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

Collating evidence to support the validation of a simulated laparotomy incision and closure-training model

BACKGROUND

It is essential to evaluate the functionality of surgical simulation models, in order to determine whether they perform as intended. In this study, we assessed the use of a simulated laparotomy incision and closure-training model by collating validity evidence to determine its utility as well as pre and post-test interval data.

METHOD

This was a quantitative study design, informed by Messick's unified validity framework. In total, 93 participants (surgical trainees ​= ​80, experts ​= ​13) participated in this study. Evaluation of content validity and the models' relationships with other variables was conducted, along with a pre and post-test confidence assessment.

RESULTS

The model was deemed realistic and useful as a teaching tool, providing strong content validity evidence. In assessment of relationships with other variables, the expert group out-performed the novice group conclusively. Pre and post-test evaluation reported a statistically significant increase in confidence levels.

CONCLUSION

We present strong validity evidence of a novel laparotomy incision and closure simulation-training model.

Do Absorbable Sutures Work for Rectus Diastasis Repair in Abdominoplasty Patients?

Background

The standard treatment for rectus diastasis is rectus sheath plication during abdominoplasty. Lasting correction of diastasis is essential, but there is currently a debate as to whether absorbable or nonabsorbable rectus plication achieves a lower rate of recurrence.

Objectives

The goal of this study is to assess long-term patient outcomes and the recurrence of rectus diastasis after plication with long-lasting absorbable sutures.

Methods

A retrospective study of abdominoplasties performed by the senior author between 2018 and 2022 was performed. Only female patients with >6 months of follow-up were included. Plication of the rectus muscles was performed with a combination of interrupted, buried, figure of eight #0 polydioxanone suture and running #0 Maxon (Covidien, Mansfield, MA). Outcomes were assessed by physical examination at postoperative visits. A retrospective chart review was used to obtain demographic and perioperative information.

Results

Seventy-one patients underwent abdominoplasty with an average follow-up of 21.1 months. The average age was 43 years, and the average BMI was 27 kg/m2. Correction of rectus diastasis was performed using absorbable sutures in all patients with no recurrence of diastasis in any patient (0% diastasis recurrence rate). Complications included delayed wound healing (11%), seroma (8.5%), hematoma (2.8%), and deep vein thrombosis/pulmonary embolism (2.8%). No patients needed reoperation.

Conclusions

Abdominal wall plication using a double-layered, long-lasting absorbable suture closure is a safe, reliable, and effective method to address rectus diastasis during abdominoplasty. Our technique achieved no recurrence of diastasis in any patient and a low complication profile.

Level of Evidence 3

A Prospective Study on the Outcome After Mass Closure of Post-laparotomy Wound Dehiscence in a Tertiary Care Hospital, Tamil Nadu, India

Introduction The ideal abdominal wound closure provides strength and a barrier to infection. The major cause of morbidity following any laparotomy is abdominal wound dehiscence. For prompt patient recovery and outcome factors influencing wound healing following mass closure of post-laparotomy, wound dehiscence patients are evaluated in this present study. The aim of the study was to evaluate the outcome and various complications following mass closure of post-laparotomy wound dehiscence. Materials and methods A prospective study was conducted among 50 patients admitted to the Department of General Surgery, Tamil Nadu, India, with wound dehiscence following emergency and elective laparotomy surgeries managed with mass closure during the study period from 2021 to 2022. The chi-square test and Fischer's exact test were done. Results Mass closure of post-laparotomy wound dehiscence was more common among males (74%, n=37) and less common in the age group 20-30 years (12%, n=6). Prolonged bleeding time and clotting time post-surgery were associated with the type of surgery with a significant p-value of 0.007 and 0.001, respectively, by Fischer's exact test. The presence of urine albumin was also associated with the type of surgery with a significant p-value of 0.02. Surgical site infection (postoperative complication) was associated with the type of surgery and operating time with a significant p-value of 0.004 and 0.03, respectively. Conclusion Abdominal wound dehiscence is a serious and challenging postoperative complication that necessitates immediate intervention. Strict postoperative care places emphasis on reducing the risk of wound infection and other factors related to wound dehiscence.

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.

Fascia Repair with Vicryl Suture in Urologic Surgeries

Background: Closing the fascia after surgery should be quick, easy, and strong but comfortable for the patient. Polydioxanone thread is not available in Iran. Thus, we used Vicryl sutures for almost all patients. Methods: This study was conducted at Imam Reza and Imam Khomeini Medical Centers in Ardabil from January 2018 to January 2020. The fascia was continuously sutured with size 0 or 1 of Vicryl in a double layer for all patients in the Urology Department. Results: Here, 642 patients were evaluated in two years. The fascia suturing was at the site of the inguinal, midline Gibson, and flank areas. The data showed that incisional hernia and infection were more prevalent in obese and diabetic patients. We had no incisional complications in radical cystectomy or even kidney transplantation, which are complicated and time-consuming surgeries. Overall, the surgical site complication rate (including incisional hernia and surgical site infection) was 0.9%, which could be negligible. Conclusions: The fascia repair could be treated with Vicryl suture in a continuous form in all urologic surgeries, with a very low rate of wound infection and hernia at the operation site, sinus formation, and long-term surgical site discomfort. However, we suggest more research to confirm the Vicryl suture safety in urologic fascia repairs.

Abdominal Wall Plication and Correction of Deformities of the Myoaponeurotic Layer: Focusing on Materials and Techniques Used for Synthesis

The different types of sutures utilized in plications and for correction of diastasis during abdominoplasty are reviewed and discussed. Because correction of abdominal deformities also involves fascia and muscle advancement, this review also covers the suture materials used in muscle advancement. The selection of specific techniques to treat different types of abdominal wall deformity is also considered. This is important, because the outcome when correcting these deformities depends not only on suture materials but also on employing the optimum technique. A PubMed/Medline search was performed with the following search terms: rectus diastasis, diastasis recti, diastasis recti abdominis, correction of rectus diastasis, abdominoplasty. Relevant articles identifying the type of suture (rapidly absorbable, slowly absorbable, nonabsorbable), monofilament or multifilament sutures, antibiotic-coated sutures, and barbed sutures were evaluated. In addition, articles about surgical technique comparing continuous and interrupted sutures, in both the anterior and posterior aponeurosis, to correct rectus diastasis are discussed. Efficacy of suture materials was evaluated based on the long-term results and recurrence rates reported in these articles. The current literature provides sufficient data to recommend a single-layer continuous suture, with slowly absorbable sutures of 0 polydioxanone or 2-0 nylon, for correction of abdominal diastasis. An interrupted triangular suture is a good alternative to correct the vertical elongation of the myoaponeurotic layer that occurs after pregnancy.

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.

Transient phase behavior of an elastomeric biomaterial applied to abdominal laparotomy closure

Secure closure of the fascial layers after entry into the peritoneal cavity is crucial to prevent incisional hernia, yet appropriate purchase of the tissue can be challenging due to the proximity of the underlying protuberant bowel which may become punctured by the surgical needle or strangulated by the suture itself. Devices currently employed to provide visceral protection during abdominal closure, such as the metal malleable retractor and Glassman Visceral Retainer, are unable to provide complete protection as they must be removed prior to complete closure. A puncture resistant, biocompatible, and degradable matrix that can be left in place without need for removal would facilitate rapid and safe abdominal closure. We describe a novel elastomer (CC-DHA) that undergoes a rapid but controlled solid-to-liquid phase transition through the application of a destabilized carbonate cross-linked network. The elastomer is comprised of a polycarbonate cross-linked network of dihydroxyacetone, glycerol ethoxylate, and tri(ethylene glycol). The ketone functionality of the dihydroxyacetone facilitates hydrolytic cleavage of the carbonate linkages resulting in a rapidly degrading barrier that can be left in situ to facilitate abdominal fascial closure. Using a murine laparotomy model we demonstrated rapid dissolution and metabolism of the elastomer without evidence of toxicity or intraabdominal scarring. Furthermore, needle puncture and mechanical properties demonstrated the material to be both compliant and sufficiently puncture resistant. These unique characteristics make the biomaterial extraordinarily useful as a physical barrier to prevent inadvertent bowel injury during fascial closure, with the potential for wider application across a variety of medical and surgical applications.

STATEMENT OF SIGNIFICANCE

Fascial closure after abdominal surgery requires delicate maneuvers to prevent incisional hernia while minimizing risk for inadvertent bowel injury. We describe a novel biocompatible and biodegradable polycarbonate elastomer (CC-DHA) comprised of dihydroxyacetone, glycerol ethoxylate, and tri(ethylene glycol), for use as a rapidly degrading protective visceral barrier to aid in abdominal closure. Rapid polymer dissolution and metabolism was demonstrated using a murine laparotomy model without evidence of toxicity or intraabdominal scarring. Furthermore, mechanical studies showed the material to be sufficiently puncture resistant and compliant. Overall, this new biomaterial is extraordinary useful as a physical barrier to prevent inadvertent bowel injury during fascial closure, with the potential for wider application across a variety of medical and surgical applications.