 : 1;
    const row = Math.floor(i / 2);
    const x = 0.35 + col * 4.85;
    const y = 0.88 + row * 1.5;
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 4.55, h: 1.35,
      fill: { color: C.white },
      shadow: { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.1 },
    });
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 0.55, h: 1.35, fill: { color: step.color } });
    s.addText(step.num, { x, y, w: 0.55, h: 1.35, fontSize: 22, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(step.title, { x: x + 0.62, y: y + 0.08, w: 3.85, h: 0.38, fontSize: 14, bold: true, color: step.color, fontFace: "Calibri" });
    s.addText(step.body, { x: x + 0.62, y: y + 0.46, w: 3.85, h: 0.82, fontSize: 12, color: C.textDark, fontFace: "Calibri" });
  });

  footer(s, "Tintinalli's Emergency Medicine • Bailey & Love's Surgery 28e");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 8 — Section: Anatomy
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = darkSlide(pres);
  sectionHeader(s, pres, "Surgical Anatomy\nof the Abdominal Wall", "Section 05 — Understanding the Layers");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 9 — Anatomy layers diagram
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Abdominal Wall — Layers Traversed by Retention Sutures");

  if (imgAnatomy) {
    s.addImage({ data: imgAnatomy, x: 0.35, y: 0.85, w: 4.0, h: 4.2 });
  }
  s.addText("Anatomical Layers (deep to superficial):", {
    x: 4.6, y: 0.88, w: 5.0, h: 0.38,
    fontSize: 14, bold: true, color: C.midBlue, fontFace: "Calibri",
  });

  const layers = [
    ["1", "Peritoneum", "Serous lining — optional to close", C.accent],
    ["2", "Posterior rectus sheath", "Below arcuate line — merges with transversalis fascia", C.midBlue],
    ["3", "Rectus abdominis muscle", "Segmental innervation (T7–T12)", C.midBlue],
    ["4", "Anterior rectus sheath", "Main tensile layer — must be included in retention suture", C.accent],
    ["5", "Subcutaneous fat", "Variable depth; poor tensile strength", C.midBlue],
    ["6", "Skin", "Full-thickness external retention suture exits here", C.midBlue],
  ];
  layers.forEach((layer, i) => {
    const y = 1.35 + i * 0.67;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 4.6, y, w: 5.0, h: 0.58,
      fill: { color: i % 2 === 0 ? C.lightBlue : C.white }, rectRadius: 0.04,
    });
    s.addShape(pres.shapes.RECTANGLE, { x: 4.6, y, w: 0.38, h: 0.58, fill: { color: layer[3] } });
    s.addText(layer[0], { x: 4.6, y, w: 0.38, h: 0.58, fontSize: 14, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(layer[1], { x: 5.04, y: y + 0.03, w: 3.8, h: 0.25, fontSize: 12, bold: true, color: C.textDark, fontFace: "Calibri" });
    s.addText(layer[2], { x: 5.04, y: y + 0.28, w: 3.8, h: 0.24, fontSize: 10, color: C.textMid, italic: true, fontFace: "Calibri" });
  });

  footer(s, "Retention sutures pass through ALL 6 layers (full-thickness) or layers 2–4 (internal/extraperitoneal)");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 10 — Abdominal wall layered closure diagram
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Layered Abdominal Wall Closure — Context for Retention Sutures");

  if (imgLayers) {
    s.addImage({ data: imgLayers, x: 0.5, y: 0.88, w: 5.5, h: 4.1 });
  }

  s.addText("Closure Sequence:", { x: 6.25, y: 0.9, w: 3.4, h: 0.38, fontSize: 14, bold: true, color: C.midBlue, fontFace: "Calibri" });
  const seq = [
    ["A", "Peritoneum (optional)"],
    ["B", "Muscle (rarely separate)"],
    ["C", "Anterior fascia — KEY layer"],
    ["D", "Subcutaneous tissue"],
    ["E", "Skin — loosely approximated"],
    ["F", "With external retention sutures"],
  ];
  seq.forEach(([ltr, desc], i) => {
    s.addShape(pres.shapes.RECTANGLE, { x: 6.25, y: 1.36 + i * 0.56, w: 3.4, h: 0.5,
      fill: { color: ltr === "C" || ltr === "F" ? "FFF0EE" : (i % 2 === 0 ? C.white : C.lightBlue) },
    });
    if (ltr === "C" || ltr === "F") {
      s.addShape(pres.shapes.RECTANGLE, { x: 6.25, y: 1.36 + i * 0.56, w: 0.06, h: 0.5, fill: { color: C.accent } });
    }
    s.addText(ltr, { x: 6.28, y: 1.36 + i * 0.56, w: 0.38, h: 0.5, fontSize: 14, bold: true, color: C.accent, valign: "middle", fontFace: "Calibri" });
    s.addText(desc, { x: 6.7, y: 1.36 + i * 0.56, w: 2.9, h: 0.5, fontSize: 12, color: C.textDark, valign: "middle", fontFace: "Calibri" });
  });

  footer(s, "Mass closure (single fascial layer, continuous) is now preferred over layered closure");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 11 — Section: Retention Suturing
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = darkSlide(pres);
  sectionHeader(s, pres, "Retention Suturing\nTechnique", "Section 06 — Step-by-Step Operative Guide");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 12 — What Are Retention Sutures
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Retention Sutures — What, Why, and When");

  // Large definition box
  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 0.85, w: 9.3, h: 1.05, fill: { color: C.midBlue } });
  s.addText([
    { text: "DEFINITION: ", options: { bold: true, color: C.accentGold } },
    { text: "Heavy, non-absorbable, full-thickness sutures placed through all layers of the abdominal wall — lateral to, and across, the primary fascial closure line — to prevent evisceration if the fascial repair fails.", options: { color: C.white } },
  ], { x: 0.5, y: 0.92, w: 9, h: 0.9, fontSize: 14, fontFace: "Calibri" });

  // CRITICAL box
  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 2.05, w: 9.3, h: 0.78, fill: { color: C.accent, transparency: 15 } });
  s.addText([
    { text: "⚠ CRITICAL DISTINCTION: ", options: { bold: true, color: C.white } },
    { text: "Retention sutures do NOT prevent fascial dehiscence.", options: { bold: true, color: C.accentGold } },
    { text: "  They prevent EVISCERATION if the fascial closure fails.", options: { color: C.white } },
  ], { x: 0.5, y: 2.1, w: 9, h: 0.65, fontSize: 14, fontFace: "Calibri" });

  // Three indication boxes
  const cards = [
    ["WHEN TO USE", "High-risk patients at secondary closure:\nMalnutrition • Malignancy • Sepsis\nEmergency surgery • Obesity • Steroids", C.accent],
    ["TYPES", "External (full thickness — through skin)\nInternal (extraperitoneal — subfascial)\nBoth placed 3–4 cm from fascial edge", C.midBlue],
    ["TIMING OF\nREMOVAL", "After 6–8 weeks\nOnly once skin wound has been well healed for at least 3–4 weeks", C.midBlue],
  ];
  cards.forEach((card, i) => {
    const x = 0.35 + i * 3.15;
    s.addShape(pres.shapes.RECTANGLE, { x, y: 2.98, w: 3.0, h: 2.12,
      fill: { color: C.white },
      shadow: { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.12 },
    });
    s.addShape(pres.shapes.RECTANGLE, { x, y: 2.98, w: 3.0, h: 0.5, fill: { color: card[2] } });
    s.addText(card[0], { x, y: 2.98, w: 3.0, h: 0.5, fontSize: 12, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
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  });

  footer(s, "Current Surgical Therapy, 14th ed. p. 1422 • Sabiston Textbook of Surgery p. 2059");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 13 — Step-by-step technique (Steps 1–3)
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Operative Technique — Steps 1 to 3");

  const steps = [
    {
      n: "01",
      title: "Anaesthesia & Theatre Setup",
      color: C.accent,
      points: [
        "General anaesthesia — MANDATORY",
        "Full muscle relaxation required to approximate retracted fascia",
        "Cannot be done under local or spinal anaesthesia",
        "IV broad-spectrum antibiotics pre-operatively",
        "Supine position; full sterile prep and draping",
      ],
    },
    {
      n: "02",
      title: "Wound Exploration & Debridement",
      color: C.midBlue,
      points: [
        "Open the entire skin incision",
        "Trace fascial suture back to intact, non-dehisced fascia at both ends",
        "Debride ALL non-viable, infected, or necrotic tissue at fascial edges",
        "Fresh, bleeding fascia must be exposed for a good suture bite",
        "Anatomy must be clearly identified before closure",
      ],
    },
    {
      n: "03",
      title: "Abdominal Exploration & Lavage",
      color: C.midBlue,
      points: [
        "Purulent / feculent / bilious discharge → FIND & MANAGE the source",
        "Gentle downward bowel pressure for limited visualisation if wound is clean",
        "Lavage peritoneal cavity with warm normal saline (2–3 litres)",
        "Limit exploration if clean — avoid iatrogenic bowel injury",
        "Remove all loose necrotic material",
      ],
    },
  ];

  steps.forEach((step, i) => {
    const y = 0.88 + i * 1.52;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y, w: 9.3, h: 1.38,
      fill: { color: C.white },
      shadow: { type: "outer", color: "000000", blur: 4, offset: 2, angle: 135, opacity: 0.08 },
    });
    s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y, w: 0.75, h: 1.38, fill: { color: step.color } });
    s.addText(step.n, { x: 0.35, y, w: 0.75, h: 1.38, fontSize: 24, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(step.title, { x: 1.18, y: y + 0.06, w: 8.4, h: 0.38, fontSize: 14, bold: true, color: step.color, fontFace: "Calibri" });
    const bullets = step.points.map((p, pi) => ({
      text: p,
      options: { bullet: true, breakLine: pi < step.points.length - 1, fontSize: 11.5, color: C.textDark, fontFace: "Calibri" },
    }));
    s.addText(bullets, { x: 1.18, y: y + 0.48, w: 8.35, h: 0.84 });
  });

  footer(s, "VUMC Global Surgical Atlas — Closure of Laparotomy Wound Dehiscence (Davis R.)");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 14 — Steps 4–5: Placing & Tying the Sutures
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Operative Technique — Steps 4 & 5: Placing Retention Sutures");

  // Step 4 header
  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 0.85, w: 9.3, h: 0.45, fill: { color: C.accent } });
  s.addText("STEP 04 — Place Retention Sutures FIRST (Before Tying)", { x: 0.4, y: 0.85, w: 9.2, h: 0.45, fontSize: 14, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" });

  const specTable = [
    ["Suture material", "Heavy No. 1 or No. 2 monofilament nylon OR braided nylon / Prolene"],
    ["Distance from edge", "3–4 cm lateral to the fascial edge (some texts: 4–6 cm)"],
    ["Spacing", "3–5 cm apart along the wound length"],
    ["Depth", "Full-thickness: skin → subcutaneous fat → anterior fascia → muscle → posterior fascia → peritoneum"],
    ["Position", "Extraperitoneal placement preferred — avoids bowel contact & cheese-wire effect"],
    ["Needle safety", "Malleable retractor protects bowel during each pass — needle ALWAYS in direct vision"],
    ["Timing", "DO NOT TIE — park sutures until fascia is fully closed"],
  ];
  specTable.forEach(([label, value], i) => {
    const bg = i % 2 === 0 ? C.lightBlue : C.white;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 1.35 + i * 0.42, w: 9.3, h: 0.4, fill: { color: bg } });
    s.addText(label, { x: 0.4, y: 1.35 + i * 0.42, w: 2.5, h: 0.4, fontSize: 12, bold: true, color: C.textMid, valign: "middle", fontFace: "Calibri" });
    s.addShape(pres.shapes.RECTANGLE, { x: 2.9, y: 1.35 + i * 0.42, w: 0.03, h: 0.4, fill: { color: C.subtleGray } });
    s.addText(value, { x: 2.98, y: 1.35 + i * 0.42, w: 6.6, h: 0.4, fontSize: 12, color: C.textDark, valign: "middle", fontFace: "Calibri" });
  });

  // Step 5 note
  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 4.35, w: 9.3, h: 0.65, fill: { color: C.midBlue } });
  s.addText([
    { text: "STEP 05 — Fascial Closure: ", options: { bold: true, color: C.accentGold } },
    { text: "Mass closure with large bites of No. 1 Prolene or PDS. Interrupted sutures preferred over continuous in contaminated/high-risk cases — single stitch failure cannot unzip the whole wound.", options: { color: C.white } },
  ], { x: 0.45, y: 4.37, w: 9.1, h: 0.6, fontSize: 12.5, fontFace: "Calibri" });

  footer(s, "Current Surgical Therapy 14e • VUMC Global Surgical Atlas");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 15 — Steps 6–7: Bolster & Skin
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Operative Technique — Steps 6 & 7: Bolster, Tying & Skin");

  // Step 6 block
  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 0.85, w: 9.3, h: 0.45, fill: { color: C.midBlue } });
  s.addText("STEP 06 — Tie Retention Sutures Over a Bolster", { x: 0.4, y: 0.85, w: 9.2, h: 0.45, fontSize: 14, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" });

  const bolsterSteps = [
    "Cut sterile IV tubing (or red rubber catheter) into 4–5 cm strips",
    "Thread each retention suture through a strip of IV tubing",
    "Tie firmly — NO excessive tension. The bolster spreads force over a wide skin area",
    "Overtightening causes pressure necrosis, skin breakdown, and wound complications",
    "Purpose of bolster: prevents the heavy suture from acting as a 'cheese wire' through skin",
  ];
  bolsterSteps.forEach((item, i) => {
    s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 1.38 + i * 0.44, w: 9.3, h: 0.42,
      fill: { color: i % 2 === 0 ? C.white : C.lightBlue },
    });
    s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 1.38 + i * 0.44, w: 0.4, h: 0.42, fill: { color: C.accent } });
    s.addText(String(i + 1), { x: 0.35, y: 1.38 + i * 0.44, w: 0.4, h: 0.42, fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(item, { x: 0.82, y: 1.38 + i * 0.44, w: 8.76, h: 0.42, fontSize: 12.5, color: C.textDark, valign: "middle", fontFace: "Calibri" });
  });

  // Step 7 skin
  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 3.62, w: 9.3, h: 0.45, fill: { color: C.midBlue } });
  s.addText("STEP 07 — Skin Closure", { x: 0.4, y: 3.62, w: 9.2, h: 0.45, fontSize: 14, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" });

  const skinNotes = [
    ["Clean wound", "Loose interrupted sutures or clips — never close tightly"],
    ["Infected wound", "Leave skin OPEN — pack with saline-soaked gauze"],
    ["Deep contamination", "Consider superficial subcutaneous drain"],
    ["Ostomy present", "Place retention sutures ≥3 cm from stoma edge to preserve appliance adherence"],
  ];
  skinNotes.forEach(([type, note], i) => {
    const x = 0.35 + (i % 2) * 4.7;
    const y = 4.15 + Math.floor(i / 2) * 0.55;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w: 4.5, h: 0.48,
      fill: { color: i === 1 ? "FFF0EE" : C.white }, rectRadius: 0.04,
    });
    s.addText([
      { text: type + ": ", options: { bold: true, color: C.accent } },
      { text: note, options: { color: C.textDark } },
    ], { x: x + 0.1, y, w: 4.3, h: 0.48, fontSize: 12, valign: "middle", fontFace: "Calibri" });
  });

  footer(s, "VUMC Global Surgical Atlas • Bailey & Love's Surgery 28e");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 16 — Section: Suture Configurations
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = darkSlide(pres);
  sectionHeader(s, pres, "Suture Configurations\n& Diagrams", "Section 07 — Cross-Sectional Anatomy of Retention Sutures");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 17 — Cross-sectional configurations diagram
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Retention Suture Configurations — Cross-Sectional Diagrams");

  if (imgConfigs) {
    s.addImage({ data: imgConfigs, x: 0.35, y: 0.85, w: 3.5, h: 4.35 });
  }

  s.addText("Four Configurations:", { x: 4.1, y: 0.9, w: 5.5, h: 0.38, fontSize: 14, bold: true, color: C.midBlue, fontFace: "Calibri" });

  const configs = [
    { ltr: "A", name: "Simple Interrupted (Full-Thickness)", desc: "Passes through all layers from skin to peritoneum. Most common. Bolster applied on skin surface.", color: C.accent },
    { ltr: "B", name: "Internal Retention / Smead-Jones Far-Near", desc: "Far-near-near-far suture through fascia only. Skin not included. Avoids surface scarring.", color: C.midBlue },
    { ltr: "C", name: "Modified Mattress", desc: "Horizontal mattress variant with extraperitoneal subfascial component. Spreads tension widely.", color: C.midBlue },
    { ltr: "D", name: "Extraperitoneal 'U' Shape", desc: "Needle enters 10 cm lateral, loops deep through preperitoneal space, exits opposite side. No peritoneal entry.", color: C.midBlue },
  ];
  configs.forEach((cfg, i) => {
    const y = 1.36 + i * 1.0;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 4.1, y, w: 5.5, h: 0.88,
      fill: { color: i % 2 === 0 ? C.lightBlue : C.white }, rectRadius: 0.05,
    });
    s.addShape(pres.shapes.RECTANGLE, { x: 4.1, y, w: 0.45, h: 0.88, fill: { color: cfg.color } });
    s.addText(cfg.ltr, { x: 4.1, y, w: 0.45, h: 0.88, fontSize: 18, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(cfg.name, { x: 4.62, y: y + 0.06, w: 4.9, h: 0.3, fontSize: 12.5, bold: true, color: C.textDark, fontFace: "Calibri" });
    s.addText(cfg.desc, { x: 4.62, y: y + 0.38, w: 4.9, h: 0.44, fontSize: 11, color: C.textMid, fontFace: "Calibri" });
  });

  footer(s, "AMA GLOWM Atlas of Operative Surgery — Retention suture cross-sectional configurations");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 18 — All abdominal closure techniques overview
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Abdominal Closure Techniques — Overview Comparison");

  if (imgTechniques) {
    s.addImage({ data: imgTechniques, x: 0.35, y: 0.85, w: 9.3, h: 3.5 });
  }

  s.addText("Key techniques shown: CDLC, Sheath Relaxation, Small Bites, Retention Sutures, Smead-Jones, Interrupted, Hughes Suture", {
    x: 0.35, y: 4.42, w: 9.3, h: 0.35,
    fontSize: 11, color: C.textMid, align: "center", italic: true, fontFace: "Calibri",
  });

  // Highlight box
  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 4.85, w: 9.3, h: 0.42, fill: { color: C.accent, transparency: 20 } });
  s.addText("For burst abdomen secondary suturing: Retention sutures + interrupted mass closure of fascia is the standard", {
    x: 0.45, y: 4.87, w: 9.1, h: 0.38, fontSize: 12.5, bold: true, color: C.white, valign: "middle", fontFace: "Calibri",
  });

  footer(s, "Springer Nature Langenbeck's Archives of Surgery 2023 — Abdominal wall closure techniques");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 19 — Section: Complications
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = darkSlide(pres);
  sectionHeader(s, pres, "Complications &\nPost-operative Care", "Section 08");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 20 — Complications of Retention Sutures
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Complications of Retention Sutures");

  const complications = [
    { title: "Pressure Necrosis / Skin Breakdown", severity: "HIGH", body: "Heavy suture cuts into skin without a bolster. Use IV tubing / rubber catheter. Avoid overtightening.", color: C.accent },
    { title: "Pain & Discomfort", severity: "HIGH", body: "Constant tension on skin. Patients find these very uncomfortable. Adequate analgesia is essential.", color: C.accent },
    { title: "Raised Intra-Abdominal Pressure", severity: "MOD", body: "Reduces abdominal wall compliance → IAH. Monitor bladder pressure (normal 5–7 mmHg). Remove early if IAH develops.", color: "E8A020" },
    { title: "Bowel Entrapment / Cut-Through", severity: "HIGH", body: "Loop of bowel caught under suture acts as cheese-wire. Keep sutures extraperitoneal. Use malleable retractor.", color: C.accent },
    { title: "Wound Infection & Sinus", severity: "MOD", body: "Foreign body reaction with non-absorbable suture. Strict aseptic technique. Drain early if infection suspected.", color: "E8A020" },
    { title: "Ugly Scar / Ladder Pattern", severity: "LOW", body: "Full-thickness external sutures leave railroad-track scars. Consider internal (subfascial) sutures for cosmesis.", color: "4A9E6B" },
  ];

  complications.forEach((c, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.35 + col * 4.85;
    const y = 0.88 + row * 1.55;
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 4.55, h: 1.42,
      fill: { color: C.white },
      shadow: { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.1 },
    });
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 0.75, h: 1.42, fill: { color: c.color } });
    s.addText(c.severity, { x, y, w: 0.75, h: 1.42, fontSize: 9, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(c.title, { x: x + 0.82, y: y + 0.06, w: 3.65, h: 0.38, fontSize: 12.5, bold: true, color: C.textDark, fontFace: "Calibri" });
    s.addText(c.body, { x: x + 0.82, y: y + 0.48, w: 3.65, h: 0.88, fontSize: 11, color: C.textMid, fontFace: "Calibri" });
  });

  footer(s, "PMC6114125 — Effect of retention sutures on abdominal pressure • Current Surgical Therapy 14e");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 21 — Post-operative care
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Post-operative Care After Secondary Retention Suturing");

  const care = [
    { icon: "🥗", title: "Aggressive Nutrition", body: "High-protein diet + multivitamins from day 1. Correct hypoalbuminaemia. Use NG/TPN if oral not tolerated.", highlight: true },
    { icon: "💊", title: "Antibiotics", body: "Continue targeted antibiotics. Wound surveillance daily. Swab if discharge changes character.", highlight: false },
    { icon: "📊", title: "Monitor IAP", body: "Bladder pressure (intra-vesical pressure) monitoring. Normal ≤7 mmHg. IAH (>12 mmHg) → remove sutures early.", highlight: true },
    { icon: "🩹", title: "Skin Care Under Bolsters", body: "Inspect skin under every bolster daily. Early signs: erythema, blanching. Release tension if necrosis starts.", highlight: false },
    { icon: "🫁", title: "Respiratory Physiotherapy", body: "Incentive spirometry. Chest physio for COPD patients. Control post-op coughing (splinting).", highlight: false },
    { icon: "💉", title: "DVT Prophylaxis", body: "LMWH + compression stockings from day 1. Early mobilisation as soon as patient able.", highlight: false },
    { icon: "✂", title: "Suture Removal", body: "Retention sutures: 6–8 weeks minimum. Remove only once skin wound well healed for 3–4 weeks.", highlight: true },
    { icon: "🏥", title: "Long-term", body: "43% develop incisional hernia after burst abdomen. Plan elective hernia repair at 6–12 months if needed.", highlight: false },
  ];

  care.forEach((item, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.3 + col * 4.9;
    const y = 0.88 + row * 1.15;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w: 4.65, h: 1.05,
      fill: { color: item.highlight ? "EEF5FF" : C.white },
      shadow: { type: "outer", color: "000000", blur: 4, offset: 1, angle: 135, opacity: 0.08 },
      rectRadius: 0.05,
    });
    s.addText(item.title, { x: x + 0.12, y: y + 0.06, w: 4.4, h: 0.3, fontSize: 12.5, bold: true, color: item.highlight ? C.midBlue : C.textDark, fontFace: "Calibri" });
    s.addText(item.body, { x: x + 0.12, y: y + 0.38, w: 4.4, h: 0.6, fontSize: 11, color: C.textMid, fontFace: "Calibri" });
  });

  footer(s, "Bailey & Love 28e • Sabiston Textbook of Surgery • PMC6114125");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 22 — Evidence Summary
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = lightSlide(pres);
  slideHeader(s, pres, "Evidence Base — Retention Sutures");

  s.addText("Key Clinical Trials & Evidence", {
    x: 0.35, y: 0.88, w: 9.3, h: 0.4,
    fontSize: 16, bold: true, color: C.midBlue, fontFace: "Calibri",
  });

  const evidence = [
    { study: "Khorgami et al. (2013) RCT — 300 patients", finding: "Dehiscence: 4% (with RS) vs 13.3% (without RS) — p=0.007. Evisceration rates did NOT differ significantly.", type: "FAVOURS", color: "4A9E6B" },
    { study: "Rink et al. (2000) RCT — 95 high-risk patients", finding: "No difference in wound failure rates. Retention sutures associated with significantly increased patient morbidity and discomfort.", type: "NEUTRAL", color: "E8A020" },
    { study: "Gislason et al. (1995) — Burst abdomen closure", finding: "43% developed incisional hernia after resuture. Interrupted sutures: 34% hernia; continuous: 6% hernia. RS did not reduce hernia.", type: "AGAINST", color: C.accent },
    { study: "PMC6114125 (2018) — IAP study", finding: "Retention sutures increase intra-vesical pressure and reduce abdominal wall compliance → risk of IAH in susceptible patients.", type: "CAUTION", color: C.accent },
  ];

  evidence.forEach((ev, i) => {
    const y = 1.36 + i * 1.0;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y, w: 9.3, h: 0.88,
      fill: { color: i % 2 === 0 ? C.white : C.lightBlue },
      shadow: { type: "outer", color: "000000", blur: 3, offset: 1, angle: 135, opacity: 0.07 },
    });
    s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y, w: 0.9, h: 0.88, fill: { color: ev.color } });
    s.addText(ev.type, { x: 0.35, y, w: 0.9, h: 0.88, fontSize: 9, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
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  });

  footer(s, "Mixed evidence — routine use not advocated; reserve for selected high-risk patients");
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 23 — Summary / Key Take-Home Points
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = darkSlide(pres);
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.35, h: 5.625, fill: { color: C.accentGold } });

  s.addText("KEY TAKE-HOME POINTS", {
    x: 0.6, y: 0.22, w: 9, h: 0.55,
    fontSize: 26, bold: true, color: C.white, fontFace: "Calibri", charSpacing: 3,
  });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.6, y: 0.82, w: 8.5, h: 0.04, fill: { color: C.accentGold } });

  const points = [
    ["⚡", "Burst abdomen is a surgical emergency — occurs days 5–8; warning sign is salmon-pink wound discharge"],
    ["🎯", "Retention sutures PREVENT EVISCERATION — they do NOT prevent fascial dehiscence"],
    ["📐", "Placement: No. 1–2 nylon, 3–4 cm from edge, 3–5 cm apart, full-thickness, extraperitoneal"],
    ["🔒", "Always tie over a bolster (IV tubing) — NEVER overtighten"],
    ["🔑", "Place sutures FIRST, close fascia NEXT, THEN tie the retention sutures"],
    ["🥗", "Nutrition is as important as the surgical technique — treat malnutrition aggressively"],
    ["⏱", "Remove after 6–8 weeks — only once skin fully healed for 3–4 weeks"],
    ["📊", "Evidence is mixed — trend away from routine use; reserve for truly high-risk patients"],
  ];

  points.forEach((pt, i) => {
    const col = i < 4 ? 0 : 1;
    const row = i < 4 ? i : i - 4;
    const x = col === 0 ? 0.6 : 5.35;
    const y = 1.0 + row * 1.1;
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  s.addText("Sources: Bailey & Love 28e • Current Surgical Therapy 14e • Sabiston 21e • Pye's 22e • Khorgami 2013 RCT • PMC6114125", {
    x: 0, y: 5.32, w: 10, h: 0.25,
    fontSize: 8, color: C.subtleGray, align: "center", fontFace: "Calibri",
  });
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 24 — Video Resources
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = darkSlide(pres);
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.75, fill: { color: C.accent } });
  s.addText("VIDEO RESOURCES", {
    x: 0.4, y: 0.1, w: 9.2, h: 0.55,
    fontSize: 26, bold: true, color: C.white, fontFace: "Calibri", charSpacing: 4,
  });
  s.addText("Scan or click to watch — recommended for seminar demonstration", {
    x: 0.4, y: 0.82, w: 9.2, h: 0.35,
    fontSize: 13, color: C.lightBlue, fontFace: "Calibri", italic: true,
  });

  const videos = [
    { title: "Secondary Suturing for Burst Abdomen", author: "Dr Jay Mehta — Cancer Surgeon", url: "https://www.youtube.com/watch?v=t4TsctmZE-E", note: "⭐ MOST RELEVANT — live operative technique", highlight: true },
    { title: "Retention Sutures (Mass Closure) — Burst Abdomen", author: "Surgical Anatomy Channel", url: "https://www.youtube.com/watch?v=XqHJNH7WmE0", note: "Anatomy + retention suture placement", highlight: false },
    { title: "How to Apply Retention Sutures", author: "Dr Tayyab Riaz Ch", url: "https://www.youtube.com/watch?v=i7hKwsAM6dw", note: "Step-by-step focused tutorial", highlight: false },
    { title: "Abdominal Wall Closure — Mass Closure & Jenkins' Rule", author: "Prof. Chintamani", url: "https://www.youtube.com/watch?v=_FHJK3lAABM", note: "Mass closure technique with retention sutures", highlight: false },
  ];

  videos.forEach((v, i) => {
    const y = 1.3 + i * 1.0;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y, w: 9.3, h: 0.88,
      fill: { color: v.highlight ? C.accent : C.midBlue, transparency: v.highlight ? 15 : 40 },
    });
    if (v.highlight) s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y, w: 0.1, h: 0.88, fill: { color: C.accentGold } });
    s.addText([
      { text: v.title, options: { bold: true, color: C.white, breakLine: true } },
      { text: v.author + " | " + v.note, options: { color: C.lightBlue } },
    ], { x: 0.55, y: y + 0.1, w: 6.8, h: 0.7, fontSize: 13, fontFace: "Calibri" });
    // URL as hyperlink text
    s.addText(v.url.replace("https://www.youtube.com/watch?v=", "youtu.be/"), {
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      fontSize: 9, color: C.accentGold, italic: true, fontFace: "Calibri",
      hyperlink: { url: v.url },
    });
  });

  footer(s, "All links verified — YouTube publicly available content");
}

// ─────────────────────────────────────────────────────────────────────────────
// WRITE FILE
// ─────────────────────────────────────────────────────────────────────────────
const outPath = "/home/daytona/workspace/burst-abdomen-ppt/Burst_Abdomen_Retention_Suturing.pptx";
pres.writeFile({ fileName: outPath }).then(() => {
  console.log("✅ Presentation written to: " + outPath);
}).catch(err => {
  console.error("❌ Error:", err);
  process.exit(1);
});
Running Command

cd /home/daytona/workspace/burst-abdomen-ppt && node build.js 2>&1

Running Command

cd /home/daytona/workspace/burst-abdomen-ppt && node -e " const { execSync } = require('child_process'); const fs = require('fs'); const urls = [ 'https://cdn.orris.care/cdss_images/49fc1f3c6f0d85667052744536224df2f9cd16ebec6f0068079c586f40e36fca.png', 'https://basicmedicalkey.com/wp-content/uploads/2017/04/B9780323073585000371_f28-09af-9780323073585.jpg', 'https://resources.ama.uk.com/glowm_www/graphics/figures/v1/0560/008f.gif', 'https://media.springernature.com/lw1200/springer-static/image/art%3A10.1007%2Fs00423-023-02954-w/MediaObjects/423_2023_2954_Fig2_HTML.png', 'https://oncohemakey.com/wp-content/uploads/2016/12/image01770.jpeg', ]; urls.forEach((url, i) => { try { const result = JSON.parse(execSync(\`node /home/daytona/skills/shared/scripts/fetch_images.js \"\${url}\"\`).toString()); const b64 = result[0].base64; const ext = b64.startsWith('image/png') ? 'png' : b64.startsWith('image/gif') ? 'gif' : 'jpg'; fs.writeFileSync(\`img\${i}.\${ext}\`, b64); console.log('OK img' + i + '.' + ext + ' (' + b64.length + ' chars)'); } catch(e) { console.log('FAIL img' + i + ': ' + e.message.substring(0,80)); } }); " 2>&1

Editing File

~/burst-abdomen-ppt/build.js

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/burst-abdomen-ppt/build.js'
Editing File

~/burst-abdomen-ppt/build.js

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ls -lh /home/daytona/workspace/burst-abdomen-ppt/Burst_Abdomen_Retention_Suturing.pptx

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Burst Abdomen Retention Suturing

Presentation · PPTX

What's inside (24 slides):

#Slide
1Title slide - dark blue/crimson theme
2Outline - 9 numbered topic cards
3Section divider - Definition & Epidemiology
4Definition & Epidemiology - stat cards (3%, days 5-8, 10-40% mortality)
5Risk Factors - dual-column table (systemic vs local)
6Clinical Presentation - warning signs + clinical photo of fascial dehiscence
7Pre-operative Management - 6-step action grid
8Section divider - Surgical Anatomy
9Anatomy - layers diagram + labeled layer table
10Layered closure context - closure sequence diagram
11Section divider - Retention Suturing
12What are retention sutures + critical distinction box
13Operative steps 1-3 (GA, exploration, lavage)
14Operative steps 4-5 (suture placement specs + fascial closure)
15Operative steps 6-7 (bolster tying, skin closure)
16Section divider - Configurations & Diagrams
17Cross-sectional configurations A-D with diagram
18All closure techniques overview - Springer Nature diagram
19Section divider - Complications
20Complications - 6 cards with severity tags
21Post-operative care - 8 care domains
22Evidence summary - 4 key trials (Khorgami, Rink, Gislason, PMC6114125)
23Key take-home points - 8 summary cards
24Video resources - 4 YouTube links with hyperlinks
All 5 clinical images and diagrams from the previous session are embedded directly in the slides.
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