Wound complications after primary and repeated midline, transverse and modified Makuuchi incision: A single-center experience in 696 patients

Clinical outcomes of triclosan-coated barbed suture in open hernia repair: a retrospective cohort study

PURPOSE

We assessed clinical outcomes of patients undergoing open hernia repair using STRATAFIX™ Symmetric, a barbed triclosan-coated suture (TCS; Ethicon), versus conventional polydioxanone suture (PDS) for abdominal wall closure.

METHODS

This single-center retrospective cohort study identified patients undergoing hernia repair. The site used PDS from 2013 to 2016 and switched exclusively to barbed TCS in 2017. Outcomes were assessed at 30, 60, and 90 days. Multivariate regression analyses and Cox proportional hazards models were used.

RESULTS

Of 821 hernia repairs, 446 used barbed TCS and 375 used conventional PDS. Surgical site infections (SSIs) were significantly less frequent with barbed TCS (60 days, 5.9% vs. 11.4%; P = 0.0083; 90 days, 5.9% vs. 11.7%; P = 0.006) and this remained consistent after multivariate adjustment (60 days, OR [95% CI]: 0.5 [0.3-0.9]; 90 days, 0.5 [0.3-0.9]). Among patients with SSI, deep SSIs were less frequent with barbed TCS (60 days, 9.1% vs. 35.7%; P = 0.022; 90 days, 9.1% vs. 34.9%; P = 0.0252). Barbed TCS significantly reduced the risk of perioperative complications (HR [95% CI]: 0.5[0.3-0.8]; P = 0.0058). Hospital length of stay was 2.5 days shorter with barbed TCS (mean [95% CI]: 5.7[4.9-6.6] vs. 8.2[7.3-9.1] days; P < 0.0001). No differences in reoperation rate over time were observed by type of suture (HR[95% CI]:1.3 [0.5-3.4]; P = 0.4793).

CONCLUSIONS

This study showed that patients who underwent open hernia repair appeared to recover equally well regardless of the suture type. In addition, the use of barbed TCS was associated with significantly reduced risk of perioperative complications and hospital length of stay.

Intraoperative and Postoperative Outcomes of Pfannenstiel and Midline Skin Incisions in Placenta Accreta Spectrum Disorders: Single-Center Experience

Background: We compared Pfannenstiel and midline skin incisions for cesarean hysterectomy in women with confirmed Placenta Accreta Spectrum Disorders. Aims: A retrospective cohort study was conducted to evaluate the outcomes of Pfannenstiel and midline skin incisions in women undergoing cesarean section hysterectomy for suspected placenta accreta at Akdeniz University Hospital between January 2010 and February 2022. Histopathological confirmation was obtained for all cases. Demographic, perioperative, and postoperative data, along with neonatal outcomes, were extracted from the hospital's electronic database. Possible complaints related to the incision site or other issues (e.g., vaginal dryness or sexual life) were identified through telephone interviews. Subjects were stratified into Pfannenstiel and midline incision cohorts, with subsequent data comparison. Results: Data from 67 women with a histopathologically confirmed PAS diagnosis were analyzed. Of these, 49 (73.1%) underwent Pfannenstiel incision, and 18 (26.9%) had a midline skin incision. Incisions were based on the surgeon's experience. Pfannenstiel incision was more common in antepartum hemorrhage, preoperative hemorrhage, and emergency surgery (p = 0.02, p = 0.014, p = 0.002, respectively). Hypogastric artery ligation occurred in 30 cases (61.2%) in the Pfannenstiel group but none in the midline group. Cosmetic dissatisfaction and sexual problems were more prevalent in the midline group (p < 0.05, all). Preoperative and postoperative blood parameters, transfused blood products, and neonatal outcomes were similar between the two groups. Conclusions: Relaparotomy, bladder injury, blood loss, and need for blood transfusion were more prevalent in the Pfannenstiel group, while greater dissatisfaction with the incision was observed in the midline incision group. Midline incision seems to be more favorable in patients with Placenta Accreta Spectrum (PAS). Patients may be informed regarding the worse cosmetic outcomes and possible sexual problems related to vaginal dryness when midline laparotomy is planned. But before opting for a Pfannenstiel incision, patients should receive comprehensive information regarding the potential risks of relaparotomy and bladder injury.

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 Prospective Randomized Controlled Trial Comparing Clinical Equivalence of PD Synth and PDS Polydioxanone Sutures

Introduction Incisional hernia is a common complication of midline laparotomy that may develop even after several years of surgery. Abdominal fascia closure with ideal suture material reduces the incidence of incisional hernia. This study compared the clinical equivalence of PD Synth (Healthium Medtech Limited) and PDS (Ethicon, Johnson & Johnson) slowly absorbed polydioxanone suture with respect to the occurrence of incisional hernia, following elective/emergency midline laparotomy. Methods Eighty-eight subjects undergoing elective/emergency midline laparotomy were randomized to PD Synth (n=45) and PDS (n=43) groups of this prospective, multicenter, randomized (1:1), single-blind, two-arm, parallel-group study (December 2020-May 2023). Primary endpoint was incidence of incisional hernia, occurring within six and 12 months of surgery. Secondary endpoints included incidence of fascial dehiscence, surgical site infection (SSI), suture sinus, seroma, hematoma, scar tenderness, and re-suturing, and evaluation of operative data, hospital stay, intra-operative suture handling, pain, time to return to normal day-to-day activities and work, overall patient satisfaction score, and adverse events. Results One subject in both PD Synth and PDS groups (p>0.05) developed incisional hernia at umbilicus 12 months post-laparotomy. In PDS group, one subject each had incidences of SSI on day 2, day 7, and one month, two subjects developed seroma on day seven, and one subject had readmission on one month; two subjects in PD Synth group developed superficial SSI (one month). Findings of other secondary endpoints were comparable between the groups. Conclusion Primary and secondary outcomes manifested that PD Synth and PDS slowly absorbed polydioxanone sutures are clinically equivalent, and can be used for abdominal fascial closure following midline laparotomy.

Transverse Incision for Pancreatoduodenectomy Reduces Wound Complications: A Single-Center Analysis of 399 Patients

BACKGROUND

Even if the minimally invasive approach is advancing in pancreatic surgery, the open approach is still the standard for a pancreatoduodenectomy. There are two types of incisions used: the midline incision (MI) and transverse incision (TI). The aim of this study was to compare these two incision types, especially regarding wound complications.

METHODS

A retrospective review of 399 patients who underwent a pancreatoduodenectomy at the University Hospital Erlangen between 2012 and 2021 was performed. A total of 169 patients with MIs were compared with 230 patients with TIs, with a focus on postoperative fascial dehiscence, postoperative superficial surgical site infection (SSSI) and the occurrence of incisional hernias during follow-up.

RESULTS

Postoperative fascial dehiscence, postoperative SSSI and incisional hernias occurred in 3%, 8% and 5% of patients, respectively. Postoperative SSSI and incisional hernias were significantly less frequent in the TI group (SSI: 5% vs. 12%, p = 0.024; incisional hernia: 2% vs. 8%, p = 0.041). A multivariate analysis confirmed the TI type as an independent protective factor for the occurrence of SSSI and incisional hernias (HR 0.45 (95% CI = 0.20-0.99), p = 0.046 and HR 0.18 (95% CI = 0.04-0.92), p = 0.039, respectively).

CONCLUSION

Our data suggest that the transverse incision for pancreatoduodenectomy is associated with reduced wound complications. This finding should be confirmed by a randomized controlled trial.

Utilizing the same incision for staged renal transplant in patients with polycystic kidney disease requiring hand-assisted laparoscopic nephrectomy

BACKGROUNDS

Many autosomal dominant polycystic kidney disease (ADPKD) patients undergo nephrectomy and subsequent renal transplantation. We report our outcomes after hand-assisted laparoscopic nephrectomy (HALN) where a Rutherford-Morrison incision is used as a hand-port site and kidney extraction site, as well the future incision site for staged transplantation.

METHODS

A retrospective review was performed on all adult nephrectomies for ADPKD by the Transplant Surgery department at Westmead Hospital between June 2011 and June 2021. Outcomes were compared between HALN, laparoscopic nephrectomy (LN) and open nephrectomy (ON) including operation time, hospital length of stay (LOS), post-operative complications, subsequent transplantation and post-transplantation wound complications.

RESULTS

Twenty-two HALN, 8 LN and 5 ON were performed during the study period. Median kidney weights for HALN, LN and ON were significantly different (1575, 403, 3420 g respectively, P = 0.001). There was a significant difference in LOS between the HALN and ON (5.8 versus 9.8 days, P = 0.04), but not between HALN and LN (5.8 versus 5.1, P = 0.06). There was no significant difference for operation time (P = 0.34) and major complication rates (P = 0.58). There were 8 HALN, 5 LN and 2 ON who have had subsequent renal transplantation with one wound complication, an incisional hernia in the HALN group.

CONCLUSION

Our HALN is associated with a shorter LOS and similar complication rate to ON and can be efficiently performed for significantly larger kidneys than LN without a significant difference in operation time or LOS. The same Rutherford-Morrison incision site can be used for transplantation.