Fascial Closure Research Articles

Surgeon perspectives on the STITCH trial: a mixed methods study.

Incisional hernia prevention strategies related to fascial closure technique during laparotomy are well described yet poorly implemented in practice. The factors hindering the surgeon's adoption of evidence-based techniques for fascial closure are poorly understood and characterized. Using an exploratory sequential mixed methods design, we first collected 139 responses to a validated quantitative survey based on a Theoretical Domain Framework for adoption of healthcare practices. Mean scores from survey responses were tabulated, and the findings were used to develop an interview guide for subsequent qualitative individual semi-structured phone interviews. Fourteen practicing surgeons were purposively sampled from social media outlets andour institution. The interviews were recorded and transcribed verbatim for coding and thematic analysis usingNVivo12 Plus. Data from the surveys and interviews were integrated using joint displays. Quantitative and qualitative analyses from surveys and semi-structured interviews revealed various themes related to surgeon decision-making related to fascial closure technique. Surgeons cited limitations of prior studies, applicability of findings, anecdotal experiences, and situation-specific environments that influence their decision-making. Peer influence and lack of training also affected surgeons' perspectives on integrating small bite technique into practice. Trial design limitations, peer influence, and patient-specific factors impacted surgeon decision-making in the choice of fascial closure technique. Future clinical trials in diverse patient populations may improve surgeons' confidence in implementing technique for fascial closure.

Does the routine skin only closure in ruptured Abdominal Aortic Aneurysm repair safely diminish abdominal compartment syndrome? A hypothesis generating retrospective study.

Abdominal compartment syndrome (ACS) often complicates ruptured abdominal aortic aneurysm (rAAA) repair. We aim to report results with routine skin-only abdominal wound closure after rAAA surgical repair. Single center, retrospective study including consecutive patients undergoing rAAA surgical repair during 7-years. Skin-only closure was routinely performed and if possible, secondary abdominal closure was performed during the same admission. Demographic information, preoperative hemodynamic condition of patients, perioperative information such as ACS, mortality and rate of abdominal closure and postoperative information were collected. During the study period 93 rAAAs were recorded. Ten patients were too frail to undergo repair or refused treatment. Eighty-three patients underwent immediate surgical repair. Mean age was 72.4±10.5 years and the vast majority were male (82:1). Preoperative systolic blood pressure <90mmHg was recorded in 31 patients. Intra-operative mortality was recorded in 9 cases. Overall in-hospital mortality was 34.9% (29/83). Primary fascial closure was performed in 5 patients, while skin-only closure was performed in 69. ACS was recorded in two cases in whom skin sutures were removed and negative pressure wound treatment was applied. Secondary fascial closure was feasible in 30 patients during the same admission. Among 37 patients not undergoing fascial closure, 18 died and 19 survived and were discharged with a planned ventral hernia. Median length of ICU and hospital stay were 5(1-24) and 13(8-35) days, respectively. After a mean follow-up of 21 months, telephone contact was possible with 14/19 patients that left the hospital with an abdominal hernia. Three reported hernia-related complications mandating surgical repair, while in 11 this was well tolerated. Routine skin-only closure during rAAA surgical repair results in low rates of ACS at the expense of a high rate of patients being discharged with a planned ventral hernia which, however, seems to be well tolerated by the majority of patients.

"Fascial defect closure versus bridged repair in laparoscopic ventral hernia mesh repair: a systematic review and meta-analysis of randomized controlled trials. Author's reply".

"Fascial defect closure versus bridged repair in laparoscopic ventral hernia mesh repair: a systematic review and meta-analysis of randomized controlled trials. Author's reply".

Mediumweight polypropylene mesh fractures after open retromuscular ventral hernia repair: incidence and associated risk factors.

Mediumweight (MW) and heavyweight (HW) polypropylene have demonstrated similar clinical and patient-reported outcomes in the setting of open retromuscular ventral hernia repair (VHR). While MW mesh has an anecdotal risk of central mesh fracture, that phenomenon is not well-characterized. We sought to assess the incidence of and risk factors for MW polypropylene mesh fractures after VHR. The ACHQC registry was queried for patients with CT-documented hernia recurrence after open retromuscular VHR with MW polypropylene mesh at our institution with 1-year follow-up between January 2014 and April 2022. Images were reviewed by five blinded surgeons at Cleveland Clinicto reach consensus that hernia recurrence mechanism was central mesh fracture.Patients without clinical recurrence or patient-reported bulge were used as a comparator group. Eighty patients were identified with radiographically documented recurrence; 28 had recurrence from mesh fractures and these were compared to 644 patients without recurrence. Incidence of MW fracture was 4.2%. Bridging of anterior fascia was more common in the group with the central mesh fracture (33.3% vs 3.3%, p < 0.001); the incidence of fracture was 30% (9/30) in patients requiring a bridged closure. Mesh fracture was associated with larger hernias (median width: 20cm [16-26] vs 15cm [12-18], p < 0.001,), length (25cm [23-30] vs 23cm [19-26], p = 0.004). MW polypropylene mechanical failures are surprisingly common, particularly in settings of bridged fascial closure and larger hernias. Use of HW polypropylene should be considered in this setting, and industry should be encouraged to create larger pieces of HW polypropylene mesh.

Open abdomen: a comprehensive review

When the abdominal viscera are visible due to a defect in the abdominal wall, which is usually caused intentionally or as a result of abdominal compartment syndrome, it is referred to as an open abdomen. As a protracted open abdomen can result in problems including fluid and protein losses, intestinal fistulization, and loss of abdominal dominance, the main goals of temporal abdominal closure techniques are to prevent fluid losses and loss of dominance. There are several techniques for short-term abdominal closure, each having advantages and disadvantages. These techniques include patch closure, silo closure, and negative pressure systems based on towels and sponges. After temporary abdominal closure, the patient is monitored in the critical care unit while any required adjustments are made to the abdominal dressings. Observational studies have shown that the Wittmann Patch has the highest average rate of primary fascial closure when compared to other operations. Yet, a temporary closure of this sort might not be adequate to stop fluid loss on its own. To monitor fluid loss, a negative pressure device (sponge- or towel-based) is advised. It can be used either on its own or in combination with other techniques for closing the temporal abdominal cavity. When the sign of an open abdomen has been removed, the abdomen is closed, ideally using a major fascial closure. If primary fascial closure cannot be achieved, functional closure may be accomplished using a biological mesh inlay method. While there is a good probability of developing a posterior hernia, this treatment adds new fascial tissue where the natural fascial limits are located. The fascia defect may be filled in with primary skin closure or skin grafts once a layer of granulation tissue has developed over the consolidated visceral mass if the space between the fascia's borders is too large for functional closure. Effective abdominal closure and the prevention of issues ultimately depend on proper management and supervision of temporary abdominal closure.

Which suture is ideal for abdominal fascial closure: polydioxanone or polypropylene?

Background: A secured fascial closure with appropriate suture material is an integral step to prevent complications in laparotomy. A costly post-operative complication is wound dehiscence which manifests as incisional hernia as a delayed complication. The present study compared prolene and polydioxanone (PDS) sutures in patients undergoing midline closure after emergency exploratory laparotomy with the aim to evaluate wound outcome after the use of either of the sutures. Methods: Sixty-six patients undergoing emergency laparotomy were randomly divided into two groups: group A (PDS) and B (prolene). Wound complications were evaluated for each patient in terms of wound pain, wound discharge, burst abdomen, stitch sinus, stitch granuloma and incisional hernia. Results: Wound pain was observed more in prolene group, p&lt;0.05 till 3rd post-op day. Wound discharge, wound dehiscence and burst abdomen were more in prolene group, but the difference was statistically insignificant (p&gt;0.05). Six patients developed incisional hernia, out of which 5 had prolene, (p&gt;0.05). Similar statistically insignificant difference was found with stitch granuloma and stitch sinus. Conclusions: Till date there is lack of agreement about the ideal suture for abdominal fascial closure. Present study concluded that any suture material is equally effective for abdominal fascial closure since there are many other factors contributing towards wound complications.

An international assessment of surgeon practices in abdominal wound closure and surgical site infection prevention by the European Society for Coloproctology.

The burden of abdominal wound failure can be profound. Recent clinical guidelines have highlighted the heterogeneity of laparotomy closure techniques. The aim of this study was to investigate current midline closure techniques and practices for prevention of surgical site infection (SSI). An online survey was distributed in 2021 among the membership of the European Society of Coloproctology and its partner societies. Surgeons were asked to provide information on how they would close the abdominal wall in three specific clinical scenarios and on SSI prevention practices. A total of 561 consultants and trainee surgeons participated in the survey, mainly from Europe (n= 375, 66.8%). Of these, 60.6% identified themselves as colorectal surgeons and 39.4% as general surgeons. The majority used polydioxanone for fascial closure, with small bite techniques predominating in clean-contaminated cases (74.5%, n= 418). No significant differences were found between consultants and trainee surgeons. For SSI prevention, more surgeons preferred the use of mechanical bowel preparation (MBP) alone over MBP and oral antibiotics combined. Most surgeons preferred 2% alcoholic chlorhexidine (68.4%) or aqueous povidone-iodine (61.1%) for skin preparation. The majority did not use triclosan-coated sutures (73.3%) or preoperative warming of the wound site (78.5%), irrespective of level of training or European/non-European practice. Abdominal wound closure technique and SSI prevention strategies vary widely between surgeons. There is little evidence of a risk-stratified approach to wound closure materials or techniques, with most surgeons using the same strategy for all patient scenarios. Harmonization of practice and the limitation of outlying techniques might result in better outcomes for patients and provide a stable platform for the introduction and evaluation of further potential improvements.

Review of incisional hernias

The 10 to 15% of patients get incisional hernias following any type of abdominal wall incision, with midline wounds carrying a larger risk (3 to 20%). Infection at the surgery site, obesity, smoking, malnutrition, and poor surgical technique are risk factors. Clinical signs include an abdominal bulge at or near a prior incision, which, in non-obese individuals, is frequently identified by palpating the split borders of the fascial defect. CT imaging is particularly useful for complicated ventral hernias, which are characterized by enormous size or considerable loss of dominance. For the purpose of detecting any contents within the hernia sac and deciding whether preoperative abdominal expansion is necessary to lower the risk of postoperative abdominal compartment syndrome, preoperative CT imaging is crucial. When clinically necessary, surgeons should think about making an incision outside the midline and employ the proper fascia closure procedures to lower the likelihood of an incisional hernia. Although the implantation of preventative mesh during the closure of abdominal incisions is being studied, routine usage is not advised owing to probable long-term problems. Incisional hernias can be treated surgically or expectantly, and the patient should be informed of both options.

Teaching Small Bite Fascial Closure Technique: Improved Accuracy and Consistency Through Simulation.

Despite evidence that small bite closure is beneficial, it is not well documented how accurately and consistently surgeons employ this technique. We created a felt model to simulate fascial closure and educate residents regarding small bites. This study aims to gauge accuracy and consistency of bite size in fascial closure and assess if utilizing a templated model could improve technique. Two 10cm incisions were made in different pieces of felt. Residents were instructed to suture the incisions to simulate fascial closure by running the incisions closed with 1cm and 5mm bites respectively. The process was repeated with templated pieces of felt marking 1 and 0.5cm to guide bite size. Residents were timed for each closure. The travel and distance from the midline for each bite was measured and analysis performed. 14 residents participated. Paired T-test compared means and standard deviations of bite size. Taking 5mm bites took more time. Standard deviation of travel and right sided distance from midline were significantly smaller when a template was utilized. Standard deviation of travel as well as right sided distance was also improved when instructed to take 5mm bites. This study demonstrates that a small bite technique results more closure and that when residents are instructed to take smaller bites. The adage, "aim small, miss small," holds true in fascial closure and may be one reason why small bites improve hernia rates. This study also suggests that the use of a template improves accuracy and consistency of closure regardless of bite size intention.

CT-measured hernia parameters can predict component separation: a cross-sectional study from China.

Currently, there are no reliable preoperative methods for predicting component separation (CS) during incisional hernia repair. By quantitatively measuring preoperative computed tomography (CT) imaging, we aimed to assess the value of hernia defect size, abdominal wall muscle quality, and hernia volume in predicting CS. The data of 102 patients who underwent open Rives-Stoppa retro-muscular mesh repair for midline incisional hernia between January 2019 and March 2022 were retrospectively analyzed. The patients were divided into two groups: ''CS group'' patients who required CS to attempt fascial closure, and ''non-CS'' group patients who required only Rives-Stoppa retro-muscular release to achieve fascial closure. Hernia defect width, hernia defect angle, rectus width, abdominal wall muscle area and CT attenuation, hernia volume (HV), and abdominal cavity volume (ACV) were measured on CT images. The rectus width to defect width ratio (RDR), HV/ACV, and HV/peritoneal volume (PV; i.e., HV + ACV) were calculated. Differences between the indices of the two groups were compared. Logistic regression models were applied to analyze the relationships between the above CT parameters and CS. Receiver operator characteristic (ROC) curves were generated to evaluate the potential utility of CT parameters in predicting CS. Of the102 patients, 69 were in the non-CS group and 33 were in the CS group. Compared with the non-CS group, hernia defect width (P < 0.001), hernia defect angle (P < 0.001), and hernia volume (P < 0.001) were larger in the CS group, while RDR (P < 0.001) was smaller. The abdominal wall muscle area in the CS group was slightly greater than that in the non-CS group (P = 0.046), and there was no significant difference in the CT attenuation of the abdominal wall muscle between the two groups (P = 0.089). Multivariate logistic regression identified hernia defect width (OR 1.815, 95% CI 1.428-2.308, P < 0.001), RDR (OR 0.018, 95% CI 0.003-0.106, P < 0.001), hernia defect angle (OR 1.077, 95% CI 1.042-1.114, P < 0.001), hernia volume (OR 1.002, 95% CI 1.001-1.003, P < 0.001), and CT attenuation of abdominal wall muscle (OR 0.962, 95% CI 0.927-0.998, P = 0.037) as independent predictors of CS. Hernia defect width was the best predictor for CS, with a cut-off point of 9.2cm and an area under the curve (AUC) of 0.890. The AUCs of RDR, hernia defect angle, hernia volume, and abdominal wall muscle CT attenuation were 0.843, 0.812, 0.747, and 0.572, respectively. Quantitative CT measurements are of great value for preoperative prediction of CS. Hernia defect size, hernia volume, and the CT attenuation of abdominal wall muscle are all preoperative predictive indicators of CS.

Open Abdomen in Elderly Patients With Surgical Sepsis: Predictors of Mortality

IntroductionElderly patients are frequently presenting with emergency surgical conditions. The open abdomen technique is widely used in abdominal emergencies needing rapid control of intrabdominal contamination. However, specific predictors of mortality identifying candidates for comfort care are understudied. MethodsThe 2013-2017 the American College of Surgeons-National Surgical Quality Improvement Program database was queried for emergent laparotomies performed in geriatric patients with sepsis or septic shock in whom fascial closure was delayed. Patients with acute mesenteric ischemia were excluded. The primary outcome was 30-d mortality. Univariable analysis, followed by multivariable logistic regression, was performed. Mortality was computed for combinations of the five predictors with the highest odds ratios (OR). ResultsA total of 1399 patients were identified. The median age was 73 (69-79) y, and 54.7% were female. 30-d mortality was 50.6%. In the multivariable analysis, the most important predictors were as follows: American Society of Anesthesiologists status 5 (OR = 4.80, 95% confidence interval [CI], 1.85-12.49 P = 0.002), dialysis dependence (OR = 2.65, 95% CI 1.54-4.57, P < 0.001), congestive hearth failure (OR = 2.53, 95% CI 1.52-4.21, P < 0.001), disseminated cancer (OR = 2.61, 95% CI 1.55-4.38, P < 0.001), and preoperative platelet count of <100,000 cells/μL (OR = 1.87, 95% CI 1.15-3.04, P = 0.011). The presence of two or more of these factors resulted in over 80% mortality. The absence of all these risk factors results in a survival rate of 62.1%. ConclusionsIn elderly patients, surgical sepsis or septic shock requiring an open abdomen for surgical management is highly lethal. The presence of several combinations of preoperative comorbidities is associated with a poor prognosis and can identify patients who can benefit from timely initiation of palliative care.

Long-term Outcomes of Non-vascularized Multilayer Fascial Closure Technique for Dural Repair in Endoscopic Transnasal Surgery: Efficacy, Durability, and Limitations

Non-vascularized multilayer fascial closure technique (NMFCT) can be used instead of nasoseptal flap reconstruction for dural repair in endoscopic transnasal surgery (ETS); however, due to the lack of blood supply, its long-term durability and possible limitations need to be clarified. This was a retrospective study on patients who underwent ETS with intraoperative cerebrospinal fluid (CSF) leakage. We assessed the postoperative and delayed CSF leakage rates and the associated risk factors. Among 200 ETSs with intraoperative CSF leakage, 148 (74.0%) ETSs were performed for skull base pathologies other than pituitary neuroendocrine tumor. The mean follow-up period was 34.4 months. Esposito grade 3 leakage was confirmed in 148 (74.0%) cases. NMFCT was used either with (67 [33.5%]) or without (133 [66.5%]) lumbar drainage. There were 10 cases (5.0%) of postoperative CSF leakage that necessitated reoperation. In 4 other cases (2.0%), CSF leakage was suspected but lumbar drainage alone successfully restored the condition. Multivariate logistic regression analyses revealed that posterior skull base location (P < 0.01, odds ratio 11.5, 95% CI 1.99-2.17× 102) and craniopharyngioma pathology (P= 0.03, odds ratio 9.4, 95% CI 1.25-1.92× 102) were significantly associated with postoperative CSF leakage. No delayed leakage occurred during the observation period except for 2 patients who underwent multiple radiotherapies. NMFCT is a reasonable alternative with long-term durability, though vascularized flap may be a better choice for cases in which vascularity of the surrounding tissues is significantly impaired due to interventions including multiple radiotherapies.

Abdominal Closure With Reinforcing Suture Decreases Incisional Hernia Incidence After CRS/HIPEC.

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) entails several risk factors for incisional hernia (IH). A few reports available showing incidences between 7% and 17%. At our institution fascia closure has been performed in a 4:1 suture to wound length manner, with a continuous 2-0 polydiaxanone suture (PDS-group) or with a 2-0 polypropylene suture preceded by a reinforced tension line (RTL) suture (RTL-group). Our hypothesis was that these patients might benefit from reinforcing the suture line with a lower IH incidence in this group. The aim was to evaluate the 1-year IH-incidence of the two different closures. Methods: Patients eligible for inclusion were treated with CRS/HIPEC between 2004 and 2019. IH was diagnosed by scrutinizing CT-scans 1year ±3months after surgery. Additional data was retrieved from clinical records and a prospective CRS/HIPEC-database. Results: Of 193 patients, 129 were included, 82 in the PDS- and 47 in the RTL-group. RTL-patients were 5years younger, had less blood loss and more frequent postoperative neutropenia. No difference regarding sex, BMI, recent midline incisions, excision of midline scars, peritoneal cancer index score, complications (≥Clavien-Dindo 3b), or chemotherapy. Ten IH (7.8%) were found, 9 (11%) in the PDS- and 1 (2.1%) in the RTL-group (p = 0.071). Conclusion: An IH incidence of 7.8% in patients undergoing CRS/HIPEC is not higher than after laparotomies in general. The IH incidence in the PDS-group was 11% compared to 2% in the RTL-group. Even though significance was not reached, the difference is clinically relevant, suggesting an advantage with RTL suture.

Cierre dinámico y toxina botulínica: una alternativa novedosa para el cierre definitivo del abdomen abierto y contenido

We report the case of a 54-year-old male patient hospitalized for COVID-19 pneumonia who developed septic shock due to acute Hinchey IV diverticulitis and required Hartmann’s surgery. The patient evolved with colonic ischemia and underwent total colectomy and open abdomen (OA) with temporary abdominal closure (TAC) that was managed with a vacuum-assisted wound closure (VAWC) system for 7 weeks, resulting in a Björck grade 3A OA with a 16-cm gap. As he had a favorable clinic course, dynamic closure with mesh-mediated fascial traction was decided, associated with botulinum toxin (BT) injection. This strategy allowed primary fascial closure (PFC) of the abdominal wall 5 weeks after treatment was initiated, thus avoiding the complications of healing by secondary intention.

Preoperative Botulinum Toxin for Abdominal Wall Reconstruction in Massive Hernia Defects-A Propensity-Matched Analysis.

Reconstruction of massive incisional hernias (IHs) poses a significant challenge with high rates of recurrence. Preoperative chemodenervation using botulinum toxin (BTX) injections in the abdominal wall is a technique that has been used to facilitate primary fascial closure. However, there is limited data directly comparing primary fascial closure rates and postoperative outcomes after hernia repair between patients who do and do not receive preoperative BTX injections. The objective of our study was to compare the outcomes of patients who did and did not receive BTX injections before abdominal wall reconstruction. This is a retrospective cohort study including adult patients from 2019 to 2021 who underwent IH repair with and without preoperative BTX injections. Propensity score matching was performed based on body mass index, age, and intraoperative defect size. Demographic and clinical data were recorded and compared. The statistical significance level was set at P < 0.05. Twenty patients underwent IH repair with preoperative BTX injections. Twenty patients who underwent IH repair without preoperative BTX injections were selected to comprise a 1:1 propensity-matched control cohort. The average defect size was 663.9 cm2 in the BTX group and 640.7 cm2 in the non-BTX group (P = 0.816). There was no difference in average age (58.6 vs 59.2 years, P = 0.911) and body mass index (33.0 vs 33.2 kg/m2, P = 0.911). However, there was a greater proportion of male patients in the BTX group (85% vs 55%, P = 0.082).Primary fascial closure was achieved in 95% of BTX patients and 90% of non-BTX patients (P = 1.0). Significantly fewer patients in the BTX group required component separation techniques to achieve primary fascial closure (65% vs 95%, P = 0.044). There was no significant difference in any postoperative surgical and medical outcomes. Hernia recurrence was 10% in the BTX group and 20% in non-BTX group (P = 0.661). In our study, we observed a lower rate of component separations to achieve primary fascial closure among patients with massive hernia defects who received preoperative BTX injections. These results suggest that preoperative BTX injections may "downstage" the complexity of hernia repair with abdominal wall reconstruction in patients with massive hernia defects and reduce the need for component separation.

A double-blinded, randomized trial comparing surgeon-administered transversus abdominis plane block with placebo after midline laparotomy in gynecologic oncology surgery

Surgeon-administered transversus abdominis plane block is a contemporary approach to providing postoperative analgesia, and this approach is performed by transperitoneally administering local anesthetic in the plane between the internal oblique and transversus abdominis muscles to target the sensory nerves of the anterolateral abdominal wall. Although this technique is used in many centers, it has not been studied prospectively in patients undergoing a midline laparotomy. This study aimed to evaluate whether surgeon-administered transversus abdominis plane block reduces postoperative opioid requirements and improves clinical outcomes. In this double-blind, randomized, placebo-controlled trial, patients with a suspected or proven gynecologic malignancy undergoing surgery through a midline laparotomy at 1 Canadian tertiary academic center were randomized to either the bupivacaine group (surgeon-administered transversus abdominis plane blocks with 40 mL of 0.25% bupivacaine) or the placebo group (surgeon-administered transversus abdominis plane blocks with 40 mL of normal saline solution) before fascial closure. The primary outcome was the total dose of opioids (in morphine milligram equivalents) received in the first 24 hours after surgery. The secondary outcomes included opioid doses between 24 and 48 hours, pain scores, postoperative nausea and vomiting, incidence of clinical ileus, time to flatus, and hospital length of stay. The exclusion criteria included contraindications to study medication, history of chronic opioid use, significant adhesions on the anterior abdominal wall preventing access to the injection site, concurrent nonabdominal surgical procedure, and the planned use of neuraxial anesthesia or analgesia. To detect a 20% decrease in opioid requirements with a 2-sided type 1 error of 5% and power of 80%, a sample size of 36 patients per group was calculated. From October 2020 to November 2021, 38 patients were randomized to the bupivacaine arm, and 41 patients were randomized to the placebo arm. The mean age was 60 years, and the mean body mass index was 29.3. A supraumbilical incision was used in 30 of 79 cases (38.0%), and bowel resection was performed in 10 of 79 cases (12.7%). Patient and surgical characteristics were evenly distributed. The patients in the bupivacaine group required 98.0±59.2 morphine milligram equivalents in the first 24 hours after surgery, whereas the patients in the placebo group required 100.8±44.0 morphine milligram equivalents (P=.85). The mean pain score at 4 hours after surgery was 3.1±2.4 (0-10 scale) in the intervention group vs 3.1±2.0 in the placebo group (P=.93). Clinically significant nausea or vomiting was reported in 1 of 38 patients (2.6%) in the intervention group vs 1 of 41 patients (2.4%) in the placebo group (P=.95). Time to first flatus, rates of clinical ileus, and length of stay were similar between groups. Subgroup analysis of patients with a body mass index of <25 and patients who received an infraumbilical incision showed similarly comparable outcomes. Surgeon-administered transversus abdominis plane block with bupivacaine was not found to be superior to the placebo intervention in reducing postoperative opioid requirements or improving other postoperative outcomes for patients undergoing a midline laparotomy. These results differed from previous reports evaluating the ultrasound-guided transversus abdominis plane block approach. Surgeon-administered transversus abdominis plane block should not be considered standard of care in postoperative multimodal analgesia.

Effect of Suture Length on the Incidence of Incisional Hernia and Surgical Site Infection in Patients Undergoing Midline Laparotomy: A Systematic Review and Meta-Analysis.

The development of an incisional hernia is a common complication of midline laparotomy. Improper fascial closure techniques have a significant role in its development. It can also lead to poor wound healing and increase the risk of developing surgical site infections (SSI). Upon conducting a thorough literature review, various studies have been conducted on closing abdominal wounds. However, there is a dearth of studies portraying the role of suture length in the prevention of incisional hernia and SSI. The effect of using a greater suture-to-wound length ratio on postoperative outcomes was not clearly analyzed or described. The objective of this study is to assess the effectiveness of using a suture length to wound length ratio ≥4:1 versus a ratio <4:1 in preventing postoperative complications such as incisional hernia and SSI. This study is a systematic review of randomized controlled trialson abdominal wound closure using a suture length to wound length ratio of≥4:1 and <4:1. published in PubMed, Google Scholar, and Cochrane library. The inclusion and exclusion criteria were defined. The relevant studies identified from 1991 to 2017, were included in the analysis. The primary endpoint was the incidence of incisional hernia, and the secondary outcome was the incidence of SSI. This meta-analysis considered five randomized controlled trials that compared the effects of using different suture lengthto wound length ratios during abdominal closure on incisional hernia and SSI. Participants ranged in size from 100 to 363. The trial follow-up period ranged from a minimum of 10 months to five years. The outcomes studied in the two groups were incisional hernia and SSI. The relative risk of the occurrence of incisional hernia if the suture length to wound length ratio was ≥4:1 was 0.42 with a p-value of <0.001 which was considered significant. This implied that usinga suture length of more than four times that of the wound i.e., 4:1, significantly decreases the risk of developing an incisional hernia by more than half. The relative risk of developing a SSI was 0.98 with a p-value of 0.966. Thus, this method of abdominal closure uing a longer suture length to wound length ratio does not contribute to an increased incidence or significant change in the risk of developing SSI.

Gastroschisis in Mozambique: current status and priorities for improving care from Hospital Central de Maputo, the largest and referral hospital of the country

Historically, gastroschisis was considered a death sentence in Mozambique. The purpose of this study was to evaluate the current state of gastroschisis management and outcomes in our facility and to identify potential areas of improvement in neonatal and surgical care. A retrospective study was performed of all gastroschisis patients admitted to Hospital Central Maputolocated inMaputo City/Mozambique from 2019 to 2020. Demographic, perinatal, operative, and mortality data were obtained from neonatal and surgical logbooks. Descriptive analysis was performed. A total of 62 gastroschisis patients were admitted to the Hospital Central Maputo. No patients had a prenatal diagnosis. Many of the infants were born preterm (48%), and 68% had low birth weight. Only 15 (24%) patients underwent operative intervention (73% primary fascial closure and 27% sutured silo). There were only three survivors (5%) all of whom underwent primary closure. However, the overall survival rate for patients undergoing an attempt at surgical closure was 20%. While the mortality rate remains high for gastroschisis patients in Mozambique, there have been a few survivors when surgery is performed. Improvements in neonatal care are needed. Given the high mortality rates and limited resources, we plan to focus our surgical efforts on bedside closure techniques.

State-of-the-art abdominal wall reconstruction and closure.

Open ventral hernia repair is one of the most common operations performed by general surgeons. Appropriate patient selection and preoperative optimization are important to ensure high-quality outcomes and prevent hernia recurrence. Preoperative adjuncts such as the injection of botulinum toxin and progressive preoperative pneumoperitoneum are proven to help achieve fascial closure in patients with hernia defects and/or loss of domain. Operatively, component separation techniques are performed on complex hernias in order to medialize the rectus fascia and achieve a tension-free closure. Other important principles of hernia repair include complete reduction of the hernia sac, wide mesh overlap, and techniques to control seroma and other wound complications. In the setting of contamination, a delayed primary closure of the skin and subcutaneous tissues should be considered to minimize the chance of postoperative wound complications. Ultimately, the aim for hernia surgeons is to mitigate complications and provide a durable repair while improving patient quality of life.

Port Site Hernia After Laparoscopic Cholecystectomy: Retrospective Clinical Experience

Abstract&#x0D; Introduction: Laparoscopic cholecystectomy is the gold standard in patients scheduled for cholecystectomy. Complications related to laparoscopy may occur during or after laparoscopic cholecystectomy. This study is aimed to examine the incidence of port-site hernia and its predisposing factors.&#x0D; Method: Laparoscopic cholecystectomy operations performed in the general surgery clinic of our hospital between January 2016 and March 2021 were reviewed retrospectively. The pneumoperitoneum was created by entering the abdomen with a mini-incision from the umbilicus using the Hasson technique. All cholecystectomies were performed using the 4-port technique. The umbilical trocar fascia was closed in all patients. Demographic data were evaluated retrospectively.&#x0D; Result: The incidence of port-site hernia was determined as 0.5%. The umbilical hernia was detected in 15 patients: 11 male and four female. The mean age was 55.4 years. The mean hernia detection time was 14.3 months. The mean body mass index [BMI] was found to be 30.11. Four patients had a chronic disease. Fourteen of the patients underwent surgery. One of the patients was operated on a mini-incision urgently due to the development of strangulation. Recurrence was detected in three patients. No mortality was observed.&#x0D; Conclusion: Obesity, age, and female gender are considered important risk factors. In our series, fascial closure was performed instead of the umbilical port in all cases, but most of the port site hernias originate from the umbilicus port.