STAPLED FASCIAL CLOSURE VS. CONTINUOUS HAND-SEWN SUTURE: EXPERIMENTAL STUDY OF THE ABDOMINAL WALL ON PORCINE MODEL AND HUMAN CADAVER

BACKGROUND

One of the primary complications associated with large incisions in abdominal surgery is the increased risk of fascial closure rupture and incisional hernia development. The choice of the fascial closure method and closing with minimal tension and trauma is crucial for optimal results, emphasizing the importance of uniform pressure along the suture line to withstand intra-abdominal pressure.

AIMS

To evaluate the resistance to pressure and tension of stapled and sutured hand-sewn fascial closure in the abdominal wall.

METHODS

Nine abdominal wall flaps from human cadavers and 12 pigs were used for the experimentation. An abdominal defect was induced after the resection of the abdominal wall and the creation of a flap in the cadaveric model and after performing a midline incision in the porcine models. The models were randomized into three groups. Group 1 was treated with a one-layer hand-sewn small bite suture, Group 2 was treated with a two-layer hand-sewn small bite suture, and Group 3 was treated with a two-layer stapled closure. Tension measurements were assessed in cadaveric models, and intra-abdominal pressure was measured in porcine models.

RESULTS

In the human cadaveric model, the median threshold for fascial rupture was 300N (300-350) in Group 1, 400N (350-500) in Group 2, and 350N (300-380) in Group 3. Statistical comparisons revealed non-significant differences between Group 1 and Group 2 (p=0.072, p>0.05), Group 1 and Group 3 (p=0.346, p>0.05), and Group 2 and Group 3 (p=0.184, p>0.05). For porcine subjects, Group 1 showed a median pressure of 80 mmHg (85-105), Group 2 had a median of 92.5 mmHg (65-95), and Group 3 had a median of 102.5 mmHg (80-135). Statistical comparisons indicated non-significant differences between Group 1 and Group 2 (p=0.243, p>0.05), Group 1 and Group 3 (p=0.468, p>0.05), and Group 2 and Group 3 (p=0.083, p>0.05).

CONCLUSIONS

Stapled and conventional suturing resist similar pressure and tension thresholds.

The increasing use of minimally invasive surgery in acute general surgical conditions: A decade of results from a national data set

BACKGROUND

To assess the rate of uptake of acute laparoscopic surgery for common general surgical conditions using national-level data.

METHODS

The use of laparoscopic surgery in the acute management of appendicitis, cholecystitis, adhesive small bowel obstruction, and inguinal hernias was assessed between 2013 and 2022 at a national level in New Zealand.

RESULTS

Laparoscopic appendicectomy increased from 83% to 95% (P = .0002). Laparoscopic cholecystectomy increased from 94% to 96% (P = .001). Laparoscopic adhesiolysis increased from 42% to 60% (P = .001). Laparoscopic inguinal hernia repair increased from 3% to 18% (P = .004). The rate of laparoscopic conversion demonstrated a decrease for appendicectomy (1.9% to 0.24%), cholecystectomy (0.77% to 0.39%), and adhesiolysis (9% to 2.4%) across this time. The laparoscopic cohorts were all associated with a shorter and less expensive length of stay compared to the open cohort. Māori and Pacific Island patients had largely equitable or superior rates of laparoscopic use compared to the rest of the population. No changes in laparoscopic use were detected during the COVID-19 pandemic. Rates of laparoscopic cholecystectomy and appendicectomy are similar throughout the regions. The largest difference in rates detected was for adhesiolysis, which was more common in the northern region.

CONCLUSION

There has been a statistically significant rise in the use of acute laparoscopic surgery for acute general surgical procedures. This rise is likely clinically and economically significant, particularly in appendicectomy and adhesiolysis, with rises of 12% and 17% across the 10 years, with the known associated patient and health care system benefits.

Association of Open Approach vs Laparoscopic Approach With Risk of Surgical Site Infection After Colon Surgery

IMPORTANCE

Colon surgery is associated with a high rate of surgical site infection (SSI), and there is an urgent need for strategies to reduce infection rates.

OBJECTIVE

To assess whether laparoscopic colon surgery is associated with a lower surgical site infection rate than open-approach laparoscopy, especially in patients with medically complex conditions.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used previously validated diagnosis and procedure codes from Medicare beneficiaries who underwent colon surgery from January 1, 2009, to November 30, 2013. Analyses were performed from August 1 to December 31, 2018.

MAIN OUTCOMES AND MEASURES

Outcome measures were SSI events, medical comorbidities, and laparoscopic or open approach procedures.

RESULTS

A total of 229 726 patients (mean [SD] age, 74.3 [9.4] years; 128 499 [55.9%] female) underwent colon procedures. There were 105 144 laparoscopic procedures and 124 582 open procedures. The overall mean SSI rate was 6.2%, varying by surgical procedure from 5.8% to 7.6%. Among the full study population, adjusted model results showed a significant association of laparoscopy with lower odds of SSI (odds ratio, 0.43; 95% CI, 0.41-0.46; P < .001). When stratified by surgical approach, the mean SSI rates were 4.1% (procedure-specific range, 3.9%-5.1%) for the laparoscopic approach and 7.9% (procedure-specific range, 7.4%-10.2%) for the open approach. When stratified by Elixhauser score groups, the mean SSI rates were 6.2% (procedure-specific range, 3.2%-8.7%) for group 1 (0-1 comorbidity), 5.5% (procedure-specific range, 3.6%-11.1%) for group 2 (2 comorbidities), and 6.6% (procedure-specific range, 4.6%-10.6%) for group 3 (3-13 comorbidities). An interaction was also observed between laparoscopic approach and Elixhauser groups, with increased odds of SSI among patients who had 3 to 13 comorbidities present at the time of the procedure (odds ratio, 1.21; 95% CI, 1.11-1.32) compared with patient groups with fewer comorbidities. The population attributable fraction of SSIs for use of the open approach was 34.2%. A total of 2317 of 3882 hospitals (59.7%) performed few (0%-10%) or most (>50%) procedures laparoscopically.

CONCLUSIONS AND RELEVANCE

Policy changes that promote surgical education and resources for laparoscopy, especially at low-adoption hospitals, may be associated with reduced colon SSI rates. Support of the development of innovative educational policies may help achieve improvement in patient outcomes and decreased health care use in colon surgery.