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Ozcan C, Colak T, Turkmenoglu O, Berkesoglu M, Ertas E. Impact of small-bite (5 mm) fascial closure on the incidence of incisional hernia following open colorectal cancer surgery: randomized clinical trial. Br J Surg 2024; 111:znae189. [PMID: 39107062 DOI: 10.1093/bjs/znae189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 07/06/2024] [Accepted: 07/10/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Incisional hernia is frequently observed after open colorectal cancer surgery, and should be considered a serious short- and long-term health issue. The present study evaluated the efficacy of small-bite abdominal closure in reducing the incidence of incisional hernia in this patient group. METHODS An RCT was conducted between June 2019 and June 2022. A total of 173 patients who underwent open colorectal cancer surgery were assigned randomly to one of two groups to undergo fascial closure with either small bites (87) or conventional bites (86). The incisional hernia rate was accepted as the primary outcome, and surgical-site infection as the secondary outcome. RESULTS The incisional hernia rates at 1 year were 7 and 27% in the small- and conventional-bite groups respectively (P < 0.001). This rate increased to 9 and 31% at the end of the second year (P < 0.001). Surgical-site infections occurred in 18% of the small-bite group and 31% of the conventional-bite group (P = 0.03). Compared with the conventional-bite group, the small-bite group had higher suture/wound length ratios (mean(s.d.) 5.18(0.84) versus 3.67(0.57); P < 0.001) and a longer fascial closure time 14.1(4.64) versus 12.9(2.39) min; P = 0.03). CONCLUSION Small-bite closure with 5-mm tissue bites placed 5 mm apart reduced the incidence of incisional hernia and surgical-site infection after open colorectal cancer surgery.
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Affiliation(s)
- Cumhur Ozcan
- Department of General Surgery, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Tahsin Colak
- Department of General Surgery, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Ozgur Turkmenoglu
- Department of General Surgery, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Mustafa Berkesoglu
- Department of General Surgery, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Elif Ertas
- Department of Biostatistics, Selcuk University, Konya, Turkey
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Maheshwari M, Khan IA. Advances and Techniques in Subcuticular Suturing for Abdominal Wall Closure: A Comprehensive Review. Cureus 2024; 16:e65069. [PMID: 39171061 PMCID: PMC11336517 DOI: 10.7759/cureus.65069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 07/21/2024] [Indexed: 08/23/2024] Open
Abstract
Subcuticular suturing has emerged as a prominent technique for abdominal wall closure, offering notable benefits in cosmetic outcomes, infection reduction, and patient satisfaction. This comprehensive review delves into the evolution and current state of subcuticular suturing, examining its principles, techniques, and advancements. Traditional methods like continuous and interrupted suturing are compared with modern innovations like barbed sutures and knotless techniques. Clinical outcomes, including healing efficacy, complication rates, and cost-effectiveness, are analyzed to highlight the technique's advantages. The review also explores specific applications in various surgical specialities, presenting case studies and clinical trials to substantiate its effectiveness. Despite certain challenges and limitations, the future of subcuticular suturing appears promising with ongoing research and technological advancements. This review aims to thoroughly understand subcuticular suturing, emphasizing its significance in improving surgical outcomes and patient care in abdominal wall closure.
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Affiliation(s)
- Maulik Maheshwari
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Imran Ali Khan
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Yii E, Onggo J, Yii MK. Small bite versus large bite stitching technique for midline laparotomy wound closure: A systematic review and meta-analysis. Asian J Surg 2023; 46:4719-4726. [PMID: 37652773 DOI: 10.1016/j.asjsur.2023.08.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/22/2023] [Indexed: 09/02/2023] Open
Abstract
Mass closure with a continuous suture using large bite stitching technique has been widely accepted for midline laparotomy wound closures. However, emerging evidence suggests the use of small bite technique to reduce rates of incisional ventral hernia, surgical site infection (SSI) and burst abdomen. This meta-analysis aims to compare small versus large bite stitching techniques to assess complication rates in midline laparotomy wound closures. A comprehensive multi-database search (OVID EBM Reviews, OVID Medline, EMBASE, Scopus) was conducted from database inception to 11th October 2021 according to PRISMA guidelines. We included studies comparing post-operative complication rates of small bite versus large bite stitching techniques for midline laparotomy wound closure. Extracted data was pooled for meta-analysis evaluating rates of incisional ventral hernia, SSI and burst abdomen. We included five randomized controlled trials (RCT) in the meta-analysis and three prospective cohort studies for qualitative analysis. A total of 1977 participants composed of 961 small bite and 1016 large bite technique patients were included from the five RCTs. There was a significant reduction in the rates of incisional ventral hernia and SSI with the small bite stitch technique with odds ratios (OR) of 0.39 (95% CI [0.21-0.71]) and 0.68 (95% CI [0.51-0.91]) respectively, and a trend in favour of reduced incidence of burst abdomen with OR of 0.60 (95% CI [0.15-2.48]). Small bite stitch technique in midline laparotomy wound closure may be superior over conventional mass closure using the large bite stitch technique, with statistically significant lower rates of incisional ventral hernia and SSI.
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Affiliation(s)
- Erwin Yii
- Box Hill Hospital, Department of Surgery, Box Hill, Victoria, Australia.
| | - James Onggo
- Box Hill Hospital, Department of Surgery, Box Hill, Victoria, Australia
| | - Ming Kon Yii
- Monash University, Department of Surgery, School of Clinical Sciences at Monash Health, Clayton, Victoria, Australia; Monash Medical Centre Clayton, Vascular and Transplant Surgery Unit at Monash Health, Clayton, Victoria, Australia
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Pous-Serrano S, García-Pastor P, Bueno-Lledó J. National survey of colorectal surgery units on abdominal wall closure. Cir Esp 2023; 101:258-264. [PMID: 36108954 DOI: 10.1016/j.cireng.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/08/2022] [Indexed: 04/21/2023]
Abstract
INTRODUCTION The purpose of this study is to assess the current status and knowledge of the Spanish colorectal surgeons on the wall closure. METHODS A single answer questionnaire of 25 closed questions was conducted using specific software for online surveys that was distributed to a cohort of colorectal surgeons. RESULTS 53 surgeons replied to the survey. The vast majority prefer a closure of the midlaparotomy with a very slow absorbing monofilament (67.92%) continuous suture (96.23%) in a single plane (81.13%). Mass stitches, retention systems, and loop sutures continue to be used. The most commonly used suture gauge was USP 1 (United States Pharmacopeia) (58.49%). The most commonly used needle is with a cylindrical body and a trocar tip. Only 50%, routinely perform wall closure after placement of a trocar equal to or greater than 10 mm. Almost everyone knows the 4:1 rule and thinks it should be applied, but the small bites technique is not performed. 50% would never place a prophylactic prosthesis. The closure is usually performed by the same surgeon who has performed the entire procedure. One out of five confesses not knowing the rate of incisional hernias in his unit. CONCLUSION There is a lack of consensus and basic knowledge regarding the technical aspects of closure and the prevention of the appearance of incisional hernias. The use of slow absorbing monofilament continuous suture in a single plane seems well accepted.
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Affiliation(s)
- Salvador Pous-Serrano
- Unidad de Cirugía de Pared, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
| | - Providencia García-Pastor
- Unidad de Cirugía de Pared, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - José Bueno-Lledó
- Unidad de Cirugía de Pared, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Theodorou A, Banysch M, Gök H, Deerenberg EB, Kalff JC, von Websky MW. Don't fear the (small) bite: A narrative review of the rationale and misconceptions surrounding closure of abdominal wall incisions. Front Surg 2022; 9:1002558. [PMID: 36504582 PMCID: PMC9727106 DOI: 10.3389/fsurg.2022.1002558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/11/2022] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Alexis Theodorou
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany,Correspondence: Alexis Theodorou
| | - Mark Banysch
- Department of Surgery, St. Bernhard Hospital Kamp-Lintfort, Kamp-Lintfort, Germany
| | - Hakan Gök
- Hernia Istanbul, Hernia Istanbul®, Hernia Surgery Center, Istanbul, Turkey
| | - Eva B. Deerenberg
- Department of Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Joerg C. Kalff
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Martin W. von Websky
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
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Pous-Serrano S, García-Pastor P, Bueno-Lledó J. Encuesta nacional a unidades de cirugía colorrectal sobre el cierre de pared abdominal. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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What Is the Proper Technique for Primary Laparotomy Closure? Adv Surg 2021; 55:197-214. [PMID: 34389092 DOI: 10.1016/j.yasu.2021.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Lai LWH, Roslani AC, Yan YW, Bhojwani KM, Jamaluddin MFH. Comparison of post-operative pain in short versus long stitch technique for abdominal wall closure after elective laparotomy: a double-blind randomized controlled trial. ANZ J Surg 2021; 91:896-901. [PMID: 33522667 DOI: 10.1111/ans.16567] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/17/2020] [Accepted: 12/22/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | - April Camilla Roslani
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603, Malaysia
| | - Yang-Wai Yan
- Department of Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Malaysia
| | - Kavita M Bhojwani
- Department of Anaesthesiology and Critical Care, Hospital Raja Permaisuri Bainun, Ipoh, Malaysia
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Kubyshkin VA, Galliamov EA, Agapov MA, Kakotkin VV, Davlyatov MR. SIGNIFICANCE OF THE STRUCTURE AND METABOLISM OF THE EXTRACELLULAR MATRIX IN THE PATHOGENESIS OF ABDOMINAL HERNIAS. REVIEW. SURGICAL PRACTICE 2020. [DOI: 10.38181/2223-2427-2020-1-24-32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- V. A. Kubyshkin
- Federal State Budget Educational Institution of Higher Education M.V. Lomonosov Moscow State University
| | - E. A. Galliamov
- Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - M. A. Agapov
- Federal State Budget Educational Institution of Higher Education M.V. Lomonosov Moscow State University
| | - V. V. Kakotkin
- Federal State Budget Educational Institution of Higher Education M.V. Lomonosov Moscow State University
| | - M. R. Davlyatov
- Federal State Budget Educational Institution of Higher Education M.V. Lomonosov Moscow State University
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Magnitude of Abdominal Wound Dehiscence and Associated Factors of Patients Who Underwent Abdominal Operation at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. Surg Res Pract 2020; 2020:1379738. [PMID: 32232116 PMCID: PMC7060443 DOI: 10.1155/2020/1379738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 01/27/2020] [Accepted: 02/04/2020] [Indexed: 12/01/2022] Open
Abstract
Background Abdominal wound dehiscence (AWD) is the separation of different layers of an abdominal wound before complete healing has taken place. It is a major cause of postoperative morbidity and mortality in sub-Saharan Africa including Ethiopia, and little is known about its prevalence and related factors in the study area. Objectives The aim of this study is to assess the magnitude of abdominal wound dehiscence and related factors on patients operated at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. Methods A hospital-based retrospective review of the chart was carried out by using the data covering three years (September 2014–September 2017) period. Data were collected from hospital medical records of sampled patients such as operation room logbooks and individual patient medical records. The collected data were checked for consistency, coded, and entered into SPSS version 20 for data processing and analysis. Descriptive analysis was conducted, and tables and graphs and summary statistics were used to depict data. Results A total of 41 patients developed abdominal wound dehiscence from among 4137 patients who underwent abdominal laparotomy in the hospital. Among the patients, 51.2% were in the age range of 41 and above with mean age 29.8 (SD = 1.21) and 70.7% of them were male. Abdominal wound dehiscence was more common in emergency patients (90%) and vertical incision was the most common type of incision. Over half (58.5%) of the wound dehiscence occurred within 6–10 postoperative days. The majority (95.2%) of dehisced patients underwent relaparotomy for the management of the wound dehiscence, and 48.8% of them were treated with tension suture during the second operation of abdominal closure. Four of the patients (9.7%) died after the management of the second operation. Conclusion The current study revealed that the overall magnitude of abdominal wound dehiscence in the study area was 0.99%. Most of the dehiscence has occurred in male patients, and older age groups were highly affected than the younger ones. Emergency admission is the most common form of admission identified in the study, and this signifies appropriate preoperative preparation of patients for an optimal outcome. However, regarding the management outcome, 9.8% of patients died in our study within the institution after the second operation which is the high mortality rate.
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Kubyshkin VA, Agapov MA, Davlyatov MR, Kakotkin VV. [Ventral hernias and extracellular matrix of connective tissue]. Khirurgiia (Mosk) 2020:62-67. [PMID: 32105257 DOI: 10.17116/hirurgia202002162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Ventral hernia is still one of the most common reason for scheduled and emergency surgery. The review is designed to reveal relationships between metabolism in extracellular matrix of connective tissue and pathogenesis of ventral hernias. These data will be valuable to develop a personalized approach to the treatment of these patients.
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Affiliation(s)
| | - M A Agapov
- Lomonosov Moscow State University, Moscow, Russia
| | | | - V V Kakotkin
- Lomonosov Moscow State University, Moscow, Russia
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Bartier AL, Atilla A, Archer R, Kwong GPS. Optimal Suture Bite Size for Closure of Feline Linea Alba-A Cadaveric Study. Front Vet Sci 2019; 6:441. [PMID: 31921902 PMCID: PMC6914685 DOI: 10.3389/fvets.2019.00441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 11/25/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aimed to determine the most appropriate suture bite and stitch interval (SBSI) size for closing feline linea alba. Study design: Randomized ex vivo mechanical testing. Sample population: Ventral abdominal walls from 35 male feline cadavers were harvested and separated into 125 segments. Methods: Segments were incised along midline then sutured back together using 3-0 polydioxanone using one of the following SBSI: 3, 5, 7.5, or 10 mm whereby the distance represents the distance both between the suture bites, and from the bite to incision line. The location of segments as well as the weight of the cadaver were recorded. A single linear distraction mechanical breaking test was performed. Statistical analyses (logistic and linear regression) were performed to determine which factors were associated with visual and mechanical failure, as well as load at failure or maximum displacement. Results: SBSI was significantly associated with load at failure or maximum displacement (p < 0.001). In particular, 5 mm SBSI had the highest load at failure amongst all the bite sizes (LSmeans = 27.55N, 95% Confidence Interval (CI): 23.65–31.44); this was significantly higher than 7.5 mm (LSmeans = 19.15N, 95% CI: 15.26–23.05, p = 0.016) and 10 mm (LSmeans = 16.55N, 95%CI:12.39–20.70, p = 0.0012) but not significantly higher than 3 mm (LSmeans = 23.78N, 95% CI: 19.69–27.86, p = 0.2). Increased SBSI increased the odds of visual failure (p < 0.001) whereas increased weight of the cadaver reduced the odds of visual failure (OR = 0.52, 95%CI: 0.30–0.88, p = 0.016). Conclusion: The 5 mm SBSI had the highest load at failure and was not significantly different from the 3 mm SBSI when apposing feline linea alba using 3-0 polydioxanone. Clinical significance: Using 5 mm SBSI is the preferred bite size compared to 7.5 or 10 mm SBSI when apposing feline linea alba with 3-0 polydioxanone.
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Affiliation(s)
- Amanda L Bartier
- Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Aylin Atilla
- Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Rebecca Archer
- Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Grace P S Kwong
- Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
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Implementation of the small bites closure of abdominal midline incisions in clinical practice is correlated with a reduction in surgical site infections. Hernia 2019; 24:839-843. [PMID: 31254134 DOI: 10.1007/s10029-019-01995-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 06/20/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Small steps wound closure of midline laparotomy has been reported to decrease the incidence of incisional hernia development in two randomized controlled trials. The aim of the present study was to evaluate the effect of implementing the small steps wound closure technique in clinical practice with regards to the development of incisional ventral hernia (IVH) and surgical site infections (SSI) in clinical practice. METHODS Implementation of the small steps wound closure technique using the small tissue bites technique as the standard closure technique for abdominal midline incisions in our clinical practice was done in March 2015. For this study, all patients from June 2013 until June 2016 with a midline laparotomy, either long or small in case of specimen extraction in laparoscopic surgery, in either elective or emergency setting were included. Conventional large bite wound closure was compared to small steps wound closure with regards to the development of SSI, IVH as well as burst abdomen. RESULTS A total of 327 patients were included. The small steps suture technique was used in 136 (42%) of the patients, whereas the conventional large bites suture technique was used in 191 patients (58%). A total of 54 patients in the large bites group developed SSI (28%) compared to 23 (17%) patients in the small steps group (p = 0.02). A total number of 10 patients (7%) developed IVH in the small steps group compared to 27 patients (14%) in the large bites group (p = 0.08). CONCLUSION Implementation of small bites wound closure of abdominal midline incisions in clinical practice was correlated with a reduction in surgical site infections.
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Bewö K, Österberg J, Löfgren M, Sandblom G. Incisional hernias following open gynecological surgery: a population-based study. Arch Gynecol Obstet 2019; 299:1313-1319. [PMID: 30911826 PMCID: PMC6475508 DOI: 10.1007/s00404-019-05069-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/25/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Incisional hernia is a common and costly complication following abdominal surgery. The incidence of incisional hernia after gynecological surgery is not as well studied as that after general surgery. MATERIALS AND METHODS The Swedish National Quality Register for Gynecological Surgery (GynOp) collects preoperative, intraoperative, and postoperative information regarding gynecological surgery. Data were extracted from 2006 to 2014. The National Patient Register (NPR) contains physicians' data from both public and private hospitals. Univariate and multivariate Cox proportional hazard analyzes were performed on risk factors. RESULTS Between 2006 and 2014, 39,312 women undergoing open surgery were registered in GynOp. The NPR recorded 526 patients who were diagnosed with or had undergone surgery for incisional hernia. The mean follow-up was 2.8 years. Five years after surgery the cumulative incidence of incisional hernias was 2.0% (95% confidence interval 1.8-2.2%). In multivariate Cox proportional hazard analysis obesity (BMI > 30), age > 60 years, midline incision, smoking, kidney, liver, and pulmonary disease were found to predict an increased risk for incisional hernias (all p < 0.05). CONCLUSIONS There is much to be gained if the patient can cease smoking and lose weight before undergoing abdominal surgery. The Pfannenstiel incision results in fewer incisional hernias and should be considered whenever possible.
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Affiliation(s)
- Kerstin Bewö
- Department of Surgery, Mora Hospital, 792 85, Mora, Sweden.
| | - Johanna Österberg
- Department of Surgery, Mora Hospital, 792 85, Mora, Sweden
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institute, Solna, Sweden
| | - Mats Löfgren
- Department of Gynecology, University Hospital of Norrland, Umeå, Sweden
| | - Gabriel Sandblom
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, Södersjukhuset, Stockholm, Sweden
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Klonner ME, Degasperi B, Bockstahler B, Dupré G. Suture length to wound length ratio for simple continuous abdominal closures in veterinary surgery: An experimental in vitro study. PLoS One 2019; 14:e0215641. [PMID: 31026296 PMCID: PMC6485905 DOI: 10.1371/journal.pone.0215641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 04/07/2019] [Indexed: 12/03/2022] Open
Abstract
Objective This study aimed to investigate the suture length to wound length ratio (SL:WL) in an in vitro model of abdominal wall closure. Effects of the surgeon’s experience level on the SL:WL ratio were evaluated, hypothesizing that small animal surgeons do not spontaneously apply SL:WL ratios equal to or larger than 4:1. Procedures Three groups of surgeons with varying levels of experience performed 4 simple continuous sutures before (3 sutures) and after (1 suture) being educated on principles of the SL:WL ratio. All sutures were evaluated for their gaping, number of stitches, stitch intervals, tissue bite size and suture length. Results No significant differences in suture parameters or SL:WL ratios were found among the 3 groups, and 60.5% of control sutures and 77.0% of test sutures had SL:WL ratios above 4:1. There was a significant improvement in the mean ratio after the information was provided (p = 0.003). Overall, the SL:WL ratios ranged from 1.54:1 to 6.81:1, with 36.3% falling between 4:1 and 5:1 (5.17 mm mean stitch interval, 5.52 mm mean tissue bite size). A significant negative correlation was observed between the SL:WL ratio and the stitch interval to tissue bite ratio (r = -0.886). Forty-nine of 120 sutures fulfilled the current recommendations for abdominal wall closure with a mean SL:WL ratio of 4.1:1. Conclusion A SL:WL ratio larger than 4:1 was achieved in 60% of the control sutures and in 77% of test sutures. Additional animal studies are necessary to evaluate the SL/WL ratio in small animal surgery.
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Affiliation(s)
- Moriz E. Klonner
- Clinical Unit of Small Animal Surgery, Department for Small Animals and Horses, University of Veterinary Medicine Vienna, Vienna, Austria
- * E-mail:
| | - Brigitte Degasperi
- Clinical Unit of Small Animal Surgery, Department for Small Animals and Horses, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Barbara Bockstahler
- Clinical Unit of Small Animal Surgery, Department for Small Animals and Horses, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Gilles Dupré
- Clinical Unit of Small Animal Surgery, Department for Small Animals and Horses, University of Veterinary Medicine Vienna, Vienna, Austria
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Hope W, Heathcote S, Williams Z, Hooks WB. Fundamentals of incisional hernia prevention. INTERNATIONAL JOURNAL OF ABDOMINAL WALL AND HERNIA SURGERY 2018. [DOI: 10.4103/ijawhs.ijawhs_3_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Harlaar JJ, Deerenberg EB, Dwarkasing RS, Kamperman AM, Kleinrensink GJ, Jeekel J, Lange JF. Development of incisional herniation after midline laparotomy. BJS Open 2017; 1:18-23. [PMID: 29951601 PMCID: PMC5989969 DOI: 10.1002/bjs5.3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/23/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Incisional herniation is a common complication after abdominal surgery associated with considerable morbidity. The aim of this study was to determine whether incisional hernia is an early complication, in order to understand better the aetiology of incisional hernia formation. METHODS This study involved the secondary analysis of a subset of patients included in a large RCT comparing small and large tissue bites (5 mm every 5 mm, or 1 cm every 1 cm) in patients scheduled to undergo elective abdominal surgery by midline laparotomy. The distance between the rectus abdominis muscles (RAM distance) was measured by standardized ultrasound imaging 1 month and 1 year after surgery. The relationship between the 1-year incidence of incisional hernia and the RAM distance at 1 month was investigated. RESULTS Some 219 patients were investigated, 113 in the small-bites and 106 in the large-bites group. At 1 month after surgery the RAM distance was smaller for small bites than for large bites (mean(s.d.) 1·90(1·18) versus 2·39(1·34) cm respectively; P = 0·005). At 1 year, patients with incisional hernia had a longer RAM distance at 1 month than those with no incisional hernia (mean(s.d.) 2·43(1·48) versus 2·03(1·19) cm respectively; relative risk 1·14, 95 per cent c.i. 1·03 to 1·26, P = 0·015). CONCLUSION A RAM distance greater than 2 cm at 1 month after midline laparotomy is associated with incisional hernia. Closure with small bites results in a smaller distance between the muscles.
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Affiliation(s)
- J. J. Harlaar
- Department of SurgeryErasmus University Medical CentreRotterdamThe Netherlands
| | - E. B. Deerenberg
- Department of SurgeryErasmus University Medical CentreRotterdamThe Netherlands
| | - R. S. Dwarkasing
- Department of RadiologyErasmus University Medical CentreRotterdamThe Netherlands
| | - A. M. Kamperman
- Department of PsychiatryErasmus University Medical CentreRotterdamThe Netherlands
| | - G. J. Kleinrensink
- Department of NeuroscienceErasmus University Medical CentreRotterdamThe Netherlands
| | - J. Jeekel
- Department of NeuroscienceErasmus University Medical CentreRotterdamThe Netherlands
| | - J. F. Lange
- Department of SurgeryErasmus University Medical CentreRotterdamThe Netherlands
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Affiliation(s)
- Leif A Israelsson
- Department of Surgery and Perioperative Sciences, Umeå University, S-902 34 Umeå, Sweden.
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Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, Wijnhoven BP, Schouten WR, Cense HA, Stockmann HB, Berends FJ, Dijkhuizen FPH, Dwarkasing RS, Jairam AP, van Ramshorst GH, Kleinrensink GJ, Jeekel J, Lange JF. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet 2015; 386:1254-1260. [PMID: 26188742 DOI: 10.1016/s0140-6736(15)60459-7] [Citation(s) in RCA: 337] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Incisional hernia is a frequent complication of midline laparotomy and is associated with high morbidity, decreased quality of life, and high costs. We aimed to compare the large bites suture technique with the small bites technique for fascial closure of midline laparotomy incisions. METHODS We did this prospective, multicentre, double-blind, randomised controlled trial at surgical and gynaecological departments in ten hospitals in the Netherlands. Patients aged 18 years or older who were scheduled to undergo elective abdominal surgery with midline laparotomy were randomly assigned (1:1), via a computer-generated randomisation sequence, to receive small tissue bites of 5 mm every 5 mm or large bites of 1 cm every 1 cm. Randomisation was stratified by centre and between surgeons and residents with a minimisation procedure to ensure balanced allocation. Patients and study investigators were masked to group allocation. The primary outcome was the occurrence of incisional hernia; we postulated a reduced incidence in the small bites group. We analysed patients by intention to treat. This trial is registered at Clinicaltrials.gov, number NCT01132209 and with the Nederlands Trial Register, number NTR2052. FINDINGS Between Oct 20, 2009, and March 12, 2012, we randomly assigned 560 patients to the large bites group (n=284) or the small bites group (n=276). Follow-up ended on Aug 30, 2013; 545 (97%) patients completed follow-up and were included in the primary outcome analysis. Patients in the small bites group had fascial closures sutured with more stitches than those in the large bites group (mean number of stitches 45 [SD 12] vs 25 [10]; p<0·0001), a higher ratio of suture length to wound length (5·0 [1·5] vs 4·3 [1·4]; p<0·0001) and a longer closure time (14 [6] vs 10 [4] min; p<0·0001). At 1 year follow-up, 57 (21%) of 277 patients in the large bites group and 35 (13%) of 268 patients in the small bites group had incisional hernia (p=0·0220, covariate adjusted odds ratio 0·52, 95% CI 0·31-0·87; p=0·0131). Rates of adverse events did not differ significantly between groups. INTERPRETATION Our findings show that the small bites suture technique is more effective than the traditional large bites technique for prevention of incisional hernia in midline incisions and is not associated with a higher rate of adverse events. The small bites technique should become the standard closure technique for midline incisions. FUNDING Erasmus University Medical Center and Ethicon.
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Affiliation(s)
- Eva B Deerenberg
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Joris J Harlaar
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands.
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Harold E Lont
- Department of Surgery, Vlietland Ziekenhuis, Schiedam, Netherlands
| | - Helena C van Doorn
- Department of Gynecology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Joos Heisterkamp
- Department of Surgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands
| | - Bas Pl Wijnhoven
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Willem R Schouten
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands; Department of Surgery, Havenziekenhuis, Rotterdam, Netherlands
| | - Huib A Cense
- Department of Surgery, Rode Kruis Ziekenhuis, Beverwijk, Netherlands
| | | | - Frits J Berends
- Department of Surgery, Rijnstate Ziekenhuis, Arnhem, Netherlands
| | | | - Roy S Dwarkasing
- Department of Radiology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - An P Jairam
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Gert-Jan Kleinrensink
- Department of Neuroscience, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Johannes Jeekel
- Department of Neuroscience, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
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Fujita T. Choosing a Better Technique for Midline Abdominal Closure. J Am Coll Surg 2014; 218:150-2. [DOI: 10.1016/j.jamcollsurg.2013.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 09/12/2013] [Indexed: 12/01/2022]
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Abstract
The development of wound complications is closely related to the surgical technique at wound closure. The risk of the suture technique affecting the development of wound dehiscence and incisional hernia can be monitored through the suture length to wound length ratio. Midline incisions should be closed in one layer by a continuous-suture technique using a monofilament suture material tied with self-locking knots. Excessive tension should not be placed on the suture. Closure must always be with a suture length to wound length ratio higher than 4.
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Millbourn D, Wimo A, Israelsson LA. Cost analysis of the use of small stitches when closing midline abdominal incisions. Hernia 2013; 18:775-80. [PMID: 23839330 DOI: 10.1007/s10029-013-1135-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 06/29/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Suturing with small stitches instead of with large reduces the risk for surgical site infection and incisional hernia in continuously closed midline abdominal incisions. The purpose was to analyse if using small stitches generated cost savings. METHODS Between 2001 and 2006 closure of midline incisions using small stitches was, in a randomised trial, compared with the use of large stitches. In 2011 all patients included in the randomised trial, who until then, had had an incisional hernia repair, were recorded. The cost for an open incisional hernia repair with mesh reinforcement during 2010 was calculated. The analysis included both direct and indirect costs. RESULTS Of 321 patients closed with small stitches incisional hernia occurred in 11 and 3 needed repair. Of 370 patients closed with large stitches herniation occurred in 45 and 14 needed repair. The direct cost per hernia repair was 59,909 Swedish krona (SEK) and the indirect cost was 26,348 SEK. Suturing time with small stitches was 4.6 min longer, increasing the cost for the index operation by 1,076 SEK. From the societal perspective (direct and indirect costs), using small stitches generated a cost reduction of 1,339 SEK for each patient. From the perspective of the public payer (direct costs) the cost reduction was 601 SEK. Using small stitches generated cost savings from a societal perspective if the suturing time was not prolonged over 10.3 min. CONCLUSIONS Using small stitches when closing midline abdominal incisions with a continuous single-layer technique generates cost savings.
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Affiliation(s)
- D Millbourn
- Department of Surgery, Sundsvall Hospital, Sundsvall, Sweden,
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Closing midline abdominal incisions. Langenbecks Arch Surg 2012; 397:1201-7. [PMID: 23143146 DOI: 10.1007/s00423-012-1019-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Accepted: 10/12/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND The most important wound complications are surgical site infection, wound dehiscence and incisional hernia. Experimental and clinical evidences support that the development of wound complications is closely related to the surgical technique at wound closure. RESULTS The suture technique monitored through the suture length-to-wound length ratio is of major importance for the development of wound complications. The risk of wound dehiscence is low with a high ratio. The ratio must be higher than 4; otherwise, the risk of developing an incisional hernia is increased four times. With a ratio higher than 4, both the rate of wound infection and incisional hernia are significantly lower if closure is done with small stitches placed 5 to 8 mm from the wound edge than with larger stitches placed more than 10 mm from the wound edge. CONCLUSIONS Midline incisions should be closed in one layer by a continuous suture technique. A monofilament suture material should be used and be tied with self-locking knots. Excessive tension should not be placed on the suture. Wounds must always be closed with a suture length-to-wound length ratio higher than 4. The only way to ascertain this is to measure, calculate and document the ratio at every wound closure. A high ratio should be accomplished with many small stitches placed 5 to 8 mm from the wound edge at very short intervals.
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Harlaar JJ, Deerenberg EB, van Ramshorst GH, Lont HE, van der Borst ECMH, Schouten WR, Heisterkamp J, van Doorn HC, Cense HA, Berends F, Stockmann HBAC, Vrijland WW, Consten ECJ, Ottow RT, Go PMNYH, Hermans JJ, Steyerberg EW, Lange JF. A multicenter randomized controlled trial evaluating the effect of small stitches on the incidence of incisional hernia in midline incisions. BMC Surg 2011; 11:20. [PMID: 21871072 PMCID: PMC3182877 DOI: 10.1186/1471-2482-11-20] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2010] [Accepted: 08/26/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The median laparotomy is frequently used by abdominal surgeons to gain rapid and wide access to the abdominal cavity with minimal damage to nerves, vascular structures and muscles of the abdominal wall. However, incisional hernia remains the most common complication after median laparotomy, with reported incidences varying between 2-20%. Recent clinical and experimental data showed a continuous suture technique with many small tissue bites in the aponeurosis only, is possibly more effective in the prevention of incisional hernia when compared to the common used large bite technique or mass closure. METHODS/DESIGN The STITCH trial is a double-blinded multicenter randomized controlled trial designed to compare a standardized large bite technique with a standardized small bites technique. The main objective is to compare both suture techniques for incidence of incisional hernia after one year. Secondary outcomes will include postoperative complications, direct costs, indirect costs and quality of life. A total of 576 patients will be randomized between a standardized small bites or large bites technique. At least 10 departments of general surgery and two departments of oncological gynaecology will participate in this trial. Both techniques have a standardized amount of stitches per cm wound length and suture length wound length ratio's are calculated in each patient. Follow up will be at 1 month for wound infection and 1 year for incisional hernia. Ultrasound examinations will be performed at both time points to measure the distance between the rectus muscles (at 3 points) and to objectify presence or absence of incisional hernia. Patients, investigators and radiologists will be blinded during follow up, although the surgeon can not be blinded during the surgical procedure. CONCLUSION The STITCH trial will provide level 1b evidence to support the preference for either a continuous suture technique with many small tissue bites in the aponeurosis only or for the commonly used large bites technique.
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Affiliation(s)
- Joris J Harlaar
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eva B Deerenberg
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Harold E Lont
- Department of Surgery, Vlietland Ziekenhuis, Schiedam, The Netherlands
| | | | - Willem R Schouten
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joos Heisterkamp
- Department of Surgery, St. Elisabeth Ziekenhuis, Tilburg, The Netherlands
| | | | - Huib A Cense
- Department of Surgery, Rode Kruis Ziekenhuis, Beverwijk, The Netherlands
| | - Frits Berends
- Department of Surgery, Rijnstate Ziekenhuis, Arnhem, The Netherlands
| | | | - Wietske W Vrijland
- Department of Surgery, Sint Franciscus Gasthuis, Rotterdam, The Netherlands
| | | | - Reyer T Ottow
- Department of Surgery, Groene Hart Ziekenhuis Gouda, The Netherlands
| | - Peter MNYH Go
- Department of Surgery, Antonius Ziekenhuis Nieuwegein, The Netherlands
| | - John J Hermans
- Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
| | | | - Johan F Lange
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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Risk factors for wound complications in midline abdominal incisions related to the size of stitches. Hernia 2011; 15:261-6. [PMID: 21279664 DOI: 10.1007/s10029-010-0775-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 12/25/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Midline abdominal incisions should be closed continuously with a suture length (SL) to wound length (WL) ratio above 4 using small stitches. The effect on the rate of wound complications of a very high ratio and other potential risk factors when closure is performed with small stitches is unknown. METHODS Patients operated on through a midline incision were randomised to closure with small stitches, placed 5-8 mm from the wound edge and less than 5 mm apart, or with large stitches, placed more than 1 cm from the wound edge. Patient and operative variables were registered. Surgical site infection and incisional hernia were recorded. RESULTS Three hundred and twenty-one patients were randomised to closure with small stitches and 370 with large stitches. Infection and herniation were less common with small stitches. With small stitches, no risk factors for infection or herniation were identified. With large stitches, wound contamination and the patient being diabetic were independent risk factors for infection, and long operation time and surgical site infection were risk factors for herniation. A very high SL to WL ratio did not affect the complication rates. CONCLUSIONS In midline abdominal incisions closed with small stitches, no risk factors for surgical site infection or incisional hernia were identified. Increasing the ratio very much above 4 had no adverse effects on the rate of wound complications. The higher rates of infection and herniation with an SL to WL ratio over 5 and in overweight patients in previous reports were probably related to wounds being closed with large stitches.
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Small stitches with small suture distances increase laparotomy closure strength. Am J Surg 2009; 198:392-5. [PMID: 19285296 DOI: 10.1016/j.amjsurg.2008.10.018] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Revised: 10/06/2008] [Accepted: 10/06/2008] [Indexed: 12/31/2022]
Abstract
BACKGROUND There is no conclusive evidence which size of suture stitches and suture distance should be used to prevent burst abdomen and incisional hernia. METHODS Thirty-eight porcine abdominal walls were removed immediately after death and divided into 2 groups: A and B (N = 19 each). Two suturing methods using double-loop polydioxanone were tested in 14-cm midline incisions: group A consisted of large stitches (1 cm) with a large suture distance (1 cm), and group B consisted of small stitches (.5 cm) with a small suture distance (.5 cm). RESULTS The geometric mean tensile force in group B was significantly higher than in group A (787 N vs 534 N; P = .006). CONCLUSIONS Small stitches with small suture distances achieve higher tensile forces than large stitches with large suture distances. Therefore, small stitches may be useful to prevent the development of a burst abdomen or an incisional hernia after midline incisions.
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Franklin JE, Marler JJ, Byrne MT, Melvin AJ, Clarson SJ, Melvin DB. Fiber technology for reliable repair of skeletal muscle. J Biomed Mater Res B Appl Biomater 2008; 90:259-66. [DOI: 10.1002/jbm.b.31280] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
The midline laparotomy is among the most common ways of accessing the peritoneal cavity. This approach is not only used for surgery of the digestive tract but is also extensively applied in vascular, gynecology and urological surgery. When this surgical procedure is conducted in an emergency setting, and depending on the type of surgery (clean and /or contaminated), the incidence of complications may be particularly high, especially when acute dehiscence of the wall occurs (evisceration). Furthermore, the rate of herniation related to midline laparotomy is still high at approximately 16% of cases. Despite efforts to evaluate different suture techniques, suture threads (reabsorbable or non-reabsorbable) and general factors that may interfere with the repair process, the incidence of complications associated with this approach has not been reduced. After multiple studies including meta-analyses, the outcome of laparotomy closure has not essentially improved. We should therefore consider the use of new ways of closing the abdomen in selected patients that might somehow reinforce the surgical wound and notably reduce the incidence of short- and medium-term complications. One such method could perhaps be the use of a biomaterial to support and strengthen conventional sutures.
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Affiliation(s)
- Juan M Bellón-Caneiro
- Departamento de Cirugía, Facultad de Medicina, Universidad de Alcalá, Madrid, España.
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Millbourn D, Israelsson LA. Wound complications and stitch length. Hernia 2003; 8:39-41. [PMID: 13680306 DOI: 10.1007/s10029-003-0159-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2003] [Accepted: 07/08/2003] [Indexed: 11/27/2022]
Abstract
The effect of suturing with a very short stitch on the development of wound complications in midline incisions was investigated. Three hundred sixty-eight patients were analysed. The suture length to wound length ratio and mean stitch length were calculated. Wound infection occurred in 4% (four of 103) of patients sutured with a mean stitch length of less than 4 cm, in 8% (nine of 117) with stitch length 4-4.9 cm, and in 16% (24 of 148) with a longer stitch ( P=0.004). At 12-month follow up, incisional hernia was present in 3% (two of 76) of patients sutured with a mean stitch length of less than 4 cm and in 12% (25 of 215) sutured with a longer stitch ( P=0.043). In midline incisions closed with a suture length to wound length ratio of at least 4, a short stitch is associated with a lower rate of both wound infection and incisional hernia.
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Affiliation(s)
- D Millbourn
- Kirurgkliniken, Sundsvalls Sjukhus, SE-85186, Sundsvall, Sweden.
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