A systematic review on the effectiveness of slowly-absorbable versus non-absorbable sutures for abdominal fascial closure following laparotomy

The enigma of incisional hernia prediction unraveled: external validation of a prognostic model in colorectal cancer patients

PURPOSE

Accurate prediction of hernia occurrence is vital for surgical decision-making and patient management, particularly in colorectal surgery patients. While a hernia prediction model has been developed, its performance in external populations remain to be investigated. This study aims to validate the existing model on an external dataset of patients who underwent colorectal surgery.

METHODS

The "Penn Hernia Calculator" model was externally validated using the Hughes Abdominal Repair Trial (HART) data, a randomized trial comparing colorectal cancer surgery closure techniques. The data encompassed demographics, comorbidities, and surgical specifics. Patients without complete follow-up were omitted. Model performance was assessed using key metrics, including area under the curve (AUC-ROC and AUC-PR) and Brier score. Reporting followed the TRIPOD consensus.

RESULTS

An external international dataset consisting of 802 colorectal surgery patients were identified, of which 674 patients with up to 2 years follow-up were included. Average patient age was 68 years, with 63.8% male. The average BMI was 28.1. Prevalence of diabetes, hypertension, and smoking were 15.7%, 16.3%, and 36.5%, respectively. Additionally, 7.9% of patients had a previous hernia. The most common operation types were low anterior resection (35.3%) and right hemicolectomy (34.4%). Hernia were observed in 24% of cases by 2-year follow-up. The external validation model revealed an AUC-ROC of 0.66, AUC-PR of 0.72, and a Brier score of 0.2.

CONCLUSION

The hernia prediction model demonstrated moderate performance in the external validation. Its potential generalizability, specifically in those undergoing colorectal surgery, may suggest utility in identifying and managing high-risk hernia candidates.

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.

Absorbable Barbed Continuous versus Nonabsorbable Nonbarbed Interrupted Suturing Methods for Donor-site Closure of the Rectus Abdominis Myocutaneous Flap

Abdominal incisional hernia is a complication of the rectus abdominis myocutaneous (RAMC) flap harvest. This study aimed to compare the incidence of abdominal incisional hernia and donor-site closure time between absorbable barbed continuous (ABC) and non-absorbable non-barbed interrupted (nAnBI) methods.

Methods

This study included 145 patients who underwent free RAMC flap reconstruction after head and neck cancer surgery at Kobe University Hospital between January 2012 and March 2020. The nAnBI method was selected between January 2012 and August 2016, and the ABC method was selected between September 2016 and March 2020. The incidence of abdominal incisional hernia and the average time required for donor-site closure were compared between the two groups.

Results

Of the 145 patients surveyed, 116 (57 and 59 in the nAnBI and ABC groups, respectively) were followed-up for at least 90 days after the surgery. The incidence rates of abdominal incisional hernia were 0% and 5.1% (n = 3) in the nAnBI and ABC groups, respectively, with no significant differences (p = 0.244). The average donor-site closure times were 127.6 and 111.3 minutes in the nAnBI and ABC groups, respectively, with no significant differences (p = 0.122).

Conclusions

No significant differences in the incidence of abdominal incisional hernia and donor-site closure time were observed between the nAnBI and ABC groups. However, there was a tendency for increased hernia occurrence and shorter wound closure time in the ABC group. A randomized prospective multicenter study is warranted to validate our findings of the ABC method.

Don't fear the (small) bite: A narrative review of the rationale and misconceptions surrounding closure of abdominal wall incisions

Background

The most common complications related to the closure of abdominal wall incisions are surgical site infections, wound dehiscence and the development of an incisional hernia. Several factors relating to the surgical technique and the materials used have been identified and analysed over the years, as mirrored in the current recommendations of the European Hernia Society, but some misconceptions still remain that hinder wide implementation.

Method

A literature search was performed in the PubMed and GoogleScholar databases on 15 July 2021 and additionally on 30 March 2022 to include recent updates. The goal was to describe the scientific background behind the optimal strategies for reducing incisional hernia risk after closure of abdominal wall incisions in a narrative style review.

Results

An aponeurosis alone, small bites/small steps continuous suture technique should be used, using a slowly resorbable USP 2/0 or alternatively USP 0 suture loaded in a small ½ circle needle. The fascial edges should be properly visualised and tension should be moderate.

Conclusion

Despite the reproducibility, low risk and effectiveness in reducing wound complications following abdominal wall incisions, utilisation of the recommendation of the guidelines of the European Hernia Society remain relatively limited. More work is needed to clear misconceptions and disseminate the established knowledge and technique especially to younger surgeons.

Effect of Squid Cartilage Chitosan Molecular Structure on the Properties of Its Monofilament as an Absorbable Surgical Suture

Suture is an important part of surgery, and wounds closing after surgery remains a challenge for postoperative care. Currently, silk, linen fiber, and cotton are available in the market as non-absorbable suture biomaterials. So, there is an urgent need to develop a novel suture with advantageous characteristics compared to the ones available on the market. In present study, a series of ultra-high molecular weight chitosan with different DD and M_V were prepared from squid cartilage by alkaline treatment and ultrasonic degradation. The corresponding chitosan monofilaments were prepared by a wet spinning process and were characterized as sutures. The effects of the DD and M_V of chitosan on the properties of its monofilament were studied, including surface morphology, mechanical property, swelling ratio, ash content, in vitro enzymatic degradation, and in vitro cytotoxicity. According to the results, AS-85 was chosen to be the best suitable as an absorbable surgical suture, which was spun from squid cartilage chitosan with DD~85% and M_V~1.2 × 10⁶. The outcome of the present study might derive tremendous possibilities for the utilization of squid cartilage β-chitin for biomedical applications.

The Voodoo that We Do: Controversies in General Surgery

Incisional hernia remains a common complication following abdominal surgery, and its incidence can be reduced with standardized wound closure techniques. Robust evidence exists to support certain fascial closure methods, such as using a small bites, 4-to-1, continuous slow absorbable suture technique for elective midline laparotomies. On the other hand, there are other common surgical practices that lack quality data to support their routine use, such as abdominal binders, negative-pressure wound therapy, and reapproximation of subcutaneous tissue.

The Effect of Absorbable and Non-Absorbable Sutures on Nasal Width Following Cinch Sutures in Orthognathic Surgery

Background: Non-absorbable materials (nylon) are always used in cinch sutures to maintain nasal width and to improve harmonious facial symmetry in orthognathic surgery. However, a few drawbacks of nylon materials have been clinically reported following orthognathic surgery, such as nasal irritation and exposure of the sutures. An absorbable material (PDS) has been proposed in cinch sutures, not only to avoid the complications of nylon but also to stabilize the nasal width for a long-term follow-up. Methods: Fifty-seven patients with Angle’s malocclusion classification III receiving orthognathic surgery were enrolled in this study. A non-absorbable material (nylon) and an absorbable material (PDS) were utilized for the cinch sutures. Pre-operative (T1) and post-operative six-month (T2) craniofacial 3D images were collected for all patients to measure the alar curvature (Ac) width and the alar base (Al) width. A significance level of p < 0.05 was applied in the statistical analysis. Results: With the approval of IRB, cinch suturing was performed with nylon in 29 patients and with PDS in 28 patients. Pre-operative Ac and Al distances showed no significant difference between these two groups. There were also no significant differences between the suture materials in the peri-operative change in nasal width, including Ac (nylon: 1.999 ± 1.40; PDS: 1.484 ± 0.97; p = 0.112) and Al (nylon: 1.861 ± 1.66; PDS: 1.115 ± 0.92; p = 0.056). Conclusions: For cinch sutures in orthognathic surgery, PDS can maintain the peri-operative nasal width similarly to nylon; additionally, it can be absorbed in a timely manner without the drawbacks of non-absorbable materials.

Incisional Hernia Following Open Abdominal Aortic Aneurysm Repair: A Contemporary Review of Risk Factors and Prevention

While the endovascular approach has been the treatment of choice for abdominal aortic aneurysm (AAA) repair in the modern era, open AAA repair remains a treatment option and may have a resurgence after the recent release of draft guidelines from the National Institute for Health and Care Excellence (NICE). Incisional hernia is a common long-term complication of open AAA repair and causes significant patient morbidity. As the number of patients undergoing open AAA repair increases, it is imperative that vascular surgeons are aware of and aim to reduce the complications associated with open surgery. This article summarises current evidence, highlighting the risk factors for incisional hernia and the modern surgical techniques that can prevent complications.

Prevention of incisional hernia using different suture materials for closing the abdominal wall: a comparison of PDS, Vicryl and Prolene in a rat model

Purpose

An incisional hernia occurs frequently after a midline incision with an incidence of 12.8%. The choice in suture material used for abdominal wall closure is not straightforward and the conflicting literature focuses on clinical outcomes. This study compares a non-absorbable, slow-absorbable and fast-absorbable suture in a rat model, focusing on histological outcomes predicting better fascia healing.

Methods

33 male Wistar rats, divided over three groups, each received two separate 1 cm incisions closed with either Prolene 4/0, PDS 4/0 or Vicryl 4/0. At 7 days and 21 days, one of the incisions was explanted. Tissue was semi-quantitatively scored regarding inflammatory cells and collagen fibres present. Using qPCR macrophage polarisation, fibroblast activity and vascularisation were evaluated. Data were analysed by Kruskal–Wallis test with Mann–Whitney U post hoc test. A p value of 0.017 was considered significant after Bonferroni correction.

Results

All animals recovered without complications and completed the 21 days of follow-up. The Vicryl group showed a higher presence of macrophages after 21 days in comparison with Prolene (p = 0.003) and PDS (p = 0.006) and more foreign body giant cells compared to Prolene at 7 days (p = 0.010) and PDS at 21 days (p < 0.001). qPCR showed 2.5-fold higher expression of clec10A in PDS compared to Prolene after 7 days (p = 0.007).

Conclusions

The results of this study carefully support the use of PDS suture, compared to Prolene and Vicryl, in abdominal wall closure based on a favourable macrophage response. The heterogeneity and variability in the data might be explained by the spectrum of the macrophage subtype paradigm.

Electronic supplementary material

The online version of this article (10.1007/s10029-019-01941-9) contains supplementary material, which is available to authorized users.

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.

Laparoscopic transabdominal cerclage in pregnancy: A single centre experience

BACKGROUND

Transabdominal cerclage can reduce the risk of preterm birth in women with cervical insufficiency.

AIMS

This study evaluated outcomes following insertion of a laparoscopic transabdominal cerclage in pregnant women.

MATERIALS AND METHODS

A retrospective observational study.

PATIENTS

pregnant women who underwent laparoscopic transabdominal cerclage from 2011 to 2017. Eligible women had cervical insufficiency and were not suitable for a transvaginal cerclage.

INTERVENTION

the insertion of a laparoscopic transabdominal cerclage in the pregnancy.

MEASUREMENTS

neonatal survival, delivery of an infant at ≥34 weeks gestation and surgical morbidity were evaluated.

RESULTS

Of 19 women who underwent laparoscopic transabdominal cerclage in pregnancy, at 6-11 weeks gestation, the perinatal survival rate was 100%. There were no complications. The average gestational age at delivery was 37.1 weeks. Sixteen women delivered after 34 weeks.

CONCLUSIONS

Laparoscopic transabdominal cerclage is a safe and effective procedure in women with poor obstetric histories. It requires the correct skill, expertise and patient selection.

Baseline performance of the ischaemic button model for induction of adhesions in laboratory rats

The ischaemic button model is frequently used for the induction of adhesions in laboratory rats. Male rats are often used because of the common belief that the peritesticular (intra-abdominal) fat in males facilitates adhesion formation, although this theory is not evidence based. Comparing the model’s performance in both sexes is an important aspect of refining animal experiments. The aim of this study is to compare baseline performance of the modified ischaemic button model in both male and female rats. Follow-up was 1 week and noted endpoints were intra-abdominal adhesion formation and differences in welfare assessment. A total of 192 ischaemic buttons (96 male/96 female) were created in 24 Wistar Han rats (12 male/12 female). After 1 week of follow-up, 93 buttons survived in the male group (96.9%) compared with 91 in the female group (94.8%) (p = 0.409). In the male group, 85 out of 93 (91.4%) buttons induced adhesions compared with 84 out of 91 (92.3%) in the female group (p = 0.881). All but one animal had a Zühlke score of 3. There were no clinically relevant differences in welfare scores. Male animals increased in weight significantly faster compared to females (p < 0.001), after correcting for physiological growth. The ischaemic button model resulted in equal quality and quantity of intra-abdominal adhesions in both male and female Wistar Han rats. Both male and female Wistar Han rats are suitable for the induction of experimental adhesions in the ischaemic button model.

Prophylactic Mesh Reinforcement versus Sutured Closure to Prevent Incisional Hernias after Open Abdominal Aortic Aneurysm Repair via Midline Laparotomy: A Systematic Review and Meta-Analysis

OBJECTIVE/BACKGROUND

Incisional hernia is a frequent late complication after open abdominal aortic aneurysm (AAA) repair. We aimed to determine whether prophylactic mesh reinforcement of the abdominal wall at open AAA repair via midline laparotomy reduces the rate of incisional hernia compared to standard sutured closure.

METHODS

A systematic review and meta-analysis was carried out in accordance with the PRISMA statement (PROSPERO registration CRD42017072508). Randomised controlled trials (RCTs) comparing prophylactic mesh reinforcement with standard sutured closure were eligible for inclusion. MEDLINE, Embase, and the Cochrane Library were searched. A meta-analysis with a random effects model was carried out to estimate pooled risk ratios (RR) with 95% confidence intervals (CIs) for the incidence of, and re-operation rate for, incisional hernias. Assessments of methodological quality, quality of evidence, and strength of recommendations were done with the Cochrane Collaboration's tool for assessing risk of bias and the GRADE approach.

RESULTS

Four RCTs with a total of 388 patients were included in the meta-analysis. Pooled analysis showed that mesh reinforcement significantly reduced the risk of incisional hernia after AAA repair compared with standard sutured closure (RR 0.27, 95% CI 0.11-0.66). The pooled rate of re-operations was not different between groups (RR 0.23, 95% CI 0.11-1.05). Mesh reinforcement did not cause more intra-operative or post-operative complications than sutured closure. The risk of bias in studies was low and the quality of evidence was rated as moderate.

CONCLUSION

Prophylactic mesh reinforcement of the abdominal wall after open AAA repair via midline laparotomy significantly reduces the risk of incisional hernia. However, no significant difference in re-operation for incisional hernia was found.

Hughes Abdominal Repair Trial (HART)-abdominal wall closure techniques to reduce the incidence of incisional hernias: feasibility trial for a multicentre, pragmatic, randomised controlled trial

OBJECTIVES

Incisional hernias are common complications of midline abdominal closure. The 'Hughes Repair' combines a standard mass closure with a series of horizontal and two vertical mattress sutures within a single suture. There is evidence to suggest this technique is as effective as mesh repair for the operative management of incisional hernias; however, no trials have compared Hughes repair with standard mass closure for the prevention of incisional hernia formation. This paper aims to test the feasibility of running a randomised controlled trial of a comparison of abdominal wall closure methods following midline incisional surgery for colorectal cancer, in preparation to a definitive randomised controlled trial.

DESIGN AND SETTING

A feasibility trial (with 1:1 randomisation) conducted perioperatively during colorectal cancer surgery.

PARTICIPANTS

Patients undergoing midline incisional surgery for resection of colorectal cancer.

INTERVENTIONS

Comparison of two suture techniques (Hughes repair or standard mass closure) for the closure of the midline abdominal wound following surgery for colorectal cancer.

PRIMARY AND SECONDARY OUTCOMES

A 30-patient feasibility trial assessed recruitment, randomisation, deliverability and early safety of the surgical techniques used.

RESULTS

A total of 30 patients were randomised from 43 patients recruited and consented, over a 5-month period. 14 and 16 patients were randomised to arms A and B, respectively. There was one superficial surgical site infection (SSI) and two organ space SSIs reported in arm A, and two superficial SSIs and one complete wound dehiscence in arm B. There were no suspected unexpected serious adverse reactions reported in either arm. Independent data monitoring committee found no early safety concerns.

CONCLUSIONS

The feasibility trial found no early safety concerns and demonstrated that the trial was acceptable to patients. Progression to the pilot and main phases of the trial has now commenced following approval by the independent data monitoring committee.

TRIAL REGISTRATION NUMBER

ISRCTN 25616490.

Mass Continuous Suture versus Layered Interrupted Suture in Transverse Abdominal Incision Closure after Liver Resection

BACKGROUND

Abdominal incision closure technique seriously influences patient prognosis. Most studies have focused on the different suture techniques and materials on midline incision, while little data are available in wide transverse or oblique incisions after liver resection (LR). The aim of the present study is to compare the two major incision suture methods after LR in our institute: Mass continuous suture (group P) and layered interrupted suture (group S).

STUDY DESIGN

258 patients undergoing LR with abdominal transverse or oblique incisions were prospectively enrolled. They were divided into two groups according to different abdominal incision suture methods and compared with the preoperative, intraoperative parameters, and postoperative wound complications.

RESULTS

There were 118 patients in group P and 140 patients in group S, which was similar in general condition, primary disease, liver, and renal function. Incision length, total operation time, intraoperative blood loss, or perioperative antibiotics use were not different between the two groups. However, abdominal incision closure time and interval time for stitches removing after operation was significantly shorter in group P than group S (both p < 0.001). After a median follow-up of 16 months, the incidence of wound infection and fat liquefaction was more than two times higher in group S than group P, which, however, was not statistically different. Moreover, there was no difference in wound disruption or incisional hernia between the two groups.

CONCLUSIONS

Although similar in occurrence of postoperative wound complications, mass continuous suture with polydioxanone seemed to be more timesaving in incision closure and motivated in wound healing.

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.

A High-Strength, Absorbable, Antibacterial Knotless Tissue Control Device for Fascial Closure

Purpose of Review

This review provides an overview of the STRATAFIX™ SYMMETRIC PDS™ Plus Knotless Tissue Control Device design and performance characteristics and highlights the device’s relevance for use in gynecological procedures. Various device testing was conducted on tensile strength, fixation tab mass comparison to conventional suture knot tower, initiation stitch strength, and wound holding strength to highlight the STRATAFIX™ SYMMETRIC PDS™ Plus Device’s key product attributes that may benefit general and minimally invasive gynecological procedures.

Recent Findings

This article serves as a technological assessment of the latest barbed suture offered by Ethicon—STRATAFIX™ SYMMETRIC PDS™ Plus Knotless Tissue Control Device. This device is indicated for soft tissue approximation and can be used to close high tension areas, such as fascia.

Summary

Barbed sutures were successfully introduced to gynecologic surgery many years ago, and their safety and effectiveness have been demonstrated in a variety of gynecological surgical procedures. By eliminating the need to tie surgical knots, barbed suture provides a few key advantages over conventional suture, such as reducing operating room time, eliminating potential knot-related complications, and reducing suturing difficulty in open and minimally invasive gynecological procedures. Additionally, there are tensile strength and wound holding strength advantages (vs. conventional PDS™ Plus Suture) described in the product testing highlighted in this review that may be relevant for gynecological procedures.

Hughes Abdominal Repair Trial (HART) - Abdominal wall closure techniques to reduce the incidence of incisional hernias: study protocol for a randomised controlled trial

Background

Incisional hernias are common complications of midline closure following abdominal surgery and cause significant morbidity, impaired quality of life and increased health care costs.

The ‘Hughes Repair’ combines a standard mass closure with a series of horizontal and two vertical mattress sutures within a single suture. This theoretically distributes the load along the incision length as well as across it. There is evidence to suggest that this technique is as effective as mesh repair for the operative management of incisional hernias; however, no trials have compared the Hughes Repair with standard mass closure for the prevention of incisional hernia formation following a midline incision.

Methods/design

This is a 1:1 randomised controlled trial comparing two suture techniques for the closure of the midline abdominal wound following surgery for colorectal cancer. Full ethical approval has been gained (Wales REC 3, MREC 12/WA/0374). Eight hundred patients will be randomised from approximately 20 general surgical units within the United Kingdom. Patients undergoing open or laparoscopic (more than a 5-cm midline incision) surgery for colorectal cancer, elective or emergency, are eligible. Patients under the age of 18 years, those having mesh inserted or undergoing musculofascial flap closure of the perineal defect in abdominoperineal wound closure, and those unable to give informed consent will be excluded. Patients will be randomised intraoperatively to either the Hughes Repair or standard mass closure. The primary outcome measure is the incidence of incisional hernias at 1 year as assessed by standardised clinical examination. The secondary outcomes include quality of life patient-reported outcome measures, cost-utility analysis, incidence of complete abdominal wound dehiscence and C-POSSUM scores. The incidence of incisional hernia at 1 year, assessed by computerised tomography, will form a tertiary outcome.

Discussion

A feasibility phase has been completed. The results of the study will be used to inform current and future practice and potentially reduce the risk of incisional hernia formation following midline incisions.

Trial registration

Trial Registration Number: ISRCTN 25616490. Registered on 1 January 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1573-0) contains supplementary material, which is available to authorized users.

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.

Development and validation of a risk stratification score for ventral incisional hernia after abdominal surgery: hernia expectation rates in intra-abdominal surgery (the HERNIA Project)

BACKGROUND

Ventral incisional hernias (VIH) develop in up to 20% of patients after abdominal surgery. No widely applicable preoperative risk-assessment tool exists. We aimed to develop and validate a risk-assessment tool to predict VIH after abdominal surgery.

STUDY DESIGN

A prospective study of all patients undergoing abdominal surgery was conducted at a single institution from 2008 to 2010. Variables were defined in accordance with the National Surgical Quality Improvement Project, and VIH was determined through clinical and radiographic evaluation. A multivariate Cox proportional hazard model was built from a development cohort (2008 to 2009) to identify predictors of VIH. The HERNIAscore was created by converting the hazards ratios (HR) to points. The predictive accuracy was assessed on the validation cohort (2010) using a receiver operator characteristic curve and calculating the area under the curve (AUC).

RESULTS

Of 625 patients followed for a median of 41 months (range 0.3 to 64 months), 93 (13.9%) developed a VIH. The training cohort (n = 428, VIH = 70, 16.4%) identified 4 independent predictors: laparotomy (HR 4.77, 95% CI 2.61 to 8.70) or hand-assisted laparoscopy (HAL, HR 4.00, 95% CI 2.08 to 7.70), COPD (HR 2.35; 95% CI 1.44 to 3.83), and BMI ≥ 25 kg/m(2) (HR1.74; 95% CI 1.04 to 2.91). Factors that were not predictive included age, sex, American Society of Anesthesiologists (ASA) score, albumin, immunosuppression, previous surgery, and suture material or technique. The predictive score had an AUC = 0.77 (95% CI 0.68 to 0.86) using the validation cohort (n = 197, VIH = 23, 11.6%). Using the HERNIAscore: HERNIAscore = 4(∗)Laparotomy+3(∗)HAL+1(∗)COPD+1(∗) BMI ≥ 25, 3 classes stratified the risk of VIH: class I (0 to 3 points),5.2%; class II (4 to 5 points),19.6%; and class III (6 points), 55.0%.

CONCLUSIONS

The HERNIAscore accurately identifies patients at increased risk for VIH. Although external validation is needed, this provides a starting point to counsel patients and guide clinical decisions. Increasing the use of laparoscopy, weight-loss programs, community smoking prevention programs, and incisional reinforcement may help reduce rates of VIH.

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.

Randomized controlled trial comparing subcuticular absorbable suture with conventional interrupted suture for wound closure at elective operation of colon cancer

BACKGROUND

Subcuticular closure provides a superior cosmetic result in clean wounds. The aim of this work was to investigate the safety in terms of postoperative infection and cosmetic effectiveness of subcuticular wound closure after elective colon cancer surgery in clean-contaminated wounds.

METHODS

Patients who underwent elective resection of colon cancer were randomized to interrupted subcuticular and interrupted transdermal suture groups. The large bowel was prepared by mechanical washout with polyethylene glycol. All patients received metronidazole and kanamycin orally and flomoxef sodium once parenterally for antimicrobial prophylaxis. The primary end point was the incidence of incisional surgical-site infections within 30 days after operation. We assessed noninferiority of subcuticular suture within a margin of 10%. Analysis was by intent-to-treat. Secondary objectives include comparison of wound closure time, comfort, and cosmesis of the scar and satisfaction of patients. This study was registered with UMIN-CTR, UMIN000003005.

RESULTS

A total of 293 patients were randomized to the two groups. Incisional surgical-site infection rates were 11.0% (90% confidence interval 7.0-16.3%) for both groups. The relative risk of subcuticular suture was 1.00 (0.58-1.73, one-tail P = .57). Interrupted subcuticular suture was noninferior to interrupted transdermal suture (P = .0088). Throughout 6 months after operation, patients expressed a significant preference for the subcuticular suture technique, noting rapid relief from pain, decreased vascularity, and smaller width, although the procedure took twice as long.

CONCLUSION

Subcuticular suture did not increase the incidence of wound complications in elective colon cancer operation. Patients preferred a technique of interrupted subcuticular closure, citing better cosmetic results, and less pain.

Peritoneal closure versus no peritoneal closure for patients undergoing non-obstetric abdominal operations

BACKGROUND

There is no consensus regarding whether the peritoneum should be closed or left open during non-obstetric operations involving laparotomy. Neither is there consensus about the method of closure of the peritoneum (continuous suture versus interrupted suture). If closing the peritoneum could be omitted without complications, or even with benefit for patients, this could result in reductions in the cost of abdominal operations by reducing both the number of sutures used and the operating time.

OBJECTIVES

To compare the benefits and harms of parietal peritoneal closure compared with no parietal peritoneal closure in patients undergoing non-obstetric abdominal operations.

SEARCH METHODS

In Februrary 2013 we searched the The Cochrane Wounds Group Specialised Register (searched 14 February 2013); The Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 1); The Database of Abstracts of Reviews of Effects (2013, Issue 1); Ovid MEDLINE (1946 to February Week 1, 2013); Ovid EMBASE (1974 to 2013 Week 06); and EBSCO CINAHL 1982 to 8 February 2013).

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) comparing peritoneal closure with no peritoneal closure in patients (adults and children) undergoing non-obstetric abdominal operations. All relevant RCTs irrespective of language, publication status, publication year, or sample size were included in the analysis.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and extracted data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for comparing the binary outcomes between the groups, and mean difference (MD) with 95% CI for comparing the continuous outcomes. We performed the meta-analysis using both a fixed-effect model and a random-effects model. Intention-to-treat analysis was performed whenever possible.

MAIN RESULTS

Five trials involving 836 participants randomised to peritoneal closure (410 participants) and no peritoneal closure (426 participants) were included in this review. All the trials were at high risk of bias. All the trials included participants undergoing laparotomy (open surgery). Four of the five trials used catgut or chromic catgut for peritoneal closure. Three trials involved vertical incisions and two trials involved transverse incisions. None of the trials reported 30-day mortality. There was no significant difference in the one-year mortality between the two groups (RR 1.11; 95% CI 0.56 to 2.19) in the only trial that reported this outcome. The only serious peri-operative adverse event reported was burst abdomen, which was reported by three trials. Overall, 10/663 (1.5%) of participants developed burst abdomen. There was no significant difference in the proportion of participants who developed burst abdomen between the two groups (RR 0.71; 95% CI 0.22 to 2.35). The same three trials reported the proportion of participants who developed incisional hernia. Details of the follow-up period were only available for one trial, and so we were unable to calculate the incidence rate. Overall, 17/663 (2.5%) of participants developed incisional hernia. There was no significant difference in the proportion of participants who developed incisional hernia between the two groups (RR 0.92; 95% CI 0.37 to 2.28). None of the trials reported quality of life; the incidence rate of, or proportion of participants who developed, intestinal obstruction due to adhesions; or re-operation due to incisional hernia or adhesions. Only one trial reported the length of hospital stay, and this trial did not include readmissions in its calculations. There was no significant difference in the length of hospital stay between the two groups (MD 0.40 days; 95% CI -0.51 to 1.31).

AUTHORS' CONCLUSIONS

There is no evidence for any short-term or long-term advantage in peritoneal closure for non-obstetric operations. If further trials are performed on this topic, they should have an adequate period of follow-up and adequate measures should be taken to ensure that the results are not subject to bias.

A prospective evaluation of the risk factors for development of wound dehiscence and incisional hernia

OBJECTIVE

Post-laparotomy wound dehiscence, evantration and evisceration are important complications leading to an increase in both morbidity and mortality. Incisional hernias are frequently observed following abdominal surgeries and their occurrence is related to various local and systemic factors. This study aims to analyze the factors affecting wound healing by investigating the parameters that may cause wound dehiscence, incisional hernia, sinus formation and chronic incisional pain.

MATERIAL AND METHODS

The records of 265 patients who underwent major abdominal surgery were analyzed. The data on patient characteristics, medication, surgical procedure type, type of suture and surgical instruments used and complications were recorded. The patients were followed up with respect to sinus formation, incisional hernia occurrence and presence of chronic incision pain. Statistical analysis was performed using SPSS 10.00 program. The groups were compared via chi-square tests. Significance was determined as p<0.05. Multi-variate analysis was done by forward logistic regression analysis.

RESULTS

115 (43.4%) patients were female and 150 (56.6%) were male. Ninety-four (35.5%) patients were under 50 years old and 171 (64.5%) were older than 50 years. The median follow-up period was 28 months (0-48). Factors affecting wound dehiscence were found to be; creation of an ostomy (p=0.002), postoperative pulmonary problems (p=0.001) and wound infection (p=0.001). Factors leading to incisional hernia were; incision type (p=0.002), formation of an ostomy (p=0.002), postoperative bowel obstruction (p=0.027), postoperative pulmonary problems (p=0.017) and wound infection (p=0.011).

CONCLUSION

Awareness of the factors causing wound dehiscence and incisional hernia in abdominal surgery, means of intervention to the risk factors and taking relevant measures may prevent complications. Surgical complications that occur in the postoperative period are especially related to wound healing problems.