A biomechanical study of the reinforced tension line (RTL) – a technique for abdominal wall closure and incisional hernias

Prevention of incisional hernia with a reinforced tension line (RTL) versus primary suture only in midline laparotomies: 3-year follow-up in a randomized clinical trial

PURPOSE

Incisional hernia (IH) has an incidence of 10-23%, which can increase to 38% in specific risk groups. The objective of this study is to report the results at 3 years of follow-up of the use of the reinforced tension line (RTL) technique compared with primary suture only (PSO) closure in the prevention of IH in high-risk patients undergoing laparotomy.

METHODS

Open randomized controlled clinical trial. Included were patients older than 18 years who underwent midline laparotomy, emergency or scheduled, who were considered high risk, and who completed 3-year follow-up. The patients were randomized 1:1 to the RTL technique or to PSO. The objective was to report the incidence of IH and the complications associated with the closure method. Intention-to-treat analysis and Cox regression were performed.

RESULTS

A total of 124 patients were randomized; 51 patients from the RTL group and 53 patients from the PSO group finished the 3-year follow-up. The incidence of IH was higher in the PSO group (15/53, 28.3%) than the RTL group (5/51, 9.8%) (p = 0.016, OR 0.35, 95% CI 0.14-0.88, number needed to treat 5.4, log-rank test p = 0.017). The groups were similar in the rates of surgical site infection, hematoma, seroma, and postoperative pain during follow-up.

CONCLUSIONS

The RTL technique is useful in the prevention of IH when compared with PSO in high-risk midline laparotomy patients, and it is not associated with a higher percentage of complications.

TRIAL REGISTRATION

Local Committee CI-HRAEB-2013-020. March 13, 2013.

CLINICAL TRIALS

NCT02136628, retrospectively registered.

Determining risk factors for surgical wound dehiscence: a literature review

Postoperative wound healing plays a significant role in facilitating a patient's recovery and rehabilitation. Surgical wound dehiscence (SWD) impacts on mortality and morbidity rates and significantly contributes to prolonged hospital stays and associated psychosocial stressors on individuals and their families. A narrative review of SWD was undertaken on English-only studies between 1945 and 2012 using three electronic databases Ovid CINHAL, Ovid Medline and Pubmed. The aim of this review was to identify predisposing factors for SWD and assessment tools to assist in the identification of at-risk patients. Key findings from the included 15 papers out of a search of 1045 revealed the most common risk factors associated with SWD including obesity and wound infection, particularly in the case of abdominal surgery. There is limited reporting of variables associated with SWD across other surgical domains and a lack of risk assessment tools. Furthermore, there was a lack of clarity in the definition of SWD in the literature. This review provides an overview of the available research and provides a basis for more rigorous analysis of factors that contribute to SWD.

Reinforced tension line suture closure after midline laparotomy in emergency surgery

Midline laparotomy is an emergency surgical operation frequently performed in cases of intra-abdominal pathology. Closure of the incision is usually done by continuous suturing by mass closure. In an emergency operation the intra-abdominal milieu is usually contaminated leading to gut oedema and, hence, an increase in postoperative intra-abdominal pressure. It is complicated by wound dehiscence, burst abdomen, etc. The cause of this complication is an increase in horizontal tensile forces on the site of the insertion of sutures which cuts the sheath. In this technique of reinforced tension line suture peak tensile forces are distributed from the suture base to the surrounding tissue through a horizontal suture, thereby preventing the suture from cutting through the tissue. From July 2007 to June 2009 patients requiring laparotomy were randomly divided into test and control groups by a 'closed envelope' technique. Their postoperative intra-abdominal pressure was recorded by urinary bladder catheter manometry. The result of this technique was compared with the incidence of burst abdomen in cases where it was closed by continuous suture. A total of 190 patients underwent laparotomy. In 90 the abdomen was closed by reinforced tension line (RTL) and in 100 patients by continuous suturing. None of the RTL group had a burst abdomen. Thirteen who had closure by continuous suture had a burst abdomen. The analysis of the results was done using the chi-square test. On comparing the incidence of burst abdomen in cases operated by continuous suture technique and by RTL, the P value was found to be 0.0026 which is highly significant. On analysis of the incidence of burst abdomen in cases having a grade II intra-abdominal pressure the P value was found to be 0.0009 which is highly significant. Closure of midline incision by RTL reduces the incidence of burst abdomen. Registration No. PROVCTRI/2008/091/000269 (http://www.ctri.in).

Preliminary results with the reinforced tension line: a new technique for patients with ventral abdominal wall hernias

BACKGROUND

After median laparotomy, excessive horizontal tensile forces on the suture base or scar tissue lead to incisional hernias or recurrent hernias. Our new suture technique, known as reinforced tension line (RTL), allows peak tensile forces to be distributed from the suture base to the surrounding tissue through a longitudinal suture, thereby preventing the suture from cutting through the tissue.

METHODS

From April 2002 to April 2005, the RTL technique was used to treat 103 patients with ventral abdominal wall hernias > or = 3 cm in size. In patients with larger hernias, tensile forces were measured intraoperatively. Patients with tensions > or = 40 N during fascial closure were excluded from the study. Comorbidities, as well as intraoperative and postoperative complications, were recorded. Early and late complications were monitored during a follow-up period of 12 to 48 months.

RESULTS

Tensile loads > or = 40 N in the fascia were recorded in 7 of 103 patients. The 7 patients were treated with mesh prostheses and excluded from the study. The mean age of the remaining 96 patients was 64 years, and the mean size of the hernial orifice was 58 cm2 (range 7-211 cm2). Twenty-eight patients with hernias underwent acute surgery. No intraoperative complications were encountered. After surgery, 5 patients developed hematomas that did not require revision surgery. Five asymptomatic recurrences (5.5%) were diagnosed during a mean follow-up period of 32 months.

CONCLUSIONS

The use of RTL allows the loads impinging on the suture base to be distributed over the surrounding tissue. Rupture of the thread from the suture base is prevented, and abdominal wall hernias can be treated effectively. Particularly in cases of acute surgery or contamination of the surgical area, or in the presence of other contraindications for using mesh, the RTL technique is an excellent alternative to mesh repair. These favorable preliminary results must be evaluated in further investigations.