Abstract
PurposeThe small bites (SB) technique for closure of elective midline laparotomies (EMLs) and a prophylactic mesh (PM) in high-risk patients are suggested by the guidelines to prevent incisional hernias (IHs) and fascial dehiscence (FD). Our aim was to implement a protocol combining both the techniques and to analyze its outcomes.MethodsProspective data of all EMLs were collected for 2 years. Results were analyzed at 1 month and during follow-up. The incidence of HI and FD was compared by groups (M = Mesh vs. S = suture) and by subgroups depending on using SB.ResultsA lower number of FD appeared in the M group (OR 0.0692; 95% CI 0.008–0.56; P = 0.01) in 197 operations. After a mean follow-up of 29.23 months (N = 163; min. 6 months), with a lower frequency of IH in M group (OR 0.769; 95% CI 0.65–0.91; P < 0.0001). (33) The observed differences persisted after a propensity matching score: FD (OR 0.355; 95% CI 0.255–0.494; P < 0.0001) and IH (OR 0.394; 95% CI 0.24–0.61; P < 0.0001). On comparing suturing techniques by subgroups, both mesh subgroups had better outcomes. PM was the main factor related to the reduction of IH (HR 11.794; 95% CI 4.29–32.39; P < 0.0001).ConclusionFollowing the protocol using PM and SB showed a lower rate of FD and HI. A PM is safe and effective for the prevention of both HI and FD after MLE, regardless of the closure technique used.
Highlights
The beneficial effect for the prevention of incisional hernia (IH) of closing a midline laparotomy with a running suture at a suture length/wound length ratio (SL/WL) of at least 4:1 [1, 2] has been recognized in several randomized controlled trials [3, 4]
We hypothesize that the combination of the small bites” technique (SB) technique with a prophylactic mesh (PM) for closure of the abdominal wall after midline laparotomy reduces the incidence of IH and fascial dehiscence (FD) in high-risk patients
Only one patient (0.9%) in group M was diagnosed with FD, compared to eight (11.9%) in group S; of which seven patients were not reported to be using SB (NSB)
Summary
The beneficial effect for the prevention of incisional hernia (IH) of closing a midline laparotomy with a running suture at a suture length/wound length ratio (SL/WL) of at least 4:1 [1, 2] has been recognized in several randomized controlled trials [3, 4]. The recommendations of societies dedicated to abdominal wall surgery [2] and several comparative studies [3,4,5,6,7] propose combining a high SL/WL ratio with a “small bites” technique (SB) [3, 4], and the use of a prophylactic mesh (PM) [5,6,7] in high-risk patients Both measures have not been widely implemented [8,9,10], those with high BMI, previous hernia repair, emergency surgery and contaminated/dirty surgery. There are several reasons for explaining this reluctance, the main ones being that the SB technique has not been satisfactorily studied in high-risk patients, and the potential complications related to PM [8,9,10].
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