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Kvist M, Jensen TK, Snitkjær C, Burcharth J. The clinical consequences of burst abdomen after emergency midline laparotomy: a prospective, observational cohort study. Hernia 2024; 28:1861-1870. [PMID: 39031235 PMCID: PMC11449993 DOI: 10.1007/s10029-024-03104-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/25/2024] [Indexed: 07/22/2024]
Abstract
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.
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Affiliation(s)
- Madeline Kvist
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital - Herlev and Gentofte Herlev, Herlev, Denmark.
| | - Thomas Korgaard Jensen
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital - Herlev and Gentofte Herlev, Herlev, Denmark
| | - Christian Snitkjær
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital - Herlev and Gentofte Herlev, Herlev, Denmark
| | - Jakob Burcharth
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital - Herlev and Gentofte Herlev, Herlev, Denmark
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Lozada Hernández EE, Hernández Bonilla JP, Hinojosa Ugarte D, Magdaleno García M, Mayagoitía González JC, Zúñiga Vázquez LA, Obregón Moreno E, Jiménez Herevia AE, Cethorth Fonseca RK, Ramírez Guerrero P. Abdominal wound dehiscence and incisional hernia prevention in midline laparotomy: a systematic review and network meta-analysis. Langenbecks Arch Surg 2023; 408:268. [PMID: 37418033 DOI: 10.1007/s00423-023-02954-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 05/22/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Incisional hernia (IH) is the main complication after laparotomy. In an attempt to reduce this complication, mesh techniques and studies in which the closure technique is modified have been proposed. Both types are characterized by comparison with the closure described as standard or conventional: 1 × 1, mass, and continuous closure. For this study, modified closure techniques (MCTs) were considered as those techniques in which an extra suture is placed (reinforced tension line (RTL), retention), the closure point is modified in distance (small bites) or shape (CLDC, Smead Jones, interrupted, Cardiff point) and which aim to reduce these complications. The objective of this network meta-analysis (NMA) was to evaluate the effectiveness of MCTs for reducing the incidence of IH and abdominal wound dehiscence (AWD) to provide objective support for their recommendation. METHODS An NMA was performed according to the PRISMA-NMA guidelines. The primary objective was to determine the incidence of IH and AWD, and the secondary objective was to determine the incidence of postoperative complications. Only published clinical trials were included. The risk of bias was analyzed, and the random-effects model was used to determine statistical significance. RESULTS Twelve studies comparing 3540 patients were included. The incidence of HI was lower in RTL, retention suture, and small bites, these techniques showed statistical differences with pooled ORs (95% CI) of 0.28 (0.09-0.83), 0.28 (0.13-0.62), and 0.44 (0.31-0.62), respectively. Associated complications, including hematoma, seroma, and postoperative pain, could not be analyzed; however, MCTs did not increase the risk of surgical site infection. CONCLUSION Small bites, RTL, and retention sutures decreased the prevalence of IH. RTL and retention suture decreased the prevalence of AWD. RTL was the best technique as it reduced both complications (IH and AWD) and had the best SUCRA and P-scores, and the number needed to treat (NNT) for net effect was 3. REGISTRATION This study was prospectively registered in the PROSPERO database under registration number CRD42021231107.
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Affiliation(s)
- Edgard Efrén Lozada Hernández
- General Surgery, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajio, Circuito Quinta los Naranjos # 145 B. Colonia Quinta los Naranjos, León Guanajuato, México.
| | - Juan Pablo Hernández Bonilla
- General Surgery, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajio, Circuito Quinta los Naranjos # 145 B. Colonia Quinta los Naranjos, León Guanajuato, México
| | - Diego Hinojosa Ugarte
- General Surgery, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajio, Circuito Quinta los Naranjos # 145 B. Colonia Quinta los Naranjos, León Guanajuato, México
| | | | | | - Luis Abraham Zúñiga Vázquez
- General Surgery, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajio, Circuito Quinta los Naranjos # 145 B. Colonia Quinta los Naranjos, León Guanajuato, México
| | - Enrique Obregón Moreno
- General Surgery, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajio, Circuito Quinta los Naranjos # 145 B. Colonia Quinta los Naranjos, León Guanajuato, México
| | - Aldo Edyair Jiménez Herevia
- General Surgery, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajio, Circuito Quinta los Naranjos # 145 B. Colonia Quinta los Naranjos, León Guanajuato, México
| | - Roland Kevin Cethorth Fonseca
- General Surgery, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajio, Circuito Quinta los Naranjos # 145 B. Colonia Quinta los Naranjos, León Guanajuato, México
| | - Paulina Ramírez Guerrero
- General Surgery, Department of Diseases of the Digestive Tract, Regional Hospital of High Specialty of Bajio, Circuito Quinta los Naranjos # 145 B. Colonia Quinta los Naranjos, León Guanajuato, México
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Kvist M, Henriksen NA, Burcharth J, Nielsen YW, Jensen TK. Rectus diastasis increases risk of burst abdomen in emergency midline laparotomies: a matched case–control study. Hernia 2022; 27:353-361. [PMID: 36422726 DOI: 10.1007/s10029-022-02719-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/13/2022] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- M Kvist
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark.
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark.
| | - N A Henriksen
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - J Burcharth
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - Y W Nielsen
- Department of Radiology, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - T K Jensen
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
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Abdominal subcutaneous obesity and the risk of burst abdomen: a matched case-control study. Langenbecks Arch Surg 2022; 407:3719-3726. [PMID: 36125516 DOI: 10.1007/s00423-022-02682-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/12/2022] [Indexed: 10/14/2022]
Abstract
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.
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Voldby AW, Boolsen AW, Aaen AA, Burcharth J, Ekeløf S, Loprete R, Jønck S, Eskandarani HA, Thygesen LC, Møller AM, Brandstrup B. Complications and Their Association with Mortality Following Emergency Gastrointestinal Surgery-an Observational Study. J Gastrointest Surg 2022; 26:1930-1941. [PMID: 35606601 DOI: 10.1007/s11605-021-05240-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 12/29/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE Emergency gastrointestinal surgery is followed by a high risk of major complications and death. This study aimed to investigate which complications showed the strongest association with death following emergency surgery for gastrointestinal obstruction or perforation. METHODS We retrospectively included adults who had undergone emergency gastrointestinal surgery for radiologically verified obstruction or perforation at three Danish hospitals between 2014 and 2015. The exposure variables comprised 16 predefined Clavien-Dindo-graded complications. Cox regression with delayed entry was used to analyze the association of these complications with 90-day mortality. We adjusted for hospital, age, American Society of Anesthesiologists classification, pre-operative Sepsis-2 score, cardiac comorbidity, renal comorbidity, hypertension, active cancer, bowel obstruction or perforation, and the surgical procedure. Subgroup analyses were done for patients with gastrointestinal obstruction or perforation. RESULTS Of the 349 included patients, 281 (80.5%) experienced at least one complication. The risk of death was 20.6% (14) for patients with no complications and varied between 21 and 57% for patients with complications. Renal impairment (hazard ratio (HR): 6.8 (95%CI: 3.7-12.4)), arterial thromboembolic events (HR 4.8 (2.3-9.9)), and atrial fibrillation (HR 4.4 (2.8-6.8)) showed the strongest association with 90-day mortality. Atrial fibrillation was the only complication significantly associated with death in patients with gastrointestinal obstruction as well as perforation. CONCLUSION This study of patients undergoing emergency gastrointestinal surgery revealed that renal impairment, arterial thromboembolic events, and atrial fibrillation had the strongest association with death. Atrial fibrillation may serve as an in-situ marker of patients needing escalation of care.
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Affiliation(s)
- Anders Winther Voldby
- Department of Surgery, Holbæk Hospital, Part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark.
| | - Anders Watt Boolsen
- Department of Surgery, Holbæk Hospital, Part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark
| | - Anne Albers Aaen
- Department of Anesthesiology and Intensive Care Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Jakob Burcharth
- Department of Surgery, Zealand University Hospital, Roskilde, Denmark
| | - Sarah Ekeløf
- Department of Surgery, Zealand University Hospital, Roskilde, Denmark
| | | | - Simon Jønck
- Department of Emergency Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Hassan Ali Eskandarani
- Department of Anesthesiology and Intensive Care Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Lau Caspar Thygesen
- Department of Population Health and Morbidity, University of Southern Denmark, Odense, Denmark
| | - Ann Merete Møller
- Department of Anesthesiology and Intensive Care Medicine, Herlev Hospital, Herlev, Denmark
| | - Birgitte Brandstrup
- Department of Surgery, Holbæk Hospital, Part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark
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Jensen TK, Nielsen YW, Gögenur I, Tolstrup MB. "Sarcopenia is associated with increased risk of burst abdomen after emergency midline laparotomy: a matched case-control study". Eur J Trauma Emerg Surg 2022; 48:4189-4196. [PMID: 35353215 DOI: 10.1007/s00068-022-01958-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 03/13/2022] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Thomas Korgaard Jensen
- Surgical Section, Department of Gastrointestinal- and Hepatic Diseases, Copenhagen University Hospital Herlev, 2730, Herlev, Denmark.
| | | | - Ismail Gögenur
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Copenhagen University Hospital, 4600, Koege, Denmark
| | - Mai-Britt Tolstrup
- Department of Surgery, North-Zealand University Hospital, 3400, Hilleroed, Denmark
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High rate of incisional hernia observed after mass closure of burst abdomen. Hernia 2021; 26:1267-1274. [PMID: 34674087 DOI: 10.1007/s10029-021-02523-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022]
Abstract
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.
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Standardized Surgical Primary Repair for Burst Abdomen Reduces the Risk of Fascial Redehiscence. Ann Surg 2020; 274:e1115-e1118. [PMID: 32209894 DOI: 10.1097/sla.0000000000003766] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Pedroso AR, Melo RMD, Oliveira ECD. Relaxation incisions and tensile strength in the abdominal wall of pigs. Acta Cir Bras 2019; 34:e201900608. [PMID: 31432999 PMCID: PMC6705344 DOI: 10.1590/s0102-865020190060000008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/05/2019] [Indexed: 11/26/2022] Open
Abstract
Purpose To analyze the resistance to medial traction of abdominal wall muscles, before and after performing relaxing incisions. Methods Seventeen live pigs were used. After a median laparotomy, the handles were made in the rectus abdominis muscles (RAM) to fit the dynamometer. Step 1 (control phase): tensile strength measured without performing relaxant incisions. Step 2: A curvilinear relaxant incision was made on the anterior blade of the right RAM sheath and then the tensile strength was measured by the edge of the wound. The same procedure was adopted after incision of the left posterior blade. Step 3: Relaxing incisions were made in the right posterior and left anterior blade, so that both sides were left with a relaxing incision on both blades. Measurements of resistance were performed. Results There was no statistically significant difference between the sides. On the right and left side, all treatments reduced the tensile strength when compared to each other and to the control. There was a reduction of 12% and 9.8% after incision of the anterior and posterior blade, respectively. Conclusion Relaxing incisions reduced tensile strength in the ventral abdominal wall.
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Affiliation(s)
- Aline Ribeiro Pedroso
- Fellow Master degree, Postgraduate Program in Health Sciences , Faculdade de Medicina , Universidade Federal de Goiás (FM-UFG), Goiania - GO , Brazil . Design of the study, technical procedures, acquisition and interpretation of data, manuscript writing
| | - Renato Miranda de Melo
- PhD, Associate Professor, Division of Operative Technique and Experimental Surgery , FM - UFG , Goiania - GO , Brazil . Conception, design, intellectual and scientific content of the study; technical procedures; critical revision
| | - Enio Chaves de Oliveira
- PhD, Associate Professor, Postgraduate Program in Health Sciences, Department of Surgery , FM - UFG , Goiania - GO , Brazil . Technical procedures, intellectual and scientific content of the study, critical revision
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A New Method for Surgical Abdominal Mass Closure After Abdominal Fascial Dehiscence Using Nasogastric Tube and Hemovac Perforator: A Case-Series Study. World J Surg 2018; 42:3106-3111. [DOI: 10.1007/s00268-018-4607-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Patel SV, Paskar DD, Nelson RL, Vedula SS, Steele SR. Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications. Cochrane Database Syst Rev 2017; 11:CD005661. [PMID: 29099149 PMCID: PMC6486019 DOI: 10.1002/14651858.cd005661.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Sunil V Patel
- Kingston General HospitalDepartment of Surgery76 Stuart StreetKingstonONCanadaK7L 2V7
| | - David D Paskar
- University of TorontoDivision of Trauma, Department of General SurgeryTorontoONCanada
| | - Richard L Nelson
- University of Illinois School of Public HealthEpidemiology/Biometry Division1603 West TaylorRoom 956ChicagoIllinoisUSA60612
| | | | - Scott R Steele
- Cleveland ClinicDepartment of Colorectal SurgeryClevelandOhioUSA44106
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Reduced Rate of Dehiscence After Implementation of a Standardized Fascial Closure Technique in Patients Undergoing Emergency Laparotomy. Ann Surg 2017; 265:821-826. [DOI: 10.1097/sla.0000000000001762] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Abstract
OBJECTIVES Postoperative wound disruption is associated with high morbidity and mortality. We sought to identify the risk factors and outcomes of wound disruption following colorectal resection. METHODS The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to examine the clinical data of patients who underwent colorectal resection from 2005 to 2013. Multivariate regression analysis was performed to identify risk factors of wound disruption. RESULTS We sampled a total of 164,297 patients who underwent colorectal resection. Of these, 2073 (1.3 %) had wound disruption. Patients with wound disruption had significantly higher mortality (5.1 vs. 1.9 %, AOR: 1.46, P = 0.01). The highest risk of wound disruption was seen in patients with wound infection (4.8 vs. 0.9 %, AOR: 4.11, P < 0.01). A number of factors are associated with wound disruption such as chronic steroid use (AOR: 1.71, P < 0.01), smoking (AOR: 1.60, P < 0.01), obesity (AOR: 1.57, P < 0.01), operation length more than 3 h (AOR: 1.56, P < 0.01), severe Chronic Obstructive Pulmonary Disease (COPD) (AOR: 1.36, P < 0.01), urgent/emergent admission (AOR: 1.31, P = 0.01), and serum Albumin Level <3 g/dL (AOR: 1.27, P < 0.01). Laparoscopic surgery had significantly lower risk of wound disruption compared to open surgery (AOR: 0.61, P < 0.01). CONCLUSION Wound disruption occurs in 1.3 % of colorectal resections, and it correlates with mortality of patients. Wound infection is the strongest predictor of wound disruption. Chronic steroid use, obesity, severe COPD, prolonged operation, non-elective admission, and serum albumin level are strongly associated with wound disruption. Utilization of the laparoscopic approach may decrease the risk of wound disruption when possible.
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Bosanquet DC, Ansell J, Abdelrahman T, Cornish J, Harries R, Stimpson A, Davies L, Glasbey JCD, Frewer KA, Frewer NC, Russell D, Russell I, Torkington J. Systematic Review and Meta-Regression of Factors Affecting Midline Incisional Hernia Rates: Analysis of 14,618 Patients. PLoS One 2015; 10:e0138745. [PMID: 26389785 PMCID: PMC4577082 DOI: 10.1371/journal.pone.0138745] [Citation(s) in RCA: 225] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 09/03/2015] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
| | - James Ansell
- University Hospital of Wales, Cardiff, CF14 4XW, United Kingdom
| | | | - Julie Cornish
- University Hospital of Wales, Cardiff, CF14 4XW, United Kingdom
| | - Rhiannon Harries
- Morriston Hospital, Heol Maes Eglwys, Swansea, SA6 6NL, United Kingdom
| | - Amy Stimpson
- Glan Clwyd Hospital, Rhyl, LL18 5UJ, United Kingdom
| | - Llion Davies
- University Hospital of Wales, Cardiff, CF14 4XW, United Kingdom
| | | | - Kathryn A. Frewer
- Cardiff University School of Medicine, Cardiff, CF14 4XN, United Kingdom
| | - Natasha C. Frewer
- Cardiff University School of Medicine, Cardiff, CF14 4XN, United Kingdom
| | - Daphne Russell
- Swansea University College of Medicine, Swansea, SA2 8AA, United Kingdom
| | - Ian Russell
- Swansea University College of Medicine, Swansea, SA2 8AA, United Kingdom
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15
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Brandl A, Laimer E, Perathoner A, Zitt M, Pratschke J, Kafka-Ritsch R. Incisional hernia rate after open abdomen treatment with negative pressure and delayed primary fascia closure. Hernia 2013; 18:105-11. [PMID: 23456149 DOI: 10.1007/s10029-013-1064-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 02/17/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE Various techniques for delayed primary fascia closure have been published in patients treated with open abdomen (OA) and application of negative pressure, but to date, no data are available on incisional hernia (IH) rate. The aim of this retrospective analysis was to investigate the long-term outcome of this patient population with special interest in IH development. METHODS Two hundred and nine consecutive patients, 90(43 %) female, were treated at our institution for various abdominal emergencies involving OA from June 2006 to June 2011. Mean age was 63(16-92) years. The indication was abdominal sepsis in 155(74 %) patients, ischemia in 24(12 %) and other reasons in 30(14 %). Hospital mortality was 21 %(n = 44); and planned ventral hernia was 7 %(n = 15); and mortality until follow-up was 16 %(n = 25), and 9 %(n = 13) patients were lost to follow-up, leaving 112 patients for evaluation of IH development. RESULTS The rate of IH for patients with OA and delayed primary fascia closure was overall 35 % at a median (range) follow-up time of 26(12-81) months. Mean time for development of a ventral hernia was 11 months; 21(57 %) patients underwent surgery for symptomatic hernia (2 emergency operations for incarceration). Kaplan-Meier estimate for 5 years gave a 66 % IH rate. BMI, small bowel as source of infection and rapid adsorbable interrupted suture were identified risk factors. CONCLUSION The rate of IH after open abdomen treatment with delayed primary fascia closure is high with a running suture with slow absorbable suture material showing the best results.
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Affiliation(s)
- A Brandl
- Department of Visceral, Thorax and Transplant Surgery, University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
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Scholtes M, Kurmann A, Seiler CA, Candinas D, Beldi G. Intraperitoneal mesh implantation for fascial dehiscence and open abdomen. World J Surg 2012; 36:1557-61. [PMID: 22402974 DOI: 10.1007/s00268-012-1534-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative fascial dehiscence and open abdomen are severe postoperative complications and are associated with surgical site infections, fistula, and hernia formation at long-term follow-up. This study was designed to investigate whether intraperitoneal implantation of a composite prosthetic mesh is feasible and safe. METHODS A total of 114 patients with postoperative fascial dehiscence and open abdomen who had undergone surgery between 2001 and 2009 were analyzed retrospectively. Contaminated (wound class 3) or dirty wounds (wound class 4) were present in all patients. A polypropylene-based composite mesh was implanted intraperitoneally in 51 patients, and in 63 patients the abdominal wall was closed without mesh implantation. The primary endpoint was incidence of incisional hernia, and the incidence of enterocutaneous fistula was a secondary endpoint. RESULTS The incidence of enterocutaneous fistulas after wound closure post-fascial dehiscence (13% vs. 6% without and with mesh, respectively) or post-open abdomen (22% vs. 28% without and with mesh, respectively) was not significantly different. The incidence of incisional hernia was significantly lower with mesh implantation compared with no-mesh implantation in both contaminated (4% vs. 28%; p = 0.025) and dirty abdominal cavities (5% vs. 34%; p = 0.01). CONCLUSIONS Intra-abdominal contamination is not a contraindication for intra-abdominal mesh implantation. The incidence of enterocutaneous fistula is not elevated despite the presence of contamination. The rate of incisional hernias is significantly reduced after intraperitoneal mesh implantation for postoperative fascial dehiscence or open abdomen.
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Affiliation(s)
- Moritz Scholtes
- Department of Visceral Surgery and Medicine, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
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Moussavian MR, Schuld J, Dauer D, Justinger C, Kollmar O, Schilling MK, Richter S. Long term follow up for incisional hernia after severe secondary peritonitis—incidence and risk factors. Am J Surg 2010; 200:229-34. [DOI: 10.1016/j.amjsurg.2009.08.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 08/17/2009] [Accepted: 08/17/2009] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Critics of minimally invasive methods sometimes argue that the summed lengths of all trocar sites have a morbidity similar to that for an open incision of equal length. This argument assumes correctly that pain and scarring are proportional to the total tension normal to a linear incision. But the argument also assumes that total tension sums linearly with incision length. This report demonstrates why that premise is not valid. METHODS Wounds of various sizes are compared using a simple mathematical model. The closing tension perpendicular to any linear incision is a function of the incision's length, varying symmetrically together with a maximum at the midpoint of length. If tension rises linearly across an incision, integration of the tension relationship demonstrates that the total wound tension actually is proportional to the square of the length. In this report, incisions of various lengths are modeled, and plausible alternative incision scenarios for various procedures (e.g., Nissen, appendectomy) are compared. RESULTS Total tension rises nonlinearly with increasing wound length. Thus, total tension across multiple incisions is always less than the total tension for an incision of the same total length. For example, an open appendectomy creates 2.7-fold more wound tension than a laparoscopic appendectomy. Similarly, two 3-mm trocars create less total tension than a single 5-mm trocar. CONCLUSION Conventional incisions are subject to more total tension than any combination of trocar incisions of equal total length. This inequality yields three clinically relevant corollaries. First, it supports the practice of using the smallest effective trocars (or even no-trocar methods) to minimize pain and scar. Second, addition of a trocar in difficult cases adds relatively little morbidity. Finally, using two small trocars is better than using a single larger trocar.
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