Introduction of Small Stitch Small Bite technique: a retrospective long-term follow-up

Small-bites versus large-bites closure of midline laparotomies: A systematic review and meta-analysis

AIM

Surgical site infection (SSI) and incisional hernia (IH) are common complications following midline laparotomy. The small-bites technique for closing a midline laparotomy has been suggested to improve SSI and IH rates compared with the classic mass closure. The aim of this work was to perform a systematic review, meta-analysis and fragility assessment of existing evidence comparing small-bites and conventional closure.

METHOD

The study was registered with PROSPERO. A systematic search of PubMed and EMBASE databases was performed for all comparative studies examining small-bites versus conventional closure for midline laparotomy. The fragility index for randomized controlled trials (RCTs) was assessed and the number of outcomes required to render results insignificant using the Fisher exact test was calculated.

RESULTS

Seven studies were included, with a total of 3807 patients. Small bites was performed in 1768 and large bites in 2039. Follow-up ranged from 12 to 52 months. On meta-analysis of all studies, small bites is associated with a lower risk of IH (p < 0.00001), SSI (p = 0.0002) and wound dehiscence (p = 0.02). On meta-analysis of RCTs there is a lower risk of IH (p = 0.01) but no difference in SSI (p = 0.06) or wound dehiscence (p = 0.73). Fragility is evident among RCTs reporting differences in IH rates.

CONCLUSION

There is evidence to suggest that small-bites closure provides a decreased likelihood of IH over varying follow-up in RCTs but significant fragility exists among studies.

Short-term outcomes in mesh versus suture-only treatment of burst abdomen: a case-series from a university hospital

PURPOSE

Surgery for a burst abdomen after midline laparotomy is associated with later incisional hernia formation. Accommodating prophylactic measures, notably mesh augmentation, are of interest. However, data regarding safety and outcomes are scarce. This study aimed to evaluate the short-term risk profile of mesh prophylaxis in the context of a burst abdomen.

METHODS

This is a single-center prospective study of patients suffering from burst abdomen from 2021 to 2023. A treatment protocol for the management of burst abdomen was introduced, including the synthetic, partially absorbable onlay mesh. Adult patients (≥ 18 years) with a life expectancy of > 1 year with no plans of future pregnancies were recommended to be treated with a prophylactic mesh. In this analysis, adult patients were included if they suffered from a burst abdomen after elective or emergency laparotomy. The study evaluates short-term outcomes, including 90-day wound complications, length of stay, and mortality.

RESULTS

Sixty-seven patients fulfilled the inclusion criteria and underwent treatment for a burst abdomen during the study period. Thirty-eight patients were treated with a suture-only technique, and 29 patients were supplemented with a mesh. 13 of 14 observed wound complications in the mesh group were of mild degree (Clavien Dindo 1-3b), while one patient (3%) needed mesh-explantation. The 90-day mortality rate was 21% and comparable between suture-only and mesh techniques.

CONCLUSION

Mesh augmentation in surgery for a burst abdomen seems safe in well-selected patients at 90 days follow-up. Long-term data on the prophylactic effect on hernia development is needed.

Incisional Hernia in Cytoreductive Surgery for Advanced-Stage Ovarian Cancer: A Single-Center Retrospective Study

BACKGROUND/OBJECTIVES

An incisional hernia (IH) is a frequent postoperative complication after cytoreductive laparotomic surgery for advanced ovarian cancer (AOC). It occurs in 2-22% of patients in the first two years of follow-up, depending on the series. Although different risk factors have been described for various types of malignancies and surgeries, few studies have analyzed the risk factors for hernia development in ovarian cancer (OC). However, none have examined the role of enhanced recovery after surgery (ERAS) programs.

METHODS

We performed a retrospective study that included patients with AOC and primary or interval debulking surgery through a median laparotomic approach. This study was conducted in Vall d'Hebron Hospital, Barcelona, Spain, between January 2015 and December 2022. Univariate and multivariate regression analyses were conducted.

RESULTS

Of the 156 patients included, 30 (19.2%) presented with an IH. The patients with IHs were smokers in a higher proportion to non-smokers (53.9% vs. 16.1%, p = 0.003) and more frequently presented with wound dehiscence (34.4% vs. 15.0%, p = 0.026). Patients in whom negative pressure wound therapy was applied had a hernia less frequently than those who had not had it (12.5% vs. 26.7%, p = 0.043). Similarly, the incidence of hernia decreased when patients went through an ERAS protocol (10.1% vs. 28.8%, p = 0.008). In the multivariate analysis, smoking was the only independent risk factor (RR 10.84, CI 2.76-42.64), and applying an ERAS protocol was seen to be the sole protective factor (RR 0.22, CI 0.08-0.61) against the development of an IH.

CONCLUSIONS

The implementation of ERAS is highly recommended due to its numerous benefits, most notably the reduction in hernia incidence. Additionally, the preoperative identification of current smokers provides an opportunity for smoking cessation and targeted respiratory prehabilitation, both of which further contribute to IH reduction.

Small bite fascial closure technique reduces incisional hernia rates in gynecologic oncology patients

BACKGROUND

The potential for the technique of small bite fascial closure in mitigating incisional hernias in gynecologic oncology patients still needs to be investigated.

OBJECTIVE

To evaluate the impact of closure of small fascial bites compared with prior standard closure on incisional hernia rates in gynecologic oncology patients.

METHODS

This is a retrospective cohort study comparing patient outcomes before and after the intervention at a single institution at a comprehensive cancer center. Patients who underwent laparotomy with a vertical midline incision for a suspected or known gynecologic malignancy with a 1-year follow-up were included. The pre-intervention cohort (large bites) had 'mass' or modified running Smead-Jones closure. In contrast, the post-intervention cohort had fascial bites taken 5-8 mm laterally with no more than 5 mm travel (small bites) closure using a 2-0 polydioxanone suture.The primary outcome was the incisional hernias rate determined by imaging or clinical examination within the first year of follow-up. Patient factors and peri-operative variates of interest were investigated for their association with hernia formation through univariate and multivariate analyses. These included age, body mass index (BMI), smoking history, estimated blood loss, pre-operative albumin, American Society of Anesthesia (ASA) physical status classification, or treatment with chemotherapy post-operatively.

RESULTS

Of the 255 patients included, the total hernia rate was 12.5% (32/255 patients). Patient characteristics were similar in both cohorts. Small bite closure led to a significant reduction in hernia rates from 17.2% (22/128 patients) to 7.9% (10/127 patients), p=0.025. According to logistic regression modeling, small bite closure (OR=0.40, 95% CI 0.17 to 0.94, p=0.036) was independently associated with lower odds of hernia formation. Other factors associated with increased hernia rates were chemotherapy (OR=3.22, 95% CI 1.22 to 8.51, p=0.019) and obesity (OR=23.4, 95% CI 3.09 to 177, p=0.002). In obese patients, small bite closures led to maximal hernia rate reduction compared with large bites.

CONCLUSIONS

The small bite closure technique effectively reduces hernia rates in gynecologic oncology patients undergoing midline laparotomy.

Small bites versus large bites during fascial closure of midline laparotomies: a systematic review and meta-analysis

PURPOSE

Incisional ventral hernias (IVH) are common after laparotomies, with up to 20% incidence in 12 months, increasing up to 60% at 3-5 years. Although Small Bites (SB) is the standard technique for fascial closure in laparotomies, its adoption in the United States is limited, and Large Bites (LB) is still commonly performed. We aim to assess the effectiveness of SB regarding IVH.

METHODS

We searched for RCTs and observational studies on Cochrane, EMBASE, and PubMed from inception to May 2023. We selected patients ≥ 18 years old, undergoing midline laparotomies, comparing SB and LB for IVH, surgical site infections (SSI), fascial dehiscence, hospital stay, and closure duration. We used RevMan 5.4. and RStudio for statistics. Heterogeneity was assessed with I2 statistics, and random effect was used if I2 > 25%.

RESULTS

1687 studies were screened, 45 reviewed, and 6 studies selected, including 3 RCTs and 3351 patients (49% received SB and 51% LB). SB showed fewer IVH (RR 0.54; 95% CI 0.39-0.74; P < 0.001) and SSI (RR 0.68; 95% CI 0.53-0.86; P = 0.002), shorter hospital stay (MD -1.36 days; 95% CI -2.35, -0.38; P = 0.007), and longer closure duration (MD 4.78 min; 95% CI 3.21-6.35; P < 0.001). No differences were seen regarding fascial dehiscence.

CONCLUSION

SB technique has lower incidence of IVH at 1-year follow-up, less SSI, shorter hospital stay, and longer fascial closure duration when compared to the LB. SB should be the technique of choice during midline laparotomies.

Duramesh registry study: short-term outcomes using mesh suture for abdominal wall closure

Introduction

Sutures are flexible linear elements that join tissue and maintain their hold with a surgeon-created knot. Tension at the suture/tissue interface can cut the very tissues that sutures are designed to hold, leading to dehiscence and incisional hernia formation. A new suture design (Duramesh, Mesh Suture Inc., Chicago, IL) was approved for marketing by the United States Food and Drug Administration in September 2022. The multiple filaments of the mesh suture are designed to diffuse tension at the suture/tissue interface thereby limiting pull-through. The macroporosity and hollow core of the mesh suture encourage fibrovascular incorporation for a durable repair. We created the first registry and clinical report of patients undergoing mesh suture implantation to assess its real-world effectiveness.

Methods

A patient registry was created based on institutional implant logs from January to August 2023 at an integrated health-care system. Operative reports were reviewed by the study team to verify use of "Duramesh" by dictation. Retrospective chart review was conducted to evaluate patient and surgical characteristics, follow-up, and short-term outcomes of interest. Results were analyzed using descriptive statistics and Chi-squared analysis with Microsoft Excel and GraphPad Prism.

Results

Three hundred seventy-nine separate implantations by 56 surgeons across 12 (sub) specialties at a university hospital and two community hospitals were performed. Mesh suture was used for treatment of the abdominal wall in 314 cases. Follow-up averaged 80.8 ± 52.4 days. The most common abdominal wall indications were ventral hernia repair (N = 97), fascial closure (N = 93), abdominal donor site closure from autologous breast reconstruction (N = 51), and umbilical hernia repair (N = 41). Mesh suture was used in all Centers for Disease Control (CDC) wound classifications, including 92 CDC class 2 or 3 abdominal operations. There were 19 surgical site infections (6.1%) and 37 surgical site events (11.8%).

Conclusions

Short-term registry data demonstrates the wide diversity of surgical disciplines and scenarios in which mesh suture has been used to date. The early adoption of mesh suture into practice highlights that consequences of suture pull-through influence operative decision making. As this is the first interim report of the Duramesh mesh suture registry, follow-up is too short for characterization of long-term durability of abdominal wall closures.

A Comparison of a Small-Stitch Closure With a Standard Closure in Midline Laparotomy Incisions: A Prospective Comparative Study

Introduction Midline incision provides a rapid and thorough approach to the abdominal cavity and, therefore, is widely employed in both emergency and elective procedures. However, midline laparotomy is associated with many post-operative complications like wound dehiscence, incisional hernia, fistula formation, and surgical site infection (SSI). The purpose of the study is to compare the complications that occurred post-operatively in association with the long and small bite suture techniques for midline laparotomy incisions. Methodology A prospective comparative study was carried out among 90 cases of midline laparotomies for 18 months (January 2021 to June 2022). The participants were categorized into two groups: (1) Group A, which included 45 patients, underwent small-suture abdominal fascia closure, and (2) Group B, which consisted of the remaining 45 patients, underwent large-suture abdominal midline wound closure. Patients were followed up in the hospital till the day of discharge and in the outpatient department (visit 1, within one month of surgery) for pain, wound dehiscence, and surgical site infection. Patients were called for visit 2 (six months post-surgery) and incisional hernia rates were assessed. Results On the numerical pain rating scale, the mean score was higher in Group B, that is, 4.1 than in Group A, which was 3.5. Wound dehiscence and incisional hernia rates were higher among Group B cases. The majority of SSIs were noted in Group B with statistically significant results. Conclusion Despite the lack of randomization, the results demonstrated in this study support the use of small bite sutures in comparison to long bite sutures for laparotomy closure.