Current practice of abdominal wall closure in elective surgery - Is there any consensus?

Protocol for an independent patient data meta-analysis of prophylactic mesh placement for incisional hernia prevention after abdominal aortic aneurysm surgery: a collaborative European Hernia Society project (I-PREVENT-AAA)

INTRODUCTION

Incisional hernia (IH) is a prevalent and potentially dangerous complication of abdominal surgery, especially in high-risk groups. Mesh reinforcement of the abdominal wall has been studied as a potential intervention to prevent IHs. Randomised controlled trials (RCTs) have demonstrated that prophylactic mesh reinforcement after abdominal surgery, in general, is effective and safe. In patients with abdominal aortic aneurysm (AAA), prophylactic mesh reinforcement after open repair has not yet been recommended in official guidelines, because of relatively small sample sizes in individual trials. Furthermore, the identification of subgroups that benefit most from prophylactic mesh placement requires larger patient numbers. Our primary aim is to evaluate the efficacy and effectiveness of the use of a prophylactic mesh after open AAA surgery to prevent IH by performing an individual patient data meta-analysis (IPDMA). Secondary aims include the evaluation of postoperative complications, pain and quality of life, and the identification of potential subgroups that benefit most from prophylactic mesh reinforcement.

METHODS AND ANALYSIS

We will conduct a systematic review to identify RCTs that study prophylactic mesh placement after open AAA surgery. Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase, Web of Science Core Collection and Google Scholar will be searched from the date of inception onwards. RCTs must directly compare primary sutured closure with mesh closure in adult patients who undergo open AAA surgery. Lead authors of eligible studies will be asked to share individual participant data (IPD). The risk of bias (ROB) for each included study will be assessed using the Cochrane ROB tool. An IPDMA will be performed to evaluate the efficacy, with the IH rate as the primary outcome. Any signs of heterogeneity will be evaluated by Forest plots. Time-to-event analyses are performed using Cox regression analysis to evaluate risk factors.

ETHICS AND DISSEMINATION

No new data will be collected in this study. We will adhere to institutional, national and international regulations regarding the secure and confidential sharing of IPD, addressing ethics as indicated. We will disseminate findings via international conferences, open-source publications in peer-reviewed journals and summaries posted online.

PROSPERO REGISTRATION NUMBER

CRD42022347881.

Incisional Small-Bowel Strangulation after a Caesarean Section: A Case Report

Background and Objectives: Every surgical procedure has the possible risk of complications, and caesarean sections (CSs) are no exception. As CS rates are increasing worldwide, being familiar with rare but possible complications has become extremely important. Case report: We present a case of 25-year-old nulliparous patient who came to our hospital with twin pregnancy for a scheduled induction of labour. An urgent CS was performed due to labour dystocia. On the second postoperative day, the patient started to complain about pain in the epigastrium, but initially showed no signs of bowel obstruction, passing gas, and stools, and could tolerate oral intake. After a thorough examination, an early postoperative complication-small-bowel strangulation at the incision site-was diagnosed. Small bowels protruded in between sutured rectus abdominis muscle causing a strangulation which led to re-laparotomy. During the surgery, there was no necrosis of intestines, bowel resection was not needed, and abdominal wall repair was performed. After re-laparotomy, the patient recovered with no further complications. Conclusions: Although there are discussions about CS techniques, most guidelines recommend leaving rectus muscle unsutured. This case demonstrates a complication which most likely could have been avoided if the rectus muscle had not been re-approximated.

FIGO good practice recommendations on surgical techniques to improve safety and reduce complications during cesarean delivery

FIGO is actively contributing to the global effort to reduce maternal morbidity, mortality, and disability worldwide. Cesarean delivery rates are increasing globally, without signs of slowing down. Bleeding associated with cesarean delivery has become an important cause of hemorrhage-related maternal deaths in many low- and middle-income countries. Correct surgical techniques to improve safety and reduce complications of cesarean delivery is of the utmost importance. This article presents FIGO's good practice recommendations for effective surgical techniques to reduce cesarean complications. Evidence-based information is included where data are available. An expanded WHO Surgical Safety Checklist for maternity cases is suggested. Different incision techniques through the layers of the abdominal wall with appropriate indications are discussed. Hysterotomy through a transverse incision is described, as are indications for low vertical and classical incisions. Important precautions when extracting the fetus are explained. Uterine closure includes a safe method ensuring adequate reapproximation of the upper segment if a vertical incision is made. The paper concludes with the management of two common bleeding problems following delivery of the placenta.

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.

Who should see the patient? on deviations from preferred patient-provider assignments in hospitals

In various organizations including hospitals, individuals are not forced to follow specific assignments, and thus, deviations from preferred task assignments are common. This is due to the conventional wisdom that professionals should be given the flexibility to deviate from preferred assignments as needed. It is unclear, however, whether and when this conventional wisdom is true. We use evidence on the assignments of generalist and specialists to patients in our partner hospital (a children's hospital), and generate insights into whether and when hospital administrators should disallow such flexibility. We do so by identifying 73 top medical diagnoses and using detailed patient-level electronic medical record (EMR) data of more than 4,700 hospitalizations. In parallel, we conduct a survey of medical experts and utilized it to identify the preferred provider type that should have been assigned to each patient. Using these two sources of data, we examine the consequence of deviations from preferred provider assignments on three sets of performance measures: operational efficiency (measured by length of stay), quality of care (measured by 30-day readmissions and adverse events), and cost (measured by total charges). We find that deviating from preferred assignments is beneficial for task types (patients' diagnosis in our setting) that are either (a) well-defined (improving operational efficiency and costs), or (b) require high contact (improving costs and adverse events, though at the expense of lower operational efficiency). For other task types (e.g., highly complex or resource-intensive tasks), we observe that deviations are either detrimental or yield no tangible benefits, and thus, hospitals should try to eliminate them (e.g., by developing and enforcing assignment guidelines). To understand the causal mechanism behind our results, we make use of mediation analysis and find that utilizing advanced imaging (e.g., MRIs, CT scans, or nuclear radiology) plays an important role in how deviations impact performance outcomes. Our findings also provide evidence for a "no free lunch" theorem: while for some task types, deviations are beneficial for certain performance outcomes, they can simultaneously degrade performance in terms of other dimensions. To provide clear recommendations for hospital administrators, we also consider counterfactual scenarios corresponding to imposing the preferred assignments fully or partially, and perform cost-effectiveness analyses. Our results indicate that enforcing the preferred assignments either for all tasks or only for resource-intensive tasks is cost-effective, with the latter being the superior policy. Finally, by comparing deviations during weekdays and weekends, early shifts and late shifts, and high congestion and low congestion periods, our results shed light on some environmental conditions under which deviations occur more in practice.

Triclosan-coated barbed sutures in elective laparoscopic colorectal cancer surgery: a propensity score matched cohort study

BACKGROUND

Most of the studies published to date which assess the role of antibacterial sutures in surgical site infection (SSI) prevention include heterogeneous groups of patients, and it is therefore difficult to draw conclusions. The objective of the present study was to investigate whether the use of Triclosan-coated barbed sutures (TCBS) was associated with a lower incidence of incisional SSI and lower duration of hospital stay compared to standard sutures, in elective laparoscopic colorectal cancer surgery.

METHOD

Observational including patients who underwent elective colorectal cancer laparoscopic surgery between January 2015 and December 2020. The patients were divided into two groups according to the suture used for fascial closure of the extraction incision, TCBS vs conventional non-coated sutures (CNCS), and the rate of SSI was analysed. The TCBS cases were matched to CNCS cases by propensity score matching to obtain comparable groups of patients.

RESULTS

488 patients met the inclusion criteria. After adjusting the patients with the propensity score, two new groups of patients were generated: 143 TCBS cases versus 143 CNCS cases. Overall incisional SSI appeared in 16 (5.6%) of the patients with a significant difference between groups depending on the type of suture used, 9.8% in the group of CNCS and 1.4% in the group of TCBS (OR 0.239 (CI 95%: 0.065-0.880)). Hospital stay was significantly shorter in TCBS group than in CNCS, 5 vs 6 days (p < 0.001).

CONCLUSION

TCBS was associated with a lower incidence of incisional SSI compared to standard sutures in a cohort of patients undergoing elective laparoscopic colorectal cancer surgery.

Postoperative Work and Activity Restrictions After Abdominal Surgery: A Systematic Review

OBJECTIVE

This systematic review aims to assess what is known about convalescence following abdominal surgery. Through a review of the basic science and clinical literature, we explored the effect of physical activity on the healing fascia and the optimal timing for postoperative activity.

BACKGROUND

Abdominal surgery confers a 30% risk of incisional hernia development. To mitigate this, surgeons often impose postoperative activity restrictions. However, it is unclear whether this is effective or potentially harmful in preventing hernias.

METHODS

We conducted 2 separate systematic reviews using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The first assessed available basic science literature on fascial healing. The second assessed available clinical literature on activity after abdominal surgery.

RESULTS

Seven articles met inclusion criteria for the basic science review and 22 for the clinical studies review. The basic science data demonstrated variability in maximal tensile strength and time for fascial healing, in part due to differences in layer of abdominal wall measured. Some animal studies indicated a positive effect of physical activity on the healing wound. Most clinical studies were qualitative, with only 3 randomized controlled trials on this topic. Variability was reported on clinician recommendations, time to return to activity, and factors that influence return to activity. Interventions designed to shorten convalescence demonstrated improvements only in patient-reported symptoms. None reported an association between activity and complications, such as incisional hernia.

CONCLUSIONS

This systematic review identified gaps in our understanding of what is best for patients recovering from abdominal surgery. Randomized controlled trials are crucial in safely optimizing the recovery period.

Subcuticular sutures versus staples for skin closure in patients undergoing abdominal surgery: A meta-analysis of randomized controlled trials

Background

Surgical site infections (SSIs) are common postoperative complications. Whether the use of staples or sutures makes a difference in abdominal surgery’s infection rate remains elusive.

Methods

A systematic review was performed to identify randomized clinical trials comparing staples and sutures after abdominal surgeries. Eligibility criteria involved the SSI occurrence as the primary outcome and the incidence of wound dehiscence, closure time, cosmesis, and patient satisfaction as the secondary outcomes.

Results

Of the 278 studies identified, seven randomized controlled trials representing 3705 patients were included in this review. There was no significant difference in SSI rates between sutures and staples in general (OR = 0.98, 95% CI = 0.79–1.22, I² = 44%, P = 0.1) or in a subgroup of gastrointestinal surgery, where subcuticular suturing was found with a comparable SSI risk with skin stapling (OR = 0.85, 95% CI = 0.66–1.09). Staple closure was associated with a shorter surgery duration, whereas sutures appeared to provide better cosmesis and patient satisfaction. Sutures and staples achieved a comparable incidence of dehiscence. There was no significant between-study publication bias.

Conclusion

Our study demonstrated similar outcomes in SSI rate between subcuticular sutures and staples for skin closure in patients undergoing abdominal surgery.

Comparison of post-operative pain in short versus long stitch technique for abdominal wall closure after elective laparotomy: a double-blind randomized controlled trial

BACKGROUND

Conventional mass closure uses suture-to-wound length ratio of 4:1 ('long stitch', LS). 'Short stitch' (SS) has a suture-to-wound length ratio of more than 4 and incorporates only the linea alba, which may reduce tension and pain. We compared the post-operative pain after laparotomy closure using LS and SS.

METHODS

Patients undergoing elective midline laparotomy through standardized incisions in two tertiary hospitals from February 2017 to September 2018 were randomized to either LS or SS. The primary outcome was post-operative patient-controlled analgesia morphine usage at 24 h. Secondary outcomes were presence of surgical site infection and length of hospital stay (LOHS). Categorical variables were analysed using chi-squared analysis. Outcomes of study were tested for normal distribution. Skewed data were analysed using Mann-Whitney U-test.

RESULTS

Eighty-six patients were recruited (42 SS and 44 LS). The median age was 66 (interquartile range (IQR) 15). Majority were males (62.8%) and Chinese (50%). The median incision length was 17 cm in both groups. The median patient-controlled analgesia morphine usage 24 h post-operatively did not differ significantly (SS 21 mg, IQR 28.3; LS 18.5 mg, IQR 33.8, P = 0.829). The median pain score at rest (SS 1, IQR 1; LS 1, IQR 2, P = 0.426) and movement (SS 3, IQR 1; LS 3, IQR 2, P = 0.307) did not differ significantly. LOHS was shorter in the SS group (SS 6, IQR 4; LS 8, IQR 5, P = 0.034). The rate of surgical site infection trended lower in the SS group with no statistical difference.

CONCLUSION

There were no differences in post-operative pain between SS and LS but we found that there were shorter LOHS in SS arm as secondary outcome.

The impact of different suturing techniques for abdominal fascia closure on the Interleukin-6 expressions in Rattus norvegicus

OBJECTIVE

Incisional hernia is a frequent complication of midline laparotomy. The suturing technique is an important determinant of the risk of developing an incisional hernia. Moreover, IL-6 has crucial roles in the wound-healing process. We aimed to compare the large stitch vs. small stitch technique for abdominal fascial closure on IL-6 expressions in rats.

RESULTS

Twenty rats were used. The small stitch group received small tissue bites of 5 mm and the large stitch group received large bites of 10 mm. The incisions of fascia were closed by running sutures. Animals were euthanized on days 4 and 7. Histological sections of the tissue-embedded sutures were analyzed for IL-6 expressions. Two-way ANOVA showed that rats in the small stitch group had similar IL-6 expressions on days 4 and 7 to those in the large stitch group (p = 0.36). In conclusion, the IL-6 expressions are similar between the small and the large stitch groups, implying that different suturing techniques might not have an impact on the incisional hernia occurrence.

Protocol for a randomized controlled trial comparing wound COmplications in elective midline laparotomies after FAscia Closure using two different Techniques Of Running sutures: COFACTOR trial

BACKGROUND

Wound complications following midline laparotomies are common and the main source of postoperative morbidity including superficial or deep wound infection, skin dehiscence, fascia dehiscence, and incisional hernia. Abdominal closure complications are strongly associated with suture technique and material, in addition to other factors related to the patient and type of surgery performed. The traditional technique is to place the fascia sutures 1 cm apart and at least 1 cm away from the fascia edge. A Swedish study described a new technique of placing the sutures 5 mm apart and 5 mm away from the fascia edge, resulting in lower rates of abdominal wound complications. This study has a number of limitations. There is a need for improved quality evidence to convince the surgical community to change the closure technique of abdominal wounds aiming to reduce morbidity, which is exemplified in incisional hernias and other various postop complications.

METHODS

This is a 1:1 randomized, controlled, patient- and assessor-blinded, parallel design, superiority trial, with a primary endpoint of incisional hernia at 1 year. The study will be conducted at AUBMC over a 3-year period. Patients planned for a non-emergent midline laparotomy for general surgery or vascular procedure will be randomized to either fascia closure technique. In order to detect a drop of 12% in the incidence of incisional hernia, with 80% power and an alpha of 0.05, we will need to recruit 114 patients per arm. After adjusting for loss to follow-up, target recruitment is 274 subjects. We will compare both arms for the primary, secondary, and exploratory outcomes, using chi-square or t test as appropriate. Univariate and multivariate logistic regression will be done.

DISCUSSION

This trial will assess postop complications following abdominal midline wound closures via two different suturing techniques. This trial will generate evidence-based conclusions that will allow surgeons to assess the role of a new abdominal closure technique in decreasing short- and long-term postoperative complications, for a commonly performed procedure.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03527433 . Registered on 17 May 2018 before starting participant enrollment.

Incisional Surgical Site Infection after Abdominal Fascial Closure with Triclosan-Coated Barbed Suture vs Triclosan-Coated Polydioxanone Loop Suture vs Polydioxanone Loop Suture in Emergent Abdominal Surgery: A Randomized Clinical Trial

BACKGROUND

Triclosan-coated sutures have been shown to reduce surgical-site infection (SSI) in emergent operation for fecal peritonitis. Barbed sutures provoke a homogeneous distribution of tension throughout the suture, implying better blood supply to the wound edges and healing. The aim of this study was to evaluate the effect, on SSI and evisceration, of using triclosan-coated and barbed sutures for fascial closure in patients undergoing emergent surgery.

STUDY DESIGN

A prospective, randomized clinical trial was performed. Patients were randomized into 3 groups: those undergoing aponeurotic closure with triclosan-coated barbed suture (Stratafix Symmetric [Johnson & Johnson]), patients undergoing closure with triclosan-coated polydioxanone loop suture (PDS plus [Johnson & Johnson]), and patients undergoing closure with polydioxanone loop suture (PDS [Johnson & Johnson]). Primary investigated outcomes were SSI and evisceration rates during a follow-up period of 30 days. The primary analysis plan was based on a per-protocol approach.

RESULTS

Incisional SSI was 6.4% (3 of 47) in the Stratafix Symmetric group, 8.9% (4 of 45) in the PDS plus group, and 23.4% (11 of 47) in PDS group (p = 0.03). The evisceration rate was 0% in Stratafix Symmetric, 8.9% (4 of 45) in PDS plus, and 12.8% (6 of 47) in PDS (p = 0.05). Median hospital stay was 4 days (range 2 to 14 days) in Stratafix Symmetric, 5 days (range 2 to 21 days) in PDS plus, and 8 days (range 2 to 60 days) in PDS (p = 0.012). The use of triclosan-coated sutures (Stratafix Symmetric and PDS plus) was associated with a lower risk of incisional SSI (p = 0.009), and the use of barbed suture was associated with a lower risk of evisceration (p = 0.019). Comparing Stratafix Symmetric with PDS plus, there were no significant differences in SSIs, but the evisceration rate was significantly higher in the PDS plus group (p = 0.036).

CONCLUSIONS

The use of triclosan-coated sutures (Stratafix Symmetric and PDS plus) in emergent surgery reduces the incidence of incisional SSIs. The use of barbed sutures reduces the incidence of evisceration.

[Preventive abdominal wall repair in high-risk groups of postoperative ventral hernia]

AIM

To identify the most important predictors of postoperative hernia and to determine the indications for preventive surgical repair of abdominal wall.

MATERIAL AND METHODS

Prospective analysis included 398 medical records of patients who underwent median laparotomy. Experimental tensiometry was applied to determine strength of intact fascia.

RESULTS

The main predictors of postoperative hernia are age over 60 years, obesity, upper median laparotomy, connective tissue insufficiency. Combination of factors increases the risk of hernia. The most 'intense' foci of aponeurosis is middle portion of epigastric and initial part of mesogastric areas. You need to consider this features during laparotomy closure.

CONCLUSION

Preventive repair may be an effective method for prophylaxis of postoperative hernia after median laparotomy.

Effect of the Abdominal Fascial Closure with Triclosan-Coated Sutures in Fecal Peritonitis, on Surgical Site Infection, and Evisceration: A Retrospective Multi-Center Study

BACKGROUND

Surgical site infection (SSI) is a frequent complication in dirty surgery, reaching rates of up to 40%. The incidence of SSI might be influenced by the suture used for closure of the abdominal fascia. Sutures coated with antibacterial substances may reduce the bacterial load in the incision.

PATIENTS AND METHODS

A retrospective study of patients with intra-operative diagnosis of fecal peritonitis undergoing a laparotomy in three Spanish hospitals was performed. Fascial closure consisted in running loop suture of Polyglactin (Vicryl loop^®, Johnson & Johnson, New Brunswick, NY; group 1), running loop suture of triclosan-coated polyglactin (Vicryl plus loop^®; group 2), running loop suture of polydioxanone (PDS loop^® Johnson & Johnson; group 3), and running loop suture of triclosan-coated polydioxanone (PDS plus loop^®; group 4). Incisional SSI and evisceration rates were assessed.

RESULTS

One hundred four patients were included. There were no differences in age, gender, comorbidities, etiology of peritonitis, and mortality among groups. Surgical site infection rate was 34.6% in group 1; 8% in group 2; 33% in group 3; and 10% in group 4 (p = 0.029). The use of triclosan-coated sutures is associated with lower risk of SSI (risk ratio [RR]: 9; p = 0.003). Evisceration rate was 0% in groups 1 and 2; 15.2% in group 3; and 10% in group 4 (p = 0.05). All patients suffering from evisceration presented previous SSI. The use of monofilament sutures is associated with higher risk of evisceration (RR: 6.35; p = 0.033).

CONCLUSION

Triclosan-coated sutures reduce SSI rate in fecal peritonitis, without differences between braided and monofilament type. The use of monofilament sutures is related to higher risk of evisceration, independent of a triclosan coating.

Impact of incisional hernia development following abdominal operations on total healthcare cost

BACKGROUND

Introduction of the category III CPT code (0437T) for prophylactic mesh augmentation (PMA) highlights efforts to reduce incisional hernia (IH). PMA's value in the context of value-based care requires understanding both the cost of IH development and the savings from prevention. We hypothesized large healthcare costs with IH development. Appreciating which subsets of patients are at highest risk for IH, and the subsets who have the costliest care is essential in targeting interventions for hernia prevention.

METHODS

Retrospective cohort study utilizing data from Truven Health Analytic MarketScan Commercial Claims and Encounters Database from calendar years 2011-2014. Adults undergoing open abdominal operations with continued enrollment 3-year post-surgery were included. Inpatient and outpatient claims were tracked over 3 years to identify IH. Quantile regression estimated the association between conditional distribution of total cost and IH. A generalized linear model with gamma distribution estimated the association of conditional mean of total cost and IH. Models were adjusted for confounding cost covariates (e.g., age, gender, obesity, smoking, cancer).

RESULTS

14,290 patients were identified, 1294 (9.1%) developed IH, 48% within 1-year, 33% at 1-2 years, and 19% at 2-3 years post-surgery. 515 underwent stoma creation, 4579 colon resection, 2263 liver/kidney, 3890 peritoneal, 3043 other (foregut, appendectomy, cholecystectomy). Rate of IH formation was 25, 13, 5.9, 6.3, and 6.3%, respectively. The difference in median expenditures for IH development versus no IH was ostomies: $26,098, colorectal: $21,211, liver/kidney: $23,811, peritoneal: $25,554, others: $28,870 (p < 0.0.01). IH within 1 year was more expensive than within 3 years in the following categories: colorectal ($16,034, p = 0.0385), liver/kidney ($27,145, p = 0.0004), and ostomy ($18,992, p = 0.0035).

CONCLUSION

IH is a common occurrence imposing significant healthcare burden. Higher costs occur when IH occurs within 1 year versus 3 years from the index-procedure. This highlights the importance of hernia prevention techniques and the question of whether temporizing closure adjuncts  are appropriate in high-risk patients.

[Comparative analysis of laparotomy closure techniques]

AIM

To assess experimentally different laparotomy closure techniques.

MATERIAL AND METHODS

Experimental research on laboratory animals was performed. Laboratory animals underwent laparotomy followed by aponeurosis suturing by using of interrupted, continuous suture and continuous suture with an arrangement of stitches at different levels. Tensometric and histological examination of tissue specimens together with sutures was made in 7, 14, 60 days after surgery.

RESULTS

Correlation of laparotomy closure technique with values of durability, elasticity and wound process course was obtained.

CONCLUSION

Continuous suture after laparotomy promotes the formation of more mature granulation tissue and more solid scar with low elasticity compared with interrupted sutures.

[Individualized or standard approach to the abdomen : Currently available data]

BACKGROUND

Every abdominal incision can lead to early (e. g. abdominal infection) and late complications (e. g. hernia). The correct incision is often important to have optimal access to the surgical area and to keep complications low.

OBJECTIVE

An analysis of the recent literature was carried out to clarify which access routes have advantages over other types of incision.

MATERIAL AND METHODS

A literature search was carried out in the following databases: Cochrane database of systematic reviews (CDSR), Cochrane library, Medline and PubMed. Systematic reviews and studies with large numbers of cases were used for the evaluation, whereas studies with small numbers of cases and case reports were not taken into account.

RESULTS

Midline incisions are the first choice for acute and elective abdominal surgery because of a good view into and rapid access to the abdominal cavity. For large upper abdominal operations transverse incisions can be considered of equal value due to excellent exploration possibilities, e.g. of the liver and pancreas. 25 years after the introduction of laparoscopy, this technique has become established for cholecystectomy, fundoplication and bariatric surgery. For appendix and colon surgery laparoscopy has the advantage of being less traumatic, whereby postoperative pain and hospitalization are reduced but under circumstances longer operating times must be expected. The single incision laparoscopic surgery (SILS) technique is beneficial in cosmetic outcome; however, incisional hernias, prolonged operating times and higher complication rates are limiting factors for this technique. Natural orifice transluminal endoscopic surgery (NOTES) and atypical incisions are rarely used.

An Economic Model: Value of Antimicrobial-Coated Sutures to Society, Hospitals, and Third-Party Payers in Preventing Abdominal Surgical Site Infections

Background

While the persistence of high surgical site infection (SSI) rates has prompted the advent of more expensive sutures that are coated with antimicrobial agents to prevent SSIs, the economic value of such sutures has yet to be determined.

Methods

Using TreeAge Pro, we developed a decision analytic model to determine the cost-effectiveness of using antimicrobial sutures in abdominal incisions from the hospital, third-party payer, and societal perspectives. Sensitivity analyses systematically varied the risk of developing an SSI (range, 5%–20%), the cost of triclosan-coated sutures (range, $5–$25/inch), and triclosan-coated suture efficacy in preventing infection (range, 5%–50%) to highlight the range of costs associated with using such sutures.

Results

Triclosan-coated sutures saved $4,109–$13,975 (hospital perspective), $4,133–$14,297 (third-party payer perspective), and $40,127–$53,244 (societal perspective) per SSI prevented, when a surgery had a 15% SSI risk, depending on their efficacy. If the SSI risk was no more than 5% and the efficacy in preventing SSIs was no more than 10%, triclosan-coated sutures resulted in extra expenditure for hospitals and third-party payers (resulting in extra costs of $1,626 and $1,071 per SSI prevented for hospitals and third-party payers, respectively; SSI risk, 5%; efficacy, 10%).

Conclusions

Our results suggest that switching to triclosan-coated sutures from the uncoated sutures can both prevent SSIs and save substantial costs for hospitals, third-party payers, and society, as long as efficacy in preventing SSIs is at least 10% and SSI risk is at least 10%.

FiberSecure suture compared to braided polyester suture

Reliability of wound closure is limited primarily by the capacity of tissues to support conventional sutures (or staples), not by strength of either material per se. We developed FiberSecure™ for closures to surpass tissue strength. We assessed and compared the mechanical and histological performance of FiberSecure™ suture versus commercially available braided polyester suture (Mersilene) in the closure of abdominal muscle incisions in miniature swine at approximately 3 months postsurgery. Four incisions were closed in the external oblique muscle of eight Sinclair minipigs. Two wounds were closed with FiberSecure™ suture size 0 and the remaining two with Mersilene suture size 0. At 90 days, specimens were removed for biomechanics and histology. In destructive tensile testing, in the 16 abdominal muscle specimens for the FiberSecure™ suture, muscle tear was not near the suture implantation region, which remained intact. Wound strength met or exceeded strength of neighboring tissue in FiberSecure™ groups, which had peak force of 55.7 ± 22.1 N (mean ± SD) and peak stress of 579.0 ± 159.2 KPa (mean ± SD). For Mersilene, 3 of the 16 samples tore at the suture site and the remaining samples tore through the abdominal muscle not near the implantation region. The wound strength was similar to surrounding tissue, and these specimens had peak force of 51.8 ± 21.7 N and peak stress of 550.3 ± 239.4 KPa (mean ± SD). No significant difference was observed in peak force or stress between groups (p > 0.05), most repairs having met or exceeded native tissue strength by this time point. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1126-1130, 2017.

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.

Abdominal fascia closure following elective midline laparotomy: a surgical experience at a tertiary care hospital in Tanzania

Background

The optimal strategy of abdominal wall closure after midline laparotomy has remained an issue of ongoing debate. This study was undertaken to describe our own experiences with abdominal fascial closure following elective midline laparotomy and compare with what is described in literature.

Methods

This was a descriptive prospective study of patients who underwent elective midline laparotomy at Bugando Medical Centre between March 2009 and February 2014.

Results

A total of 872 patients (M:F = 2.8:1) were studied. The median age was 38 years. The fascia closure was performed with a continuous and interrupted sutures in 804 (92.2%) and 68 (7.8%) patients, respectively. Mass closure and layered closure were performed in 842 (96.6%) and 30 (3.4%) patients, respectively. Monofilament sutures were applied for fascia closure in 366 (42.0%) patients, multifilament sutures in 506 (58.0%) patients. Non-absorbable sutures were chosen in 304 (34.9%) patients, slowly absorbable sutures in 506 (58.0%), and moderately absorbable sutures in 62 (7.1%) patients. Sutures used for fascial closure were vicryl 464 (53.2%), nylon 250 (28.7%), prolene 62 (7.1%), PDSII 54 (6.2%) and silk 42 (4.8%). Sutures with the strength of 0 were used in 214 (24.4%) patients, with strength of 1 in 524 (60.1%) patients, and with strength of 2 in 134 (15.4%) patients. The mean time required for massive closure of the midline incision was 8.20 ± 6.12 min whereas in layered closure, the mean time required for closure was 12.22 ± 7.11 min and this was statistically significant (p = 0.002). Mass closure was significantly associated with low incidence of wound dehiscence and incisional hernia (p < 0.001). Continuous suture was significantly associated with low incidence of wound dehiscence and incisional hernia as compared to interrupted suture (p < 0.001). Non-absorbable sutures were significantly associated with increased incidence of persistent wound pain and stitch sinus as compared to absorbable sutures (p < 0.001). The use of monofilament sutures was insignificantly associated with low incidence of surgical site infection as compared to multifilament sutures (p = 0.051). Prolene was significantly associated with persistent wound pain as compared to vicryl (p = 0.017).

Conclusion

Continuous mass closure with vicryl is commonly used for abdominal fascial closure following elective midline laparotomy in our setting and gives satisfactory results.

The effect of relaparotomy timing on wound healing in an animal model

BACKGROUND

The effect of the timing of the second laparotomy on wound healing is not clear. In an experimental study in rats, we aimed to investigate the effect of timing on wound healing after reoperations on the same surgical site.

MATERIAL AND METHODS

Forty-eight rats were divided into four groups. The control group (GC) didn't have another laparotomy whereas the relaparotomies on the same surgical site were performed either on the 3rd, 15th or the 30th postoperative days in the three study groups (G3, G15, G30 respectively). The midline tension pressure, collagen types I, III and, histological analysis were performed from the specimens in order to assess the wound healing and strength.

RESULTS

The tensile strength was the highest in GC and decreased gradually in G3, G15 and G30, the difference between the groups did not reach statistical significance. Higher collagen levels, increased fibrosis, and large defects were observed in relaparotomy groups than CG. The musculoaponeurotic gap was shortest in GC when compared to other three relaparotomy groups (P < 0.001) and, it was the longest in G30 (P = 0.004 between G3 and G30).

CONCLUSIONS

Although non-statistically significant the gradual decrease in the tensile strength and the statistically significant increase in the musculoaponeurotic gap with time point out the importance of the timing of relaparotomy in the healing process. Early relaparotomies do not disrupt the healing process as much as relaparotomy performed later.

Subcutaneous application of gentamicin collagen implants as prophylaxis of surgical site infections in laparoscopic colorectal surgery: a randomized, double-blinded, three-arm trial

PURPOSE

Despite a standardized prophylaxis with antibiotics, surgical site infections (SSI) are a characteristic problem in colorectal surgery. Local administration of gentamicin-collagen sponges (GCS) has been shown to decrease the infection rate after contaminated procedures. So far, the effect has not been tested for standardized laparoscopic colorectal resections.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial to investigate the efficacy of GCS to reduce wound infection after laparoscopic colorectal resections. Patients underwent a standardized operative procedure with standardized incision treatment. The intervention was the application of a GCS in the subcutaneous tissue of the bowel extraction site (GCS group). In the collagen group, a collagen sponge without antibiotics was used, and no sponge was used in the control group. The primary endpoint was SSI within 30 days postoperatively, according to the Center of Disease Control and Prevention definition.

RESULTS

We randomly assigned 291 patients to all three groups. There was no difference between the groups regarding demographic characteristics and perioperative course. SSI was diagnosed in 8.2 % (GCS group), 13.5 % (collagen group), and 11.3 % (control group) of patients. No significant difference was found among the groups.

CONCLUSION

The local administration of GCS showed no significant benefit regarding wound infection after standardized laparoscopic colorectal resections. However, there was a trend toward reduced SSI in the GCS group. Therefore, a larger trial or meta-analysis is necessary to validate this result.

A case of small-bowel obstruction secondary to inadvertent ingestion of impression material

BACKGROUND

Small-bowel obstruction (SBO) is responsible for approximately 12 to 16 percent of surgical hospital admissions and more than 300,000 operations annually in the United States. This has resulted in more than $2.3 billion in health care delivery per year. SBO is a serious complication, carrying a 10 percent risk of mortality.

CASE DESCRIPTION

The authors report a case of SBO resulting from inadvertent ingestion of polysulfide impression material. A 74-year-old man visited the emergency department with diffuse, nonradiating, colicky periumbilical pain. The patient was admitted to the general surgery service of the hospital, and after four days of supportive therapy without evidence of progression of the foreign body, he underwent an exploratory laparotomy. The authors later identified the foreign body as polysulfide impression material.

PRACTICAL IMPLICATIONS

SBO is a rare but significant complication that can result from a procedure that clinicians perform on a routine basis. Dentists should consider this complication whenever they are concerned that a high-risk patient may have ingested dental materials.

Skin closure after laparotomy with staples or sutures: a study of the mature scar

BACKGROUND

Surgeons are divided in their method of choice for skin closure following laparotomy. We suggest that the most important determinant should be the resulting scar. This study aims to compare both patients' and independent observers' assessment of mature laparotomy scars that had been closed with either subcuticular sutures or external staples.

METHODS

Consecutive patients were enrolled at least 1 year following colorectal surgery. Scars were assessed with the validated Patient and Observer Scar Assessment Scoring (POSAS) tool. Photographs were assessed by a blinded independent panel.

RESULTS

Overall, 232 patients were enrolled (90 suture, 143 staples). The two groups were well matched by factors affecting wound healing. Patients' overall opinion of their scar was significantly better for the Suture group than the Staples group (P = 0.028) despite there being no difference in their self-assessment of the components of their scar score (pain, itch, colour, stiffness, thickness, irregularity). The panel recorded similar overall scores for the Suture and Staples groups (P = 0.059). There was a significant lower (better) score recorded for the scar area component for the Suture group than the Staples group (P = 0.008) but no differences for the other components (vascularity, pigmentation or thickness).

DISCUSSION

This study has shown that independent of skin closure method, patients who have undergone major abdominal surgery have a positive opinion of their mature scars. The patients' overall impression of the wound favours a sutured closure due to a smaller scar area (no staple marks). In all other respects, skin closure with staples would appear acceptable.

[Results of a national survey on abdominal wall closure]

OBJECTIVE

To assess knowledge on the abdominal wall closure through a surgeon cohort survey.

METHODS

A twenty question individual questionnaire on laparotomy in elective surgery.

RESULTS

A total of 131 surgeons from seven hospitals responded (72% specialists and 28% in training). 71% of respondents estimated the frequency of incisional hernia to be higher than 15% and 54% considered the technique to be the most significant risk factor. 85% considered midline laparotomy closed with slow absorbable suture (57%) in a single layer (66%) to be the most appropriate technique. 67% believed retention sutures to be the appropriate prevention technique. 50% did not know or could not apply the 4:1 technique. 87% considered that an incisional hernia can be prevented and that the technique is the most important factor on which to act. 84% believed that a prosthesis can prevent the occurrence of incisional hernia, whereas 40% of respondents never use it and only 38% use it in patients at risk. On comparing surveys between specialists and residents, significant differences appeared in terms of a better understanding of the theoretical technical aspects in trainee surgeons.

CONCLUSIONS

Although the results show an adequate understanding of the epidemiology and risk factors for development of incisional hernia, training and consensus measures are likely to be introduced in some basic technical aspects in order to improve results in laparotomy closure.

Design and current status of CONTINT: continuous versus interrupted abdominal wall closure after emergency midline laparotomy - a randomized controlled multicenter trial [NCT00544583]

Background

The optimal strategy for abdominal wall closure has been an issue of ongoing debate. Available studies do not specifically enroll patients who undergo emergency laparotomy and thus do not consider the distinct biological characteristics of these patients. The present randomized controlled trial evaluates the efficacy and safety of two commonly applied abdominal wall closure strategies in patients undergoing primary emergency midline laparotomy.

Methods/design

The CONTINT trial is a multicenter, open label, randomized controlled trial with a two-group parallel design. Patients undergoing a primary emergency midline laparotomy are enrolled in the trial. The two most commonly applied strategies of abdominal wall closure after midline laparotomy are compared: the continuous, all-layer suture technique using slowly absorbable monofilament material (two Monoplus® loops) and the interrupted suture technique using rapidly absorbable braided material (Vicryl® sutures). The primary endpoint within the CONTINT trial is an incisional hernia within 12 months or a burst abdomen within 30 days after surgery. As reliable data on this primary endpoint is not available for patients undergoing emergency surgery, an adaptive interim analysis will be conducted after the inclusion of 80 patients, allowing early termination of the trial if necessary or modification of design characteristics such as recalculation of sample size.

Discussion

This is a randomized controlled multicenter trial with a two-group parallel design to assess the efficacy and safety of two commonly applied abdominal wall closure strategies in patients undergoing primary emergency midline laparotomy.

Trial registration

NCT00544583

Elective midline laparotomy closure: the INLINE systematic review and meta-analysis

OBJECTIVE

To evaluate the optimal technique and material for abdominal fascia closure after midline laparotomy, first by means of a precisely defined study population and follow-up period and second by the surgically driven aspects.

METHODS

Overview of existing systematic reviews and meta-analysis of randomized controlled trials. A systematic literature search (Medline, Embase, and The Cochrane Central Register of Controlled Trials) was performed to identify randomized controlled trials in elective and emergency populations comparing suture techniques (continuous vs. interrupted) and materials (rapidly vs. slowly vs. nonabsorbable). Random effects conventional and cumulative meta-analyses were calculated and presented as odds ratios and the corresponding 95% confidence intervals.

RESULTS

Five systematic reviews and 14 trials including 7711 patients (6752 midline incisions) were analyzed. None of the systematic reviews differentiated elective versus emergency laparotomy. The analysis of available primary studies revealed significant lower hernia rates using a continuous (vs. interrupted) technique (OR: 0.59; P=0.001) with slowly absorbable (vs. rapid-absorbable) suture material (OR: 0.65; P=0.009) in the elective setting, which was in contrast to the conflicting results of existing systematic reviews. No statistical heterogeneity was detected in the elective setting (I=0%). Seven studies incorporating elective and emergency procedures revealed inconclusive and heterogeneous results (I=45%-85%). No studies have evaluated closure methods solely in the emergency setting so far.

CONCLUSION

No further trials should be conducted for evaluation of technique and available materials for elective midline abdominal fascial closure, according to the results of our cumulative meta-analysis. Future trials will have to define the optimal closure strategy in the emergency setting and relevance of new suture materials and other strategies such as the use of prophylactic mesh in targeted subpopulations.