Randomized clinical trial comparing polypropylene or polydioxanone for midline abdominal wall closure

The clinical consequences of burst abdomen after emergency midline laparotomy: a prospective, observational cohort study

PURPOSE

The emergency midline laparotomy is a commonly performed procedure with a burst abdomen being a critical surgical complication requiring further emergency surgery. This study aimed to investigate the clinical outcomes of patients with burst abdomen after emergency midline laparotomy.

METHODS

A single-center, prospective, observational cohort study of patients undergoing emergency midline laparotomy during a two-year period was done. Abdominal wall closure followed a standardized technique using monofilament, slowly absorbable suture in a continuous suturing technique with a suture-to-wound ratio of at least 4:1. Treatment of burst abdomen was surgical. Data, including intra-hospital postoperative complications, were collected and registered chronologically based on journal entries. The primary outcome was to describe postoperative complications, length of stay, and the overall morbidity based on the Comprehensive Complication Index (CCI), stratified between patients who did and did not suffer from a burst abdomen during admission.

RESULTS

A total of 543 patients were included in the final cohort, including 24 patients with burst abdomen during admission. The incidence of burst abdomen after emergency midline laparotomy was 4.4%. Patients with a burst abdomen had a higher total amount of complications per patient (median of 3, IQR 1.3-5.8 vs. median of 1, IQR 0.0-3.0; p = 0.001) and a significantly higher CCI (median of 53.0, IQR 40.3-94.8 vs. median of 21.0, IQR 0.0-42.0; p =  < 0.001).

CONCLUSION

Patients with burst abdomen had an increased risk of postoperative complications during admission as well as a longer and more complicated admission with multiple non-surgical complications.

Laparoscopic Ventral Hernia Repair

The laparoscopic approach to ventral hernia repair is a safe and effective approach for both elective and emergent repair. The preoperative technical considerations include assessment of incarceration and potential for extensive adhesiolysis, size of defect, and atypical hernia locations. Preoperative considerations include weight loss and lifestyle modification. There are multiple methods of fascial defect closure and mesh fixation that the surgeon may consider via a laparoscopic approach, making it adaptable to varying clinical scenarios and anatomic challenges. Compared with open repair laparoscopic repair is associated with reduced surgical wound site infection, and compared with robotic repair outcomes are similar.

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

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.

Rectus diastasis increases risk of burst abdomen in emergency midline laparotomies: a matched case–control study

PURPOSE

Burst abdomen is a serious complication requiring immediate surgical treatment. This study aimed to investigate the association between rectus diastasis and burst abdomen in patients undergoing emergency midline laparotomy.

METHODS

A single-center, retrospective, matched case-control study of patients undergoing emergency midline laparotomy from May 2016 to August 2021 was conducted. Cases (patients who suffered from burst abdomen) were matched 1:4 with controls based on age and sex. Rectus diastasis was evaluated on CT imaging and was defined as a distance of at least three centimeters between the rectus abdominis muscles, three centimeters above the umbilicus. Midline laparotomy aponeurosis closure was standardized during the study period, using a slowly absorbable suture, sutured continuously with small bites of five millimeters and a minimum suture-to-wound ratio of 4:1. The primary outcome was the association between rectus diastasis and burst abdomen, evaluated against other suspected risk factors including obesity, liver cirrhosis, previous laparotomy, midline hernias and active smoking in a multivariate analysis.

RESULTS

A total of 465 patients were included in the study, with 93 cases matched to 372 controls. Eighty-four patients had rectus diastasis (35.5% cases vs. 13.7% controls; p =  < 0.001). Multivariate analysis found rectus diastasis significantly associated with burst abdomen (OR 3.06, 95% CI 1.71-5.47; p =  < 0.001). No other suspected risk factors showed a significant association with burst abdomen.

CONCLUSION

Rectus diastasis was highly associated with an increased risk of burst abdomen after emergency midline laparotomy.

Abdominal subcutaneous obesity and the risk of burst abdomen: a matched case-control study

PURPOSE

The causes of burst abdomen after midline laparotomy remain uncertain. Obesity is a suspected risk factor. The purpose of this study was to investigate the association between abdominal subcutaneous obesity (ASO) and burst abdomen in patients undergoing emergency midline laparotomy.

METHODS

We conducted a single-centre, retrospective, matched case-control study of patients undergoing emergency midline laparotomy from May 2016 to August 2021. Patients suffering from burst abdomen were matched 1:4 with controls based on age and sex. Abdominal wall closure was standardized in the study period with the small bites, small stitches technique. ASO was defined as the highest sex-specific quartile (≥ 75%) of subcutaneous fat layer evaluated on CT. The primary outcome was the association between ASO and burst abdomen, stratified between cases and controls. Secondary outcomes included 30- and 90-day mortality, length of stay, and suspected risk factors of burst abdomen, assessed by multivariate analysis across cases and controls.

RESULTS

A total of 475 patients were included in this study, with 95 cases matched to 380 controls. Liver cirrhosis, active smoking, and high alcohol consumption were more common among cases in an unadjusted analysis. Liver cirrhosis (odds ratio (OR) 3.32, p = 0.045) and active smoking (OR 1.98, p = 0.009) remained significant in a multivariate analysis and were associated with burst abdomen. One hundred twenty-four patients had ASO. ASO was not significantly associated with burst abdomen (OR 1.11, p = 0.731).

CONCLUSION

ASO was not found to be associated with an increased risk of burst abdomen after emergency midline laparotomy.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

"Sarcopenia is associated with increased risk of burst abdomen after emergency midline laparotomy: a matched case-control study"

PURPOSE

Burst abdomen is a serious complication commonly observed after emergency midline laparotomy. Sarcopenia has been associated with increased morbidity and mortality after abdominal surgery. This single-center, retrospective, matched case-control study aimed to investigate the association between sarcopenia and burst abdomen in patients undergoing emergency midline laparotomy.

METHODS

Patients who had burst abdomen after emergency midline laparotomy were matched 1:4 with controls based on age and sex. Abdominal wall closure was standardized in the study period with the small bites, small stitches technique. CT assessed psoas cross-sectional area was used as a surrogate measure of sarcopenia. Sarcopenia was defined as the sex-specific lowest quartile of psoas cross-sectional area adjusted for body surface area. The primary outcome was the incidence rate of sarcopenia amongst cases and controls. Secondary outcomes were risk factors for burst abdomen and death that were identified using multivariate logistic regression analysis.

RESULTS

67 cases were matched to 268 controls during May 2016-December 2019. BMI > 30 kg/m², liver cirrhosis, smoking, high ASA score and peritonitis were more frequently observed among cases. Multivariate analysis revealed that sarcopenia (odds ratio (OR) 2.3, p = 0.01), active smoking (OR 2.3, p = 0.006) and liver cirrhosis (OR 3.7, p = 0.042) were significantly associated with burst abdomen. ASA score ≥ 3 (OR 5.5, p = 0.001) and ongoing malignant disease (OR 3.2, p = 0.001) were significantly associated with increased 90-day mortality.

CONCLUSION

Sarcopenia is associated with increased risk of burst abdomen after midline laparotomy. Prospective trials are needed.

Guidelines for Treatment of Umbilical and Epigastric Hernias From the European and Americas Hernia Societies-A Web-Based Survey on Surgeons' Opinion

Background and aims: The European and Americas Hernia Society's (EHS and AHS) Guidelines on the treatment of primary midline ventral hernias were launched to guide surgeons. As a part of a dissemination plan of the guideline, this study aimed to evaluate the level of consensus between recommendations and the current surgical practices of EHS and AHS members before implementation. Material and methods: A questionnaire was constructed including questions on the current practice of the members and nine selected key recommendations from the guidelines. An on-stage consensus voting was performed at the EHS Congress in Hamburg 2019 followed by a SurveyMonkey sent to all EHS and AHS members. Consensus with a recommendation was defined as an agreement of ≥70%. Results: A total of 178 votes were collected in Hamburg. A further 499/1,754 (28.4%) of EHS and 150/1,100 (13.6%) of AHS members participated in the SurveyMonkey. A consensus was reached for 7/9 (78%) of the recommendations. The two recommendations that did not reach consensus were on indication and the technique used for laparoscopic repair. In current practice, more AHS participants used a preformed patch; 50.7% (76/150) compared with EHS participants 32.1% (160/499), p < 0.001. Conclusion: A consensus was achieved for most recommendations given by the new guideline for the treatment of umbilical and epigastric hernias. Recommendations that did not reach consensus were on indication and technique for laparoscopic repair, which may reflect the lack of evidence on these topics.

High rate of incisional hernia observed after mass closure of burst abdomen

PURPOSE

This study investigated the long-term development of incisional hernia after implementation of a standardized surgical treatment strategy for burst abdomen in abdominal midline incisions with a continuous mass closure technique.

METHODS

The study was a single-center, observational study evaluating all patients treated for burst abdomen between June 2014 and April 2019 with a long-term follow-up in October 2020. In June 2014, a standardized surgical treatment for burst abdomen involving a monofilament, slowly absorbable suture in a continuous mass-closure stitch with large bites of 3 cm and small steps of 5 mm was introduced. The occurrence of incisional hernia was investigated and defined as a radiological-, clinical-, or intraoperative finding of a hernia in the abdominal midline incision at follow-up.

RESULTS

Ninety-four patients suffered from burst abdomen during the study period. Eighty patients were eligible for follow-up. The index surgery prior to burst abdomen was an emergency laparotomy in 78% (62/80) of the patients. Nineteen patients died within the first 30 postoperative days and 61 patients were available for further analysis. The long-term incisional hernia rate was 33% (20/61) with a median follow-up of 17 months (min 4, max 67 months).

CONCLUSION

Standardized surgery for burst abdomen with a mass-closure technique using slow absorbable running suture results in high rates of long-term incisional hernias, comparable to the hernia rates reported in the literature among this group of patients.

Novel suturing technique, based on physical principles, achieves a breaking point double that obtained by conventional techniques

BACKGROUND

Sutures have been used to repair wounds since ancient times. However, the basic suture technique has not significantly changed. In Phase I of our project, we proposed a “double diabolo” suture design, using a theoretical physical study to show that this suture receives 50% less tension than conventional sutures, and so a correspondingly greater force must be applied to break it.

AIM

To determine whether these theoretical levels of resistance were met by the new type of suture.

METHODS

An observational study was performed to compare three types of sutures, using a device that exerted force on the suture until the breaking point was reached. The tension produced by this traction was measured. The following variables were considered: Tearing stress on entry/exit points, edge separation stress, and suture break stress. The study sample consisted of 30 sutures with simple interrupted stitches (Group 1), 30 with continuous stitches (Group 2), and 30 with the “double diabolo” design (Group 3).

RESULTS

The mean degree of force required to reach the breaking point for each of these variables (tearing, separation, and final breaking) was highest in Group 3 (14.56, 18.28, and 21.39 kg), followed by Group 1 (7.36, 10.38, and 12.81 kg) and Group 2 (5.77, 7.7, and 8.71 kg). These differences were statistically significant (P < 0.001) in all cases.

CONCLUSION

The experimental results show that with the “double diabolo” suture, compared with conventional sutures, greater force must be applied to reach the breaking point (almost twice as much as in the simple interrupted suture and more than double that required for the continuous suture). If these results are confirmed in Phase III (the clinical phase) of our study, we believe the double diabolo technique should be adopted as the standard approach, especially when the suture must withstand significant tension (e.g., laparotomy closure, thoracotomy closure, diaphragm suture, or hernial orifice closure).

Laparoscopic Treatment of Incisional and Ventral Hernia

Background and Objectives

Although several large studies regarding patients undergoing minimally invasive repair of incisional hernia are currently available, the results are not particularly reliable as they are based on heterogeneous groups, different surgical techniques, different mesh types, or with a too short follow period.

Methods

We conducted a retrospective observational trial, collecting data from patients who underwent laparoscopic repair of a primary abdominal wall or an incisional hernia using the laparoscopic Intraperitoneal Onlay Mesh technique and a single mesh type, i.e., a composite polyester mesh with a hydrophilic film (Parietex Composite^TM mesh - Medtronic, Minneapolis, MN - USA). All patients signed an informed consent.

Results

One thousand seven hundred seventy-seven patients were enrolled. The median surgery time was 50 minutes and the median length of hospital stay was 2 days. Intraoperative complications occurred in 12 patients (0.7%), while early postoperative surgical complications occurred in 115 (6.5%); during follow-up, bulging mesh was diagnosed in 4.5% of cases and hernia recurred in 4.3% of patients. An overlap equal or greater than 4 cm resulted as a significant protective factor, while the use of absorbable fixing devices was a risk factor for recurrence (odds ration: 9.06, p < 0.001, 95% confidence interval: 4.19 - 19.57).

Conclusions

Minimally invasive treatment of primary and postincisional abdominal wall hernias is a safe, effective, and reproducible procedure. An overlap equal or greater than 4 cm, the use of nonabsorbable fixing devices and a postoperative care and follow-up regime are crucial in order to obtain good results and low recurrence rates.

Incidence, Burden on the Health Care System, and Factors Associated With Incisional Hernia After Trauma Laparotomy

Importance

The evidence provided supports routine and systematic capture of long-term outcomes after trauma, lengthening the follow-up for patients at risk for incisional hernia (IH) after trauma laparotomy (TL), counseling on the risk of IH during the postdischarge period, and consideration of preventive strategies before future abdominal operations to lessen IH prevalence as well as the patient and health care burden.

Objective

To determine burden of and factors associated with IH formation following TL at a population-based level across health care settings.

Design, Setting, and Participants

This population-based cohort study included adult patients who were admitted with traumatic injuries and underwent laparotomy with follow-up of 2 or more years. The study used 18 statewide databases containing data collected from January 2006 through December 2016 and corresponding to 6 states in diverse regions of the US. Longitudinal outcomes were identified within the Statewide Inpatient, Ambulatory, and Emergency Department Databases. Patients admitted with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for traumatic injuries with 1 or more concurrent open abdominal operations were included. Data analysis was conducted from March 2020 through June 2020.

Main Outcomes and Measures

The primary outcome was IH after TL. Risk-adjusted Cox regression allowed identification of patient-level, operative, and postoperative factors associated with IH.

Results

Of 35 666 patients undergoing TL, 3127 (8.8%) developed IH (median [interquartile range] follow-up, 5.6 [3.4-8.6] years). Patients had a median age of 49 (interquartile range, 31-67) years, and most were male (21 014 [58.9%]), White (21 584 [60.5%]), and admitted for nonpenetrating trauma (28 909 [81.1%]). The 10-year IH rate and annual incidence were 11.1% (95% CI, 10.7%-11.5%) and 15.6 (95% CI, 15.1-16.2) cases per 1000 people, respectively. Within risk-adjusted analyses, reoperation (adjusted hazard ratio [aHR], 1.28 [95% CI, 1.2-1.37]) and subsequent abdominal surgeries (aHR, 1.71 [95% CI, 1.56-1.88]), as well as obesity (aHR, 1.88 [95% CI, 1.69-2.10]), intestinal procedures (aHR, 1.47 [95% CI, 1.36-1.59]), and public insurance (aHRs: Medicare, 1.38 [95% CI, 1.20-1.57]; Medicaid, 1.35 [95% CI, 1.21-1.51]) were among the variables most strongly associated with IH. Every additional reoperation at the index admission and subsequently resulted in a 28% (95% CI, 20%-37%) and 71% (95% CI, 56%-88%) increased risk for IH, respectively. Repair of IH represented an additional $36.1 million in aggregate costs (39.9%) relative to all index TL admissions.

Conclusions and Relevance

Incisional hernia after TL mirrors the epidemiology and patient profile characteristics seen in the elective setting. We identified patient-level, perioperative, and novel postoperative factors associated with IH, with obesity, intestinal procedures, and repeated disruption of the abdominal wall among the factors most strongly associated with this outcome. These data support preemptive strategies at the time of reoperation to lessen IH incidence. Longer follow-up may be considered after TL for patients at high risk for IH.

Total endoscopic sublay mesh repair for umbilical hernias

Umbilical hernias constitute some of the most common surgical diseases addressed by surgeons. Endoscopic techniques have become standard of care together with the conventional open techniques for the treatment of umbilical hernias. Several different approaches were described to achieve laparoscopic sublay repair.We prospectively collected and reviewed the medical records of 10 patients with umbilical hernias underwent total endoscopic sublay repair (TES) at our institution from November 2017 to November 2019. All operations were performed by a same surgical team. The demographics, intraoperative details, and postoperative complications were evaluated.All TES procedures were successfully performed without conversion to an open operation. No intraoperative morbidity was encountered. The average operative time was 109.5 minutes (range, 80-140 minutes). All the patients resumed an oral diet within 6 hours after the intervention. The mean time to ambulation was 7.5 hours (range, 4-14 hours), and mean postoperative hospital stay was 2.2 day (range, 1-4 days). One patient developed postoperative seroma. No wound complications, chronic pain, or recurrence were registered during the follow-up.Initial experiences with this technique show that the TES is a safe, and effective procedure for the treatment of umbilical hernias.

Interrupted sutures prevent recurrent abdominal fascial dehiscence: a comparative retrospective single center cohort analysis of risk factors of burst abdomen and its recurrence as well as surgical repair techniques

Background

Burst abdomen (BA) is a severe complication after abdominal surgery, which often requires urgent repair. However, evidence on surgical techniques to prevent burst abdomen recurrence (BAR) is scarce.

Methods

We conducted a retrospective analysis of patients with BA comparing them to patients with superficial surgical site infections from the years 2015 to 2018. The data was retrieved from the institutional wound register. We analyzed risk factors for BA occurrence as well as its recurrence after BA repair and surgical closure techniques that would best prevent BAR.

Results

We included 504 patients in the analysis, 111 of those suffered from BA. We found intestinal resection (OR 172.510; 22.195–1340.796, p < 0.001), liver cirrhosis (OR 4.788; 2.034–11.269, p < 0.001) and emergency surgery (OR 1.658; 1.050–2.617; p = 0.03) as well as postoperative delirium (OR 5.058; 1.349–18.965, p = 0.016) as the main predictor for developing BA. The main reason for BA was superficial surgical site infection (40.7%). 110 patients received operative revision of the abdominal fascial dehiscence and 108 were eligible for BAR analysis with 14 cases of BAR. Again, post-operative delirium was the patient-related predictor for BAR (OR 13.73; 95% CI 1.812–104-023, p = 0.011). The surgical technique of using interrupted sutures opposed to continuous sutures showed a preventive effect on BAR (OR 0.143, 95% CI 0.026–0,784, p = 0.025). The implantation of an absorbable IPOM mesh did not reduce BAR, but it did reduce the necessity of BAR revision significantly.

Conclusion

The use of interrupted sutures together with the implantation of an intraabdominal mesh in burst abdomen repair helps to reduce BAR and the need for additional revision surgeries.

Management of abdominal wound dehiscence: update of the literature and meta-analysis

PURPOSE

Abdominal wound dehiscence (AWD) is associated with significant morbidity and mortality. We aimed to provide a contemporary overview of management strategies for AWD.

METHODS

PubMed, EMBASE, the Cochrane library and a clinical trials registry were searched from 2009 onwards using the key words "abdominal wound dehiscence", "fascial dehiscence" and "burst abdomen". Study outcomes included surgical site infection (SSI), recurrence, incisional hernia and 30-day mortality. Studies reported by the EHS clinical guidelines on AWD were included and compared with. OpenMetaAnalyst was used for meta-analysis to calculate statistical significance and odds ratios (OR).

RESULTS

Nineteen studies were included reporting on a total of 632 patients: 16 retrospective studies, one early terminated randomized controlled trial, one review and the European Hernia Society guidelines. Nine studies reported use of synthetic mesh (n = 241), two of which used vacuum-assisted mesh-mediated fascial traction (VAWCM) (n = 19), six without VAWCM (n = 198) and one used synthetic mesh with both VAWCM (n = 6) and without VAWCM (n = 18); two used biological mesh (n = 19). Seven studies reported primary suture closure (n = 299). Three studies reported on an alternative method (n = 91). Follow-up ranged between 1 and 96 months. Meta-analysis was performed to compare the primary suture group with the synthetic mesh group. Heterogeneity was low to moderate depending on outcome. The overall SSI rate in the primary suture group was 27.6% versus 27.9% in the synthetic mesh group, resulting in mesh explantation in five patients; OR 0.65 (95% CI 0.23-1.81). Incisional hernia rates were 11.1% in the synthetic mesh group (19/171) and 30.7% in the primary suture group (67/218); OR 4.01 (95% CI 1.70-9.46). Recurrence rate did not show a statistically significant difference at 2.7% in the synthetic mesh group (3/112), compared to 10.2% in the primary suture group (21/206); OR 1.81 (95% CI 0.18-17.80). Mortality rates varied between 11.2% and 16.7% for primary suture group versus synthetic mesh; OR 1.85 (95% CI 0.91-3.76).

CONCLUSION

Included studies were of low to very low quality. The use of synthetic mesh results in a significantly lower rate of incisional hernia, whereas SSI rate was comparable to primary suture repair.

Laparoscopic Abdominal Wall Hernia Repair

Background and Objectives

The aim of this retrospective monocentric study was to evaluate results and recurrence rate with long-term follow-up after laparoscopic incisional/ventral hernia repair.

Methods

This was a retrospective, single-center, observational trial, collecting data from patients who underwent laparoscopic incisional/ventral abdominal hernia repair using the open intraperitoneal onlay mesh technique and a single mesh type. All patients signed an informed consent form before surgery.

Results

A total of 1,029 patients were included. The median surgery time was 40 min (range 30-55) and the median length of hospital stay was 2 d (range 2-3). Intraoperative complications occurred in two of 1,029 patients (0.19%), whereas early postoperative surgical complications (within 30 d) occurred in 50 patients (4.86%). Postoperative complications according to Clavien-Dindo classification were as follows: I, 3.30% (34 of 1,029); II, 0.97% (10 of 1,029); IIIB, 0.58% (six of 1,029); IV, 0.00% (none of 1,029); and V, 0.00% (none of 1,029). During follow-up, bulging mesh was diagnosed in 58 of 1,029 patients (5.6%), and hernia recurred in 40 of 1,029 patients (3.9%). A mesh overlap equal to or greater than 4 cm appeared to be a significant protective factor for hernia recurrence (P < .001); a mesh overlap equal or greater than 5 cm appeared to be a significant protective factor for bulging (P < .001), whereas the use of resorbable fixing devices was a significant risk factor for hernia recurrence (odds ratio, 111.53, P < .001, 95% confidence interval, 21.53-577.67).

Conclusion

This study demonstrates that laparoscopic repair of ventral/incisional abdominal wall hernias is a safe, effective, and reproducible procedure. Identified risk factors for recurrence are an overlap of less than 4 cm and the use of resorbable fixation means.

Standardized Surgical Primary Repair for Burst Abdomen Reduces the Risk of Fascial Redehiscence

OBJECTIVE

To determine whether a standardized surgical primary repair for burst abdomen could lower the rate of fascial redehiscence.

SUMMARY BACKGROUND DATA

Burst abdomen after midline laparotomy is associated with increased morbidity and mortality. The surgical treatment is poorly investigated but known for a poor outcome with high rates of re-evisceration (redehiscence).

METHODS

This study was a single-center, interventional study comparing rates of fascial redehiscence after surgery for burst abdomen in a study cohort (July 2014-April 2019) to a historical cohort (January 2009-December 2013). A standardized surgical strategy was introduced for burst abdomen: The abdominal wall was closed using a slowly absorbable running suture in a mass closure technique with "large bites" of 3 cm in "small steps" of 5 mm, in an approximate wound-suture ratio of 1:10. Demographics, comorbidities, preceding type of surgery, and surgical technique were registered. The primary outcome was fascial redehiscence. The secondary outcome was 30- and 90-day mortality.

RESULTS

The study included 186 patients with burst abdomen (92 patients in the historical cohort vs 94 patients in the study cohort). No difference in sex, performance status, comorbidity, or body mass index was found. In 77% of the historical cohort and 80% of the study cohort, burst abdomen occurred after emergency laparotomy (P = 0.664). The rate of redehiscence was reduced from 13% (12/92 patients) in the historical cohort to 4% (4/94 patients) in the study cohort (P = 0.033). There was no difference in 30- or 90-day mortality.

CONCLUSION

Standardized surgical primary repair for burst abdomen reduced the rate of fascial redehiscence.

The PINCH-Phone: a new screenings method for recurrent incisional hernias

BACKGROUND

Debate persists on the optimal management of incisional hernias due to paucity of accurate recurrence rates. Reoperation rates implicate a severe underestimation of the risk of a recurrence. Therefore, long-term postoperative clinic visits allowing physical examination of the abdomen are deemed necessary. However, these are time and costs consuming. Aim of this study was to develop and evaluate a new screenings method for recurrent hernias, the 'PINCH-Phone' (Post-INCisional-Hernia repair-Phone).

METHODS

The PINCH-Phone is a telephone questionnaire. In this multicenter prospective study, the PINCH-Phone was answered by patients after incisional hernia repair. Afterwards the patients were seen at the clinic and physical examination was done to detect any recurrences.

RESULTS

The PINCH-Phone questions were answered by 210 patients with a median postoperative follow-up of 36 months. Fifty-six patients were seen after multiple incisional hernia repairs. In 137 patients who had replied positively to one or more questions, 28 recurrent incisional hernias were detected at physical examination. Six recurrences were noted in 73 patients who had replied negatively to all questions. The overall sensitivity and specificity of the PINCH-Phone were 82% and 38%, respectively.

CONCLUSION

The PINCH-Phone appears a simple and valuable screenings method for recurrences after incisional hernia repair and, hence, is recommended for implementation.

Modified Peritoneal Flap Hernioplasty Versus Retromuscular Technique for Incisional Hernia Repair: a Retrospective Cohort Study

BACKGROUND AND AIMS

We present an open retromuscular mesh technique for incisional hernia repair, the modified peritoneal flap hernioplasty, where the fascia is sutured to the mesh and the hernia sac utilized for anterior mesh coverage. The aim was to describe the modified peritoneal flap hernioplasty technique and to compare it to a retromuscular repair, without component separation, regarding short-term complications, patient satisfaction, abdominal wall complaints, and recurrent incisional hernia.

MATERIALS AND METHODS

Consecutive patients operated electively with modified peritoneal flap hernioplasty technique (December 2012-December 2015) or retromuscular technique (Jan 2011-Oct 2014) were included in a retrospective single-center cohort study. Outcomes were evaluated from the Swedish Ventral Hernia Registry, by chart review, physical examination, and an abdominal wall complaints questionnaire.

RESULTS

The modified peritoneal flap hernioplasty group (n = 78) had larger hernias (mean width 10.4 vs 8.5 cm, p = 0.005), more advanced Centers for Disease Control classification (p = 0.009), and more simultaneous gastrointestinal-tract surgery (23.1% vs 11.5%, p = 0.041) than the retromuscular group (n = 96). No difference in short-term complications was seen. Incisional hernia recurrence was lower in the modified peritoneal flap hernioplasty group (1.4% vs 10.3%, p = 0.023), and patients were more satisfied (93.8% vs 81.7%, p = 0.032). Follow-up time was shorter in the modified peritoneal flap hernioplasty group (614 vs 1171 days, p < 0.001).

CONCLUSION

This retrospective study showed similar rates of short-term complications, despite more complex hernias in the modified peritoneal flap hernioplasty group. Furthermore, a lower incisional hernia recurrence rate for the modified peritoneal flap hernioplasty technique compared with the retromuscular technique used in our department was found. If this holds true with equally long follow-up remains to be proven.

Meta-analysis on Materials and Techniques for Laparotomy Closure: The MATCH Review

BACKGROUND

The aim of this systematic review and meta-analysis was to evaluate closure materials and suture techniques for emergency and elective laparotomies. The primary outcome was incisional hernia after 12 months, and the secondary outcomes were burst abdomen and surgical site infection.

METHODS

A systematic literature search was conducted until September 2017. The quality of the RCTs was evaluated by at least 3 assessors using critical appraisal checklists. Meta-analyses were performed.

RESULTS

A total of 23 RCTs were included in the meta-analysis. There was no evidence from RCTs using the same suture technique in both study arms that any suture material (fast-absorbable/slowly absorbable/non-absorbable) is superior in reducing incisional hernias. There is no evidence that continuous suturing is superior in reducing incisional hernias compared to interrupted suturing. When using a slowly absorbable suture for continuous suturing in elective midline closure, the small bites technique results in significantly less incisional hernias than a large bites technique (OR 0.41; 95% CI 0.19, 0.86).

CONCLUSIONS

There is no high-quality evidence available concerning the best suture material or technique to reduce incisional hernia rate when closing a laparotomy. When using a slowly absorbable suture and a continuous suturing technique with small tissue bites, the incisional hernia rate is significantly reduced compared with a large bites technique.

Prophylactic Intraperitoneal Onlay Mesh Reinforcement Reduces the Risk of Incisional Hernia, Two-Year Results of a Randomized Clinical Trial

BACKGROUND

Incisional hernias still are a major concern after laparotomy and are causing substantial morbidity. This study examines the feasibility, safety and incisional hernia rate of the use of a prophylactic intraperitoneal onlay mesh stripe (IPOM) to prevent incisional hernia following midline laparotomy.

METHODS

This prospective, randomized controlled trial randomly allocated patients undergoing median laparotomy either to mass closure of the abdominal wall with a PDS-loop running suture reinforced by an intraperitoneal composite mesh stripe (Group A) or to the same procedure without the additional mesh stripe (Group B). Primary endpoint was the incidence of incisional hernias at 2 years following midline laparotomy. Secondary endpoints are were the feasibility, the safety of the mesh stripe implantation including postoperative pain, and the incidence of incisional hernias at 5 years.

RESULTS

A total of 267 patients were included in this study. Follow-up data 2 years after surgery was available from 210 patients (Group A = 107; Group B = 103). An incisional hernia was diagnosed in 18/107 (17%) patients in Group A and in 40/103 (39%) patients in Group B (p < 0.001). A surgical operation due to an incisional hernia was conducted for 12/107 (11%) patients in Group A and for 24/103 (23%) patients in Group B (p = 0.039). In both groups, minor and major complications as well as postoperative pain are reported with no statistically significant difference between the groups, even in contaminated situations.

CONCLUSIONS

This first randomized clinical trial indicates that the placement of a non-absorbable IPOM-stripe with prophylactic intention may significantly reduce the risk for a midline incisional hernia.

TRIAL REGISTRATION

Ref. NCT01003067 (clinicaltrials.gov).

Suture choice to reduce occurrence of surgical site infection, hernia, wound dehiscence and sinus/fistula: a network meta-analysis

BACKGROUND

There are many options and little guiding evidence when choosing suture types with which to close the abdominal wall fascia. This network meta-analysis investigated the effect of suture materials on surgical site infection, hernia, wound dehiscence and sinus/fistula occurrence after abdominal surgery. The aim was to provide clarity on whether previous recommendations on suture choice could be followed with confidence.

METHODS AND METHODS

In February 2017, the Cochrane Central Register of Controlled Trials, Medline, EMBASE and Science Citation Index Expanded were searched for randomised controlled trials investigating the effect of suture choice on these four complications in closing the abdomen. A reference search of identified trials was performed. Prisma guidelines and the Cochrane risk of bias tool were followed in the data extraction and synthesis. Two review authors screened titles and abstracts of trials identified. A random effect model was used for the surgical site infection network based on the deviance information criterion statistics.

RESULTS

Thirty-one trials were included (11,533 participants). No suture material reached the predetermined 90% probability threshold for determination of 'best treatment' for any outcome. Pairwise comparisons largely showed no differences between suture types for all outcomes measured. However, nylon demonstrated a reduction in the occurrence of incisional hernias with respect to two commonly used absorbable sutures: polyglycolic acid (odds ratio, OR 1.91; 95% confidence interval, CI, 1.01-3.63) and polyglyconate (OR 2.18; 95% CI 1.17-4.07).

CONCLUSIONS

No suture type can be considered the 'best treatment' for the prevention of surgical site infection, hernia, wound dehiscence and sinus/fistula occurrence.

Comparing different modalities for the diagnosis of incisional hernia: a systematic review

PURPOSE

Incisional hernia (IH) is the most frequent complication after abdominal surgery. The diagnostic modality, observer, definition, and diagnostic protocol used for the diagnosis of IH potentially influence the reported prevalence. The objective of this systematic review is to evaluate the diagnostic accuracy of different modalities used to identify IH.

METHODS

Embase, MEDLINE OvidSP, Web of Science, Google Scholar, and Cochrane databases were searched to identify studies diagnosing IH. Studies comparing the IH detection rate of two different diagnostic modalities or inter-observer variability of one modality were included. Quality assessment of studies was done by Cochrane Collaboration's tool. Article selection and data collection were performed independently by two researchers. PROSPERO registration: CRD42017062307.

RESULTS

Fifteen studies representing a total of 2986 patients were included. Inter-observer variation for CT-scan ranged from 11.2 to 69% (n = 678). Disagreement between ultrasound and CT-scan ranged between 6.6 and 17% (n = 221). Ten studies compared physical examination to CT-scan or ultrasound. Disagreement between physical examination and imaging ranged between 7.6 and 39% (n = 1602). Between 15 and 58% of IHs were solely detected by imaging (n = 483). Relative increase in IH prevalence for imaging compared to physical examination ranged from 0.92 to 2.4 (n = 1922).

CONCLUSIONS

Ultrasound or CT-scan will result in substantial additional IH diagnosis. Lack of consensus regarding the definition of IH might contribute to the disagreement rates. Both the observer and diagnostic modality used could be additional factors explaining variability in IH prevalence and should be reported in IH research.

Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications

BACKGROUND

Surgeons who perform laparotomy have a number of decisions to make regarding abdominal closure. Material and size of potential suture types varies widely. In addition, surgeons can choose to close the incision in anatomic layers or mass ('en masse'), as well as using either a continuous or interrupted suturing technique, of which there are different styles of each. There is ongoing debate as to which suturing techniques and suture materials are best for achieving definitive wound closure while minimising the risk of short- and long-term complications.

OBJECTIVES

The objectives of this review were to identify the best available suture techniques and suture materials for closure of the fascia following laparotomy incisions, by assessing the following comparisons: absorbable versus non-absorbable sutures; mass versus layered closure; continuous versus interrupted closure techniques; monofilament versus multifilament sutures; and slow absorbable versus fast absorbable sutures. Our objective was not to determine the single best combination of suture material and techniques, but to compare the individual components of abdominal closure.

SEARCH METHODS

On 8 February 2017 we searched CENTRAL, MEDLINE, Embase, two trials registries, and Science Citation Index. There were no limitations based on language or date of publication. We searched the reference lists of all included studies to identify trials that our searches may have missed.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared suture materials or closure techniques, or both, for fascial closure of laparotomy incisions. We excluded trials that compared only types of skin closures, peritoneal closures or use of retention sutures.

DATA COLLECTION AND ANALYSIS

We abstracted data and assessed the risk of bias for each trial. We calculated a summary risk ratio (RR) for the outcomes assessed in the review, all of which were dichotomous. We used random-effects modelling, based on the heterogeneity seen throughout the studies and analyses. We completed subgroup analysis planned a priori for each outcome, excluding studies where interventions being compared differed by more than one component, making it impossible to determine which variable impacted on the outcome, or the possibility of a synergistic effect. We completed sensitivity analysis, excluding trials with at least one trait with high risk of bias. We assessed the quality of evidence using the GRADEpro guidelines.

MAIN RESULTS

Fifty-five RCTs with a total of 19,174 participants met the inclusion criteria and were included in the meta-analysis. Included studies were heterogeneous in the type of sutures used, methods of closure and patient population. Many of the included studies reported multiple comparisons.For our primary outcome, the proportion of participants who developed incisional hernia at one year or more of follow-up, we did not find evidence that suture absorption (absorbable versus non-absorbable sutures, RR 1.07, 95% CI 0.86 to 1.32, moderate-quality evidence; or slow versus fast absorbable sutures, RR 0.81, 95% CI 0.63 to 1.06, moderate-quality evidence), closure method (mass versus layered, RR 1.92, 95% CI 0.58 to 6.35, very low-quality evidence) or closure technique (continuous versus interrupted, RR 1.01, 95% CI 0.76 to 1.35, moderate-quality evidence) resulted in a difference in the risk of incisional hernia. We did, however, find evidence to suggest that monofilament sutures reduced the risk of incisional hernia when compared with multifilament sutures (RR 0.76, 95% CI 0.59 to 0.98, I² = 30%, moderate-quality evidence).For our secondary outcomes, we found that none of the interventions reduced the risk of wound infection, whether based on suture absorption (absorbable versus non-absorbable sutures, RR 0.99, 95% CI 0.84 to 1.17, moderate-quality evidence; or slow versus fast absorbable sutures, RR 1.16, 95% CI 0.85 to 1.57, moderate-quality evidence), closure method (mass versus layered, RR 0.93, 95% CI 0.67 to 1.30, low-quality evidence) or closure technique (continuous versus interrupted, RR 1.13, 95% CI 0.96 to 1.34, moderate-quality evidence).Similarily, none of the interventions reduced the risk of wound dehiscence whether based on suture absorption (absorbable versus non-absorbable sutures, RR 0.78, 95% CI 0.55 to 1.10, moderate-quality evidence; or slow versus fast absorbable sutures, RR 1.55, 95% CI 0.92 to 2.61, moderate-quality evidence), closure method (mass versus layered, RR 0.69, 95% CI 0.31 to 1.52, moderate-quality evidence) or closure technique (continuous versus interrupted, RR 1.21, 95% CI 0.90 to 1.64, moderate-quality evidence).Absorbable sutures, compared with non-absorbable sutures (RR 0.49, 95% CI 0.26 to 0.94, low-quality evidence) reduced the risk of sinus or fistula tract formation. None of the other comparisons showed a difference (slow versus fast absorbable sutures, RR 0.88, 95% CI 0.05 to 16.05, very low-quality evidence; mass versus layered, RR 0.49, 95% CI 0.15 to 1.62, low-quality evidence; continuous versus interrupted, RR 1.51, 95% CI 0.64 to 3.61, very low-quality evidence).

AUTHORS' CONCLUSIONS

Based on this moderate-quality body of evidence, monofilament sutures may reduce the risk of incisional hernia. Absorbable sutures may also reduce the risk of sinus or fistula tract formation, but this finding is based on low-quality evidence.We had serious concerns about the design or reporting of several of the 55 included trials. The comparator arms in many trials differed by more than one component, making it impossible to attribute differences between groups to any one component. In addition, the patient population included in many of the studies was very heterogeneous. Trials included both emergency and elective cases, different types of disease pathology (e.g. colon surgery, hepatobiliary surgery, etc.) or different types of incisions (e.g. midline, paramedian, subcostal).Consequently, larger, high-quality trials to further address this clinical challenge are warranted. Future studies should ensure that proper randomisation and allocation techniques are performed, wound assessors are blinded, and that the duration of follow-up is adequate. It is important that only one type of intervention is compared between groups. In addition, a homogeneous patient population would allow for a more accurate assessment of the interventions.

Synthetic sutures: Clinical evaluation and future developments

Today's sutures are the result of a 4000-year innovation process with regard to their materials and manufacturing techniques, yet little has been done to enhance the therapeutic value of the suture itself. In this review, we explore the historical development, regulatory database and clinical literature of sutures to gain a fuller picture of suture advances to date. First, we examine historical shifts in suture manufacturing companies and review suture regulatory databases to understand the forces driving suture development. Second, we gather the existing clinical evidence of suture efficacy from reviewing the clinical literature and the Food and Drug Administration database in order to identify to what extent sutures have been clinically evaluated and the key clinical areas that would benefit from improved suture materials. Finally, we apply tissue engineering and regenerative medicine design hypotheses to suture materials to identify routes by which bioactive sutures can be designed and passed through regulatory hurdles, to improve surgical outcomes. Our review of the clinical literature revealed that many of the sutures currently in use have been available for decades, yet have never been clinically evaluated. Since suture design and development is industry driven, incremental modifications have allowed for a steady outflow of products while maintaining a safe regulatory position and limiting costs. Until recently, there has been little academic interest in suture development, however the rise of regenerative medicine strategies is shifting the suture paradigm from an inert material, which mechanically approximates tissue, to a bioactive material, which also actively promotes cell-directed repair and a positive healing response. These materials hold significant therapeutic potential, but could be associated with an increased regulatory burden, cost, and clinical evaluation compared with current devices.

Current Trends in Laparoscopic Ventral Hernia Repair

Background and Objectives:

The purpose of this study was to analyze the surgical technique, postoperative complications, and possible recurrence after laparoscopic ventral hernia repair (LVHR) in comparison with open ventral hernia repair (OVHR), based on the international literature.

Database:

A Medline search of the current English literature was performed using the terms laparoscopic ventral hernia repair and incisional hernia repair.

Conclusions:

LVHR is a safe alternative to the open method, with the main advantages being minimal postoperative pain, shorter recovery, and decreased wound and mesh infections. Incidental enterotomy can be avoided by using a meticulous technique and sharp dissection to avoid thermal injury.

Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial

BACKGROUND

Incisional hernia is a frequent complication of midline laparotomy and is associated with high morbidity, decreased quality of life, and high costs. We aimed to compare the large bites suture technique with the small bites technique for fascial closure of midline laparotomy incisions.

METHODS

We did this prospective, multicentre, double-blind, randomised controlled trial at surgical and gynaecological departments in ten hospitals in the Netherlands. Patients aged 18 years or older who were scheduled to undergo elective abdominal surgery with midline laparotomy were randomly assigned (1:1), via a computer-generated randomisation sequence, to receive small tissue bites of 5 mm every 5 mm or large bites of 1 cm every 1 cm. Randomisation was stratified by centre and between surgeons and residents with a minimisation procedure to ensure balanced allocation. Patients and study investigators were masked to group allocation. The primary outcome was the occurrence of incisional hernia; we postulated a reduced incidence in the small bites group. We analysed patients by intention to treat. This trial is registered at Clinicaltrials.gov, number NCT01132209 and with the Nederlands Trial Register, number NTR2052.

FINDINGS

Between Oct 20, 2009, and March 12, 2012, we randomly assigned 560 patients to the large bites group (n=284) or the small bites group (n=276). Follow-up ended on Aug 30, 2013; 545 (97%) patients completed follow-up and were included in the primary outcome analysis. Patients in the small bites group had fascial closures sutured with more stitches than those in the large bites group (mean number of stitches 45 [SD 12] vs 25 [10]; p<0·0001), a higher ratio of suture length to wound length (5·0 [1·5] vs 4·3 [1·4]; p<0·0001) and a longer closure time (14 [6] vs 10 [4] min; p<0·0001). At 1 year follow-up, 57 (21%) of 277 patients in the large bites group and 35 (13%) of 268 patients in the small bites group had incisional hernia (p=0·0220, covariate adjusted odds ratio 0·52, 95% CI 0·31-0·87; p=0·0131). Rates of adverse events did not differ significantly between groups.

INTERPRETATION

Our findings show that the small bites suture technique is more effective than the traditional large bites technique for prevention of incisional hernia in midline incisions and is not associated with a higher rate of adverse events. The small bites technique should become the standard closure technique for midline incisions.

FUNDING

Erasmus University Medical Center and Ethicon.

Systematic Review and Meta-Regression of Factors Affecting Midline Incisional Hernia Rates: Analysis of 14,618 Patients

BACKGROUND

The incidence of incisional hernias (IHs) following midline abdominal incisions is difficult to estimate. Furthermore recent analyses have reported inconsistent findings on the superiority of absorbable versus non-absorbable sutures.

OBJECTIVE

To estimate the mean IH rate following midline laparotomy from the published literature, to identify variables that predict IH rates and to analyse whether the type of suture (absorbable versus non-absorbable) affects IH rates.

METHODS

We undertook a systematic review according to PRISMA guidelines. We sought randomised trials and observational studies including patients undergoing midline incisions with standard suture closure. Papers describing two or more arms suitable for inclusion had data abstracted independently for each arm.

RESULTS

Fifty-six papers, describing 83 separate groups comprising 14,618 patients, met the inclusion criteria. The prevalence of IHs after midline incision was 12.8% (range: 0 to 35.6%) at a weighted mean of 23.7 months. The estimated risk of undergoing IH repair after midline laparotomy was 5.2%. Two meta-regression analyses (A and B) each identified seven characteristics associated with increased IH rate: one patient variable (higher age), two surgical variables (surgery for AAA and either surgery for obesity surgery (model A) or using an upper midline incision (model B)), two inclusion criteria (including patients with previous laparotomies and those with previous IHs), and two circumstantial variables (later year of publication and specifying an exact significance level). There was no significant difference in IH rate between absorbable and non-absorbable sutures either alone or in conjunction with either regression analysis.

CONCLUSIONS

The IH rate estimated by pooling the published literature is 12.8% after about two years. Seven factors account for the large variation in IH rates across groups. However there is no evidence that suture type has an intrinsic effect on IH rates.

Systematic review of intervention design and delivery in pragmatic and explanatory surgical randomized clinical trials

BACKGROUND

Surgical interventions are complex, with multiple components that require consideration in trial reporting. This review examines the reporting of details of surgical interventions in randomized clinical trials (RCTs) within the context of explanatory and pragmatic study designs.

METHODS

Systematic searches identified RCTs of surgical interventions published in 2010 and 2011. Included studies were categorized as predominantly explanatory or pragmatic. The extent of intervention details in the reports were compared with the CONSORT statement for reporting trials of non-pharmacological treatments (CONSORT-NPT). CONSORT-NPT recommends reporting the descriptions of surgical interventions, whether they were standardized and adhered to (items 4a, 4b and 4c). Reporting of the context of intervention delivery (items 3 and 15) and operator expertise (item 15) were assessed.

RESULTS

Of 4541 abstracts and 131 full-text articles, 80 were included (of which 39 were classified as predominantly pragmatic), reporting 160 interventions. Descriptions of 129 interventions (80.6 per cent) were provided. Standardization was mentioned for 47 (29.4 per cent) of the 160 interventions, and 22 articles (28 per cent) reported measurement of adherence to at least one aspect of the intervention. Seventy-one papers (89 per cent) provided some information about context. For one-third of interventions (55, 34.4 per cent), some data were provided regarding the expertise of personnel involved. Reporting standards were similar in trials classified as pragmatic or explanatory.

CONCLUSION

The lack of detail in trial reports about surgical interventions creates difficulties in understanding which operations were actually evaluated. Methods for designing and reporting surgical interventions in RCTs, contributing to the quality of the overall study design, are required. This should allow better implementation of trial results into practice.

Subcutaneous Suture Can Accelerate Wound Healing of Lower Midline Incision: A Randomized Controlled Trial

Poor wound healing is one of the most common complications after laparotomy, especially in lower abdominal midline incisions. The aims of this trial are to assess the value of subcutaneous suture and identify risk factors to prevent poor wound healing. From October 2010 to October 2011, a total of 180 patients were randomized to the subcutaneous suture group (n = 89) or control group (n = 91) after laparotomy with a lower midline incision. Univariate and multivariate analyses were performed to determine the predictive significance of variables of poor wound healing. Patients’ demographics, preoperative laboratory values, and operative details were comparable between the two groups. The overall rate of poor wound healing was 16.7 per cent (30 of 180). Patients randomized to subcutaneous suture group (n = 89) had poor healing in 10.1 per cent (nine of 89) and those without suture (n = 91) in 23.1 per cent (21 of 91) ( P = 0.020). Multivariate logistic regression analysis revealed that American Society of Anesthesiologists (ASA) score (3 to 4) (odds ratio [OR], 2.933), subcutaneous suture (OR, 0.323), and blood loss (greater than 200 mL) (OR, 5.995) were independent risk factors for poor wound healing. Subcutaneous suture can effectively accelerate wound healing. Nonsubcutaneous suture, ASA score (3 to 4), and blood loss (greater than 200 mL) are independent risk factors for poor would healing.

New suture materials for midline laparotomy closure: an experimental study

Background

Midline laparotomy closure carries a significant risk of incisional hernia. This study examines the behavior of two new suture materials, an elastic material, polyurethane (PUe), and a barbed polydioxanone (PDXb) suture thread in a rabbit model of midline incision closure.

Methods

Three 2-cm midline incisions were made in 68 New Zealand White rabbits. The incisions were closed by running suture using four 3/0 threads: polypropylene (PP) (Surgipro®, Covidien), PUe (Assuplus®, Assut Europe), PDX (Assufil®, Assut Europe) or PDXb (Filbloc®, Assut Europe). Animals in each suture group were euthanized 3 weeks and 6 months after surgery. Histological sections of the tissue-embedded sutures were subjected to morphological, collagen expression, macrophage response and uniaxial tensiometry studies.

Results

No signs of wound dehiscence or complications were observed. At 3 weeks, all sutures were surrounded by connective tissue composed mainly of collagen III. PUe showed greater collagen I expression than the other sutures. All sutures elicited a macrophage response that diminished from 3 weeks to 6 months (p < 0.001). This response was similar for the non-reabsorbable sutures (PP and PUe) yet PDXb showed a significantly greater response than the other reabsorbable suture (PDX) at 3 weeks (p < 0.01). At this early time point, the tensile strength of PUe was similar to that of control intact tissue (p > 0.05).

Conclusion

Three weeks after surgery, PUe revealed more collagen I deposition than the remaining materials and this translated to a similar biomechanical behavior to linea alba, that could avoid the appearance of short term dehiscences and thus reduce the incidence of incisional hernia. PDXb provides no additional advantages in their behavior regarding PDX suture.

Wound dehiscence: outcome comparison for sutured and mesh reconstructed patients

PURPOSE

Treatment guidelines for abdominal wound dehiscence (WD) are lacking. The primary aim of the study was to compare suture to mesh repair in WD patients concerning incisional hernia incidence. Secondary aims were to compare recurrent WD, morbidity, mortality and long-term abdominal wall complaints.

METHODS

A retrospective chart review of 46 consecutive patients operated for WD between January 2010 and August 2012 was conducted. Physical examination and a questionnaire enquiry were performed in January 2013.

RESULTS

Six patients were treated by vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) before definitive closure. Three patients died early resulting in 23 patients closed by suture and 20 by mesh repair. Five sutured, but no mesh repair patients had recurrent WD (p = 0.051) with a mortality of 60 %. Finally, 18 sutured and 21 mesh repair patients were eligible for follow-up. The incidence of incisional hernia was higher for the sutured patients (53 vs. 5 %, p = 0.002), while mesh repair patients had a higher short-term morbidity rate (76 vs. 28 %, p = 0.004). Abdominal wall complaints were rare in both groups.

CONCLUSIONS

Suture of WD was afflicted with a high incidence of recurrent WD and incisional hernia formation. Mesh repair overcomes these problems at the cost of more wound complications. VAWCM seems to be an alternative for treating contaminated patients until definitive closure is possible. Long-term abdominal wall complaints are uncommon after WD treatment.

Short- and long-term biomechanical and morphological study of new suture types in abdominal wall closure

To perform an abdominal-wall closure, a continuous suture is the preferred method. The suture materials that are most commonly employed in abdominal surgery are polypropylene and polydioxanone. However, in recent times, new products have been marketed, such as non-absorbable polyurethane with elastic properties (Assuplus(®), Assut Europe, Italy) and absorbable barbed polydioxanone (Filbloc(®), Assut Europe, Italy). The purpose of this study was to compare the ability of those against the standard polypropylene (Surgipro(TM), Covidien, USA) and polydioxanone (Assufil(®), Assut Europe, Italy) to mimic the biomechanical behavior of the abdominal wall closure. Comparison of the sutures was made first with the materials alone and later in a laparotomy closure of a rabbit abdomen, used as an animal model. The biomechanical analysis consisted of uniaxial tensile tests of threads and sutured samples of the animal abdomen. In the latter case, results were analyzed at short- (21days) and long- (180days) term intervals after the surgery. The morphology studies and collagen expression of the samples were also investigated. The results determined that polydioxanone and polypropylene sutures showed a linear elastic behavior, with barbed polydioxanone as the most compliant suture and polyurethane as the stiffest. The sutured samples showed a statistically significant loss of resistance, measured as the load needed to perform a certain stretch, when compared with the corresponding control tissue. Analysis of the stress-stretch curves showed that elastic polyurethane was the only suture able to reproduce the mechanical behavior of healthy tissue in the short term, while the rest of the sutures remained less stiff. This coincides with the expression of type I collagen observed in this group at this point in the study. In the long term, there was no difference among the sutures, and none was able to mimic control behavior.

Prevention of incisional hernias: how to close a midline incision

The development of wound complications is closely related to the surgical technique at wound closure. The risk of the suture technique affecting the development of wound dehiscence and incisional hernia can be monitored through the suture length to wound length ratio. Midline incisions should be closed in one layer by a continuous-suture technique using a monofilament suture material tied with self-locking knots. Excessive tension should not be placed on the suture. Closure must always be with a suture length to wound length ratio higher than 4.

Short-term outcomes for open and laparoscopic midline incisional hernia repair: a randomized multicenter controlled trial: the ProLOVE (prospective randomized trial on open versus laparoscopic operation of ventral eventrations) trial

OBJECTIVE

: The aim of the trial was to compare laparoscopic technique with open technique regarding short-term pain, quality of life (QoL), recovery, and complications.

BACKGROUND

: Laparoscopic and open techniques for incisional hernia repair are recognized treatment options with pros and cons.

METHODS

: Patients from 7 centers with a midline incisional hernia of a maximum width of 10 cm were randomized to either laparoscopic (LR) or open sublay (OR) mesh repair. Primary end point was pain at 3 weeks, measured as the bodily pain subscale of Short Form-36 (SF-36). Secondary end points were complications registered by type and severity (the Clavien-Dindo classification), movement restrictions, fatigue, time to full recovery, and QoL up to 8 weeks.

RESULTS

: Patients were recruited between October 2005 and November 2009. Of 157 randomized patients, 133 received intervention: 64 LR and 69 OR. Measurements of pain did not differ, nor did movement restriction and postoperative fatigue. SF-36 subscales favored the LR group: physical function (P < 0.001), role physical (P < 0.012), mental health (P < 0.022), and physical composite score (P < 0.009). Surgical site infections were 17 in the OR group compared with 1 in the LR group (P < 0.001). The severity of complications did not differ between the groups (P < 0.213).

CONCLUSIONS

: Postoperative pain or recovery at 3 weeks after repair of midline incisional hernias does not differ between LR and OR, but the LR results in better physical function and less surgical site infections than the OR does. (ClinicalTrials.gov Identifier: NCT00472537).

A Prospective Randomized Study Comparing Non-absorbable Polypropylene (Prolene®) and Delayed Absorbable Polyglactin 910 (Vicryl®) Suture Material in Mass Closure of Vertical Laparotomy Wounds

Wound dehiscence is a postoperative complication encountered following abdominal surgery. A prospective randomized study was conducted to compare the incidence of wound dehiscence with a delayed absorbable and a nonabsorbable suture material in the mass closure of vertical laparotomy wounds. In one group, 100 patients were analyzed after closure with Prolene®, and in another group, 100 patients were analyzed after closure with Vicryl®. The incision was closed by continuous far and near suture technique using polypropylene (Prolene) suture in one group and a synthetic delayed absorbable polyglactin 910 (Vicryl) suture in the other group. There was significant difference in the incidence of wound dehiscence between the two groups: 6 % with Prolene and 17 % with Vicryl, (χ (2) = 5.944, 1 DF, P value = 0.0148). The overall incidence of wound dehiscence was 11.5 % in this study. The incidence of wound dehiscence in both the study groups was higher than expected as compared to previous literature. There was a significant difference between the two suture materials. In our study, Prolene is a better suture material for closure of vertical laparotomy wounds.

[Results of a national survey on abdominal wall closure]

OBJECTIVE

To assess knowledge on the abdominal wall closure through a surgeon cohort survey.

METHODS

A twenty question individual questionnaire on laparotomy in elective surgery.

RESULTS

A total of 131 surgeons from seven hospitals responded (72% specialists and 28% in training). 71% of respondents estimated the frequency of incisional hernia to be higher than 15% and 54% considered the technique to be the most significant risk factor. 85% considered midline laparotomy closed with slow absorbable suture (57%) in a single layer (66%) to be the most appropriate technique. 67% believed retention sutures to be the appropriate prevention technique. 50% did not know or could not apply the 4:1 technique. 87% considered that an incisional hernia can be prevented and that the technique is the most important factor on which to act. 84% believed that a prosthesis can prevent the occurrence of incisional hernia, whereas 40% of respondents never use it and only 38% use it in patients at risk. On comparing surveys between specialists and residents, significant differences appeared in terms of a better understanding of the theoretical technical aspects in trainee surgeons.

CONCLUSIONS

Although the results show an adequate understanding of the epidemiology and risk factors for development of incisional hernia, training and consensus measures are likely to be introduced in some basic technical aspects in order to improve results in laparotomy closure.

Closing midline abdominal incisions

BACKGROUND

The most important wound complications are surgical site infection, wound dehiscence and incisional hernia. Experimental and clinical evidences support that the development of wound complications is closely related to the surgical technique at wound closure.

RESULTS

The suture technique monitored through the suture length-to-wound length ratio is of major importance for the development of wound complications. The risk of wound dehiscence is low with a high ratio. The ratio must be higher than 4; otherwise, the risk of developing an incisional hernia is increased four times. With a ratio higher than 4, both the rate of wound infection and incisional hernia are significantly lower if closure is done with small stitches placed 5 to 8 mm from the wound edge than with larger stitches placed more than 10 mm from the wound edge.

CONCLUSIONS

Midline incisions should be closed in one layer by a continuous suture technique. A monofilament suture material should be used and be tied with self-locking knots. Excessive tension should not be placed on the suture. Wounds must always be closed with a suture length-to-wound length ratio higher than 4. The only way to ascertain this is to measure, calculate and document the ratio at every wound closure. A high ratio should be accomplished with many small stitches placed 5 to 8 mm from the wound edge at very short intervals.