Lower Incidence Of Incisional Hernia Research Articles

COMPARISON OF POST-OPERATIVE OUTCOMES OF MASS CLOSURE CONTINUOUS TECHNIQUE VS HUGHES REPAIR IN PATIENTS UNDERGOING EXPLORATORY LAPAROTOMY

Surgical techniques for abdominal closure following exploratory laparotomy play a crucial role in determining postoperative complications. The mass closure continuous approach and Hughes repair are commonly employed methods with unique characteristics and outcomes. Objective: This retrospective comparative study aimed to evaluate the incidence of postoperative complications associated with the mass closure continuous approach and Hughes repair in patients undergoing exploratory laparotomy. Methods: The study was conducted at Nishtar Hospital Multan from July 2023 to December 2023. A total of 50 patients aged between 18 and 60 years of both genders, undergoing exploratory laparotomy, were included through non-probability sampling. Patients were treated either with the mass closure continuous technique or Hughes repair for abdominal closure. The mean operative time for each technique was recorded. The incidence of postoperative complications, including incisional hernia, wound infection, abdominal burst, and seroma, was assessed. Statistical analysis was performed using appropriate methods. Results: The mean operative time for the mass closure continuous technique was 16.32±2.1 minutes, significantly lower than that of Hughes repair (p<0.0001). Patients treated with Hughes repair demonstrated a significantly lower incidence of incisional hernia, wound infection, abdominal burst, and seroma compared to those treated with the mass closure continuous technique. Conclusion: Hughes's repair technique for abdominal closure following exploratory laparotomy is associated with reduced occurrence of postoperative complications, including incisional hernia and wound-related issues. Therefore, it may be considered a safe and effective option for abdominal closure in these patients.

Strength of small-bites abdominal wall closure using different suturing methods and materials in an experimental animal model.

Using small instead of large bites for laparotomy closure results in lower incidence of incisional hernia, but no consensus exists on which suture material to use. This study aimed to compare five different closure strategies in a standardized experimental setting. Fifty porcine abdominal walls were arranged into 5 groups: (A) running 2/0 polydioxanone; (B) interlocking 2/0 polydioxanone; (C) running size 0 barbed polydioxanone; (D) running size 0 barbed glycolic acid and trimethylene carbonate; (E) running size 0 suturable polypropylene mesh. The small-bites technique was used for linea alba closure in all. The abdominal walls were divided into a supra- and infra-umbilical half, resulting in 20 specimens per group that were pulled apart in a tensile testing machine. Maximum tensile force and types of suture failure were registered. The highest tensile force was measured when using barbed polydioxanone (334.8N ± 157.0), but differencesdid not reach statisticalsignificance. Infra-umbilical abdominal walls endured a significantly higher maximum tensile force compared to supra-umbilical (397N vs 271N, p < 0.001). Barbed glycolic acid and trimethylene carbonate failed significantly more often (25% vs 0%, p = 0.008). Based on tensile force, both interlocking and running suture techniques using polydioxanone, and running sutures using barbed polydioxanone or suturable mesh, seem to be suitable for abdominal wall closure. Tensile strength was significantly higher in infra-umbilical abdominal walls compared to supra-umbilical. Barbed glycolic acid and trimethylene carbonate should probably be discouraged for fascial closure, because of increased risk of suture failure.

PD31-02 ROBOTIC ASSISTED KIDNEY TRANSPLANT STILL FAILING TO IMPRESS: A SYSTEMATIC REVIEW AND META-ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023PD31-02 ROBOTIC ASSISTED KIDNEY TRANSPLANT STILL FAILING TO IMPRESS: A SYSTEMATIC REVIEW AND META-ANALYSIS Tuan Thanh Nguyen, Adnan El-Achkar, Berut Lebanon, Ho Yee Tiong, Ryan W. Dobbs, Huy Gia Vuong, Jacob Basilius, Le Quy Van Dinh, Ho Chi Minh, Vietnam, Jad Najdi, Trong Hieu Le, Tien-Dat Hoang, Khoa Quy, Ali Sohrab Naushad, Mohammed Shahait, Amman Jordan, and David I. Lee Tuan Thanh NguyenTuan Thanh Nguyen More articles by this author , Adnan El-AchkarAdnan El-Achkar More articles by this author , Berut LebanonBerut Lebanon More articles by this author , Ho Yee TiongHo Yee Tiong More articles by this author , Ryan W. DobbsRyan W. Dobbs More articles by this author , Huy Gia VuongHuy Gia Vuong More articles by this author , Jacob BasiliusJacob Basilius More articles by this author , Le Quy Van DinhLe Quy Van Dinh More articles by this author , Ho Chi MinhHo Chi Minh More articles by this author , Vietnam Vietnam More articles by this author , Jad NajdiJad Najdi More articles by this author , Trong Hieu LeTrong Hieu Le More articles by this author , Tien-Dat HoangTien-Dat Hoang More articles by this author , Khoa QuyKhoa Quy More articles by this author , Ali Sohrab NaushadAli Sohrab Naushad More articles by this author , Mohammed ShahaitMohammed Shahait More articles by this author , Amman JordanAmman Jordan More articles by this author , and David I. LeeDavid I. Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003324.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Several centers have reported their recent experiences with the robotic approach in kidney transplantation. Previous reports suggest lower incidence of incisional hernia and lymphocele. However, these reported improvements in perioperative and follow-up outcomes are still debated. This most comprehensive and updated meta-analysis sought to compare the perioperative and follow-up outcomes between robot-assisted kidney transplantation (RAKT) and open kidney transplantation (OKT). METHODS: For relevant articles, three electronic databases, including PubMed, Scopus, and Web of Science, were searched from their inception until May 21, 2022. A meta-analysis has been reported in line with PRISMA 2020 and AMSTAR Guidelines. The risk ratio (RR) and mean difference (MD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CI). RESULTS: Of the 1580 retrieved abstracts, 95 underwent full-text review, and 15 studies were included in the final analysis, comprising a total cohort of 2,319 cases of kidney transplantation (667 RAKT and 1,652 OKT). The quality of the studies remains low with large heterogeneity in the cohorts. the RAKT group still has longer warm ischemia time, cold ischemia time, rewarming time, total ischemia time and operative time compared to the OKT group. Even though RAKT group had shorter incision length (RR=1.42, 95%CI (0.350 - 5.766), p=0.623) resulting in lower pain score (MD=-1.37, 95%CI (-1.59 - -1.15), p=<0.001), less morphine use (SMD=-3.478, 95%CI (-5.619 - -1.336), p=0.001), and shorter length of stay (LOS) (SMD=-0.496, 95%CI (-0.819 - -0.173), p=0.003), it has similar clinical estimated blood loss, similar rates of surgical site hernia and postoperative lymphocele. Both techniques have equivalent renal function, graft, and patient survival. Decrease surgical site infection remains only significant in obese patients. CONCLUSIONS: Our study showed that with a larger series and more patients, the initial promise that RAKT have lower rates rate of lymphocele incisional hernia is not true. While RKT does have shorter wound incision, less pain, and LOS, this comes at a cost of longer op times with no improvement in graft survival. The answer to whether RAKT is worthwhile remains to be answered by a randomized controlled study. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e900 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tuan Thanh Nguyen More articles by this author Adnan El-Achkar More articles by this author Berut Lebanon More articles by this author Ho Yee Tiong More articles by this author Ryan W. Dobbs More articles by this author Huy Gia Vuong More articles by this author Jacob Basilius More articles by this author Le Quy Van Dinh More articles by this author Ho Chi Minh More articles by this author Vietnam More articles by this author Jad Najdi More articles by this author Trong Hieu Le More articles by this author Tien-Dat Hoang More articles by this author Khoa Quy More articles by this author Ali Sohrab Naushad More articles by this author Mohammed Shahait More articles by this author Amman Jordan More articles by this author David I. Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

Comment on: Intracorporeal Versus Extracorporeal Anastomosis in Robotic Right Colectomy: A Multicenter, Triple-Blind, Randomized Clinical Trial.

We would like to thank Dohrn et al1 for their randomized controlled trial comparing intracorporeal anastomosis (ICA) with specimen extraction through a Pfannenstiel incision with extracorporeal anastomosis (ECA) with specimen extraction through a transverse right upper quadrant incision in patients undergoing robotic right hemicolectomy (rRHC). The authors state that the main advantage of ICA during rRHC is that it allows for specimen extraction through a Pfannenstiel incision with, as a corollary, reduced postoperative pain and therefore improved postoperative recovery. To this end, they performed a sample size calculation based on the “Quality of Recovery-15” (QoR-15) questionnaire, which is a patient-reported composite outcome. Unfortunately, the trial was not powered on the semiquantitative assessment of postoperative pain or on any objective measurement of postoperative recovery. Second, the main advantage of the robotic approach for RHC is the improved possibility of performing ICA and choosing a Pfannenstiel incision as the extraction site when compared to laparoscopy. Performing ECA during rRHC offers, to our opinion, absolutely no advantage over ICA, and we therefore question the pertinence of the comparison chosen by the authors, especially when considering the increased cost of the robotic approach. A Pfannenstiel incision is more discreet that a right upper quadrant incision, and is esthetically preferred by patients. On this aspect, we note that the esthetical scoring of the extraction site was not considered in the outcomes and was not included in the QoR-15 questionnaire. Moreover, Pfannenstiel incisions have lower incidence of incisional hernia than transverse right upper quadrant incisions (0.9% vs 3.7%),2 which may support ICA over ECA from both a medical point of view but also an economical point of view. This outcome was not assessed in the trial. Finally, we note that a significant proportion of eligible patients were not randomized and that recruitment was paused during 1 year due to the unavailability of qualified surgeons. However, no threshold of experience was set. We believe it would have been preferable to set a threshold in terms of experience, or to audit the surgical procedures as performed for example in the robotic versus laparoscopic surgery for middle and low rectal cancer trial.3 For instance, it was shown that the results of the Robotic-Assisted versus conventional Laparoscopic surgery on risk of conversion to open laparotomy Among patients undergoing Resection for Rectal cancer trial4 were potentially biased by the experience of participating surgeons.5,6 To conclude, we believe that, despite the results of this randomized controlled trial, ICA should be preferred over ECA during rRHC. ACKNOWLEDGMENTS J.M. conceived and designed the study. All authors interpreted the data and contributed to the writing of the draft manuscript. All authors approved the final version of the manuscript.

Does small bite closure reduce the incidence of incisional hernia compared to standard mass closure for midline laparotomy?

A best evidence topic was constructed using a defined protocol. The three-part question addressed was: in closure of midline laparotomy, which technique had lower incidence of incisional hernia: small bite closure or mass closure? The best evidence demonstrated that small bite technique has lower incidence of hernia.

Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy: a retrospective cohort study of anastomotic complications.

Laparoscopic right hemicolectomy (LRH) can be performed with an intracorporeal anastomosis (IA) or extracorporeal anastomosis (EA). It is not clear which technique is best. This study evaluated the impact of each anastomosis technique on perioperative safety and postoperative evolution. We performed a retrospective study at a tertiary colorectal surgery center. All patients who had an elective LRH from 2015 to 2019 were analyzed according to the anastomosis technique used. In total, 285 patients were included in the study. IA was performed in 64 patients (22.5%). Mean operative time was longer in the patients with IA (IA, 160±31 minutes vs. EA, 138±42 minutes; P<0.001). No differences were observed in intraoperative complications, time to first bowel movement, length of stay, reoperation, or rehospitalization. Time to first flatus was longer in the patients with IA (P=0.049). At 30 days after surgery, there were no differences in the frequency of anastomotic leak (IA, 0% vs. EA, 2.3%; P=0.59), bleeding (IA, 3.1% vs. EA, 2.7%; P>0.99), or intraabdominal abscess (IA, 0% vs. EA, 0.5%; P>0.99). During follow-up, we noted more incisional hernias in patients with EA (IA, 1.6% vs. EA, 11.3%; P=0.01) and a trend toward more hernia in patients with EA in multivariate analysis (hazard ratio, 7.13; P=0.06). Anastomosis technique had no influence on recurrence. For LRH, both IA and EA are safe, with a low incidence of complications when performed by experienced surgeons. IA may be associated with a lower incidence of incisional hernia.

Periumbilical Transverse Incision for Reducing Incisional Hernia in Laparoscopic Colon Cancer Surgery.

Although off-midline incisions (unilateral low transverse or Pfannenstiel incision) have been reported to have a lower incidence of incisional hernia (IH) than periumbilical vertical incision for the purpose of specimen extraction, it is most commonly used in laparoscopic colon cancer surgery because off-midline incisions are associated with the limitation of colon exteriorization. This study aims to investigate the risk of IH after laparoscopic colectomy and compare midline vertical incision versus transverse incision focusing on the incidence of IH. Patients who underwent elective laparoscopic colectomy due to colon malignancy from June 2015 to May 2017 were included. All patients had either vertical (n = 429) or muscle splitting periumbilical transverse incisions (n = 125). Median duration of the follow-up period was 23.6months, during which IHs occurred in 12.1% patients. The incidence of hernia was significantly lower in the transverse group (3 vs. 64, 2.4% vs. 14.9%, p < 0.001). On multivariate analysis, BMI ≥ 23 [odds ratio (OR) 2.282, 95% confidence interval (CI) 1.245-4.182, p = 0.008], postoperative surgical site infection (OR 3.780, 95% CI 1.969-7.254, p < 0.001) and vertical incision (OR 7.113, 95% CI 2.173-23.287, p < 0.001) were independently related with increased incidence of IH. A muscle splitting periumbilical transverse incision could significantly reduce the rate of IH in minimally invasive colon cancer surgery.

O05 1-YEAR RESULTS OF AN INTERNATIONAL RANDOMIZED CONTROLLED TRIAL (ESTOIH STUDY) COMPARING THE “SHORT STITCH” VERSUS “LONG STITCH” TECHNIQUE USING AN ULTRA-LONG ABSORBABLE ELASTIC SUTURE MATERIAL

Abstract Aim The aim of this multicenter, randomized, double blinded study was to compare the short stitch technique for elective, primary, median laparotomy closure with the long stitch closure using the ultra-long absorbable, elastic monofilament suture made of poly 4-hydroxybutyrate (MonoMax®). Material and Methods Eligible patients were randomly allocated to receive either the short or the long stitch suture technique in a 1:1 ratio in 9 centers in Austria and Germany after elective midline laparotomy. Results 425 patients were randomized to receive either the short stitch (n = 215) or long stitch technique (n = 210). In a cox proportional hazards model, the risk for burst abdomen was reduced by 7-fold (HR 0.183 (0.0427 - 0.7435), p = 0.0179) for the short stitch group. Complications such as seroma, hematoma and other wound healing disorders occurred without significant differences between groups. After one year, the incisional hernia rate was 3.65% in the short stitch group compared to 8.80% in the long stitch group (p = 0.055). The combination of burst abdomen and incisional hernia rate had a significantly lower rate of 5.38% for the short stitch technique compared to 13.17% for the long stitch technique (p = 0.0142). Conclusions Both in the short-term results, the short-stitch technique showed substantial advantages in burst abdomen rate, as well as in the 1-year follow-up regarding the incidence of incisional hernias. The low incidence of incisional hernia in the short stitch technique with MonoMax® is promising in comparison to previously published data and should be confirmed in the 3-year follow-up.

Risk factors of incisional hernia after single-incision cholecystectomy and safety of barbed suture material for wound closure.

PurposeSingle-incision cholecystectomy is a surgical method that offers comparable results to conventional laparoscopic cholecystectomy. However, a high risk of postoperative incisional hernia is an issue in single-incision cholecystectomy. This study evaluated the risk factors and incidences of incisional hernia after single-incision cholecystectomy and the advantage issue of using barbed suture material during wound closures.MethodsA total of 1,111 patients underwent laparoscopic or robotic single-incision cholecystectomy between March 2014 and February 2020 at our institution at CHA Bundang Medical Center. During this period, there were 693 patients who underwent wound closure with monofilament suture material (Monosyn 2-0; B. Braun) and the other 418 patients used barbed suture material (Stratafix 2-0; Ethicon).ResultsThe two patient groups were comparable in age, body mass index, and diagnosis. The total incidence of incisional hernia after single-incision cholecystectomy was 0.5% (five cases). All patients who developed incisional hernia were in the monofilament suture material group (0.7% vs. 0%, p = 0.021). The influence of predictive and possible risk factors on incisional hernia rate was analyzed. Among these factors, only old age was an independent predictive risk factor of incisional hernia.ConclusionOur study showed a low incidence of incisional hernia, all of which occurred in the monofilament suture material group. If technically appropriate, single-incision cholecystectomy does not appear to present a high incidence of hernia. Barbed suture material can be safely applied in wound closure showing comparable incisional hernia incidence to monofilament suture material.

Small bites technique for midline laparotomy closure: From theory to practice: Still a long way to go

BackgroundThe closure technique of the abdominal wall is a key factor in the development of incisional hernia. Our aim was to implement a protocol for closure of median laparotomy, to evaluate the grade of implementation, as well as to assess the results and safety of the technique. MethodsA series of formative activities to implement the small bites technique for closure of median laparotomy in elective operations were designed. After 1 year, a survey was conducted on knowledge and use of the technique. Prospective compilation of data of all median laparotomy in elective operations and their follow-up was done for 1 year. The incidence of incisional hernia depending on the fulfilment of the protocol was compared. ResultsA total of 74 surgeons participated in the activities. All the participants accomplished the technique perceiving low difficulty (1.9/10). After 1 year, 44 surgeons answered the survey; 95% stated that they knew the small bites technique and used it always or almost always, but only 52% performed the calculation of the suture length and the incision length ratio. A total of 114 median laparotomy in elective operations were analyzed; among them, 30.7% were closed with small bites presenting a lower frequency of incisional hernia and burst abdomen (small bites 3.6% vs large bites 12.1%; odds ratio 1.30; confidence interval, 0.992--1.711; P = .20). ConclusionThe measures were effective for learning, but education alone was not enough to implement the technique in the real scenario. Small bites technique is reproducible, has no risks, and provides low incidence of incisional hernia. More incentives and actions are needed to improve laparotomy closure.

Safety of Barbed Suture Material for Wound Closure in Single Incisional Cholecystectomy

Single incisional cholecystectomy is surgical methods that provide comparable results to standard laparoscopic cholecystectomy (LC). However, single incisional cholecystectomy has been accused for post-operative incisional hernia. The incidence of incisional hernia after single incisional cholecystectomy is reported about 2.4% in short-term follow-up studies and up to 10.9% in long-term follow-up. One of incisional hernia's risk factor is surgical technique failure during wound closure. This study evaluated the incidence of patients developing incisional hernia after single incisional cholecystectomy, and we hope to suggest a solution in overcoming incisional hernia arising out surgical technique failure by using barbed suture material during wound closure. Total number of 984 patients underwent single incisional cholecystectomy between March 2014 and December 2019. During this period, there were 689 patients who underwent wound closure with non-barbed suture material and 295 patients with barbed suture material. Both Patient groups were comparable in age, gender, BMI and operation time. 2 patients developed incisional hernia in non-barbed suture group and none in the barbed suture group. The incidence of incisional hernia was higher in the non-barbed suture group, but statistically insignificant. (p=1.00) Our large volume study showed lower incidence of incisional hernia to comparing previous studies. Also, there was no incisional hernia patient in barbed suture group, although statistically insignificant, which means possibility of overcoming the surgical technique failure using barbed suture material. We hope to share our experience on safety and advantage of using barbed suture in wound closure leading to a decrease in the incidence of incisional hernia.

Risk of hernia formation after radical prostatectomy: a comparison between open and robot-assisted laparoscopic radical prostatectomy within the prospectively controlled LAPPRO trial

PurposeIn addition to incisional hernia, inguinal hernia is a recognized complication to radical retropubic prostatectomy. To compare the risk of developing inguinal and incisional hernias after open radical prostatectomy compared to robot-assisted laparoscopic prostatectomy.MethodPatients planned for prostatectomy were enrolled in the prospective, controlled LAPPRO trial between September 2008 and November 2011 at 14 hospitals in Sweden. Information regarding patient characteristics, operative techniques and occurrence of postoperative inguinal and incisional hernia were retrieved using six clinical record forms and four validated questionnaires.Results3447 patients operated with radical prostatectomy were analyzed. Within 24 months, 262 patients developed an inguinal hernia, 189 (7.3%) after robot-assisted laparoscopic prostatectomy and 73 (8.4%) after open radical prostatectomy. The relative risk of having an inguinal hernia after robot-assisted laparoscopic prostatectomy was 18% lower compared to open radical retropubic prostatectomy, a non-significant difference. Risk factors for developing an inguinal hernia after prostatectomy were increased age, low BMI and previous hernia repair. The incidence of incisional hernia was low regardless of surgical technique. Limitations are the non-randomised setting.ConclusionsWe found no difference in incidence of inguinal hernia after open retropubic and robot-assisted laparoscopic radical prostatectomy. The low incidence of incisional hernia after both procedures did not allow for statistical analysis. Risk factors for developing an inguinal hernia after prostatectomy were increased age and BMI.

PTU-228 Abdominal fascial wound closure with 2–0 sutures does not lead to increased rates of dehiscence or incisional hernia

Introduction Emerging evidence has shown that using smaller more frequent sutures close to the fascial wound edge is associated with a lower incidence of incisional hernia, dehiscence and surgical site infection compared to conventional wound closure. 1 However in implementing this practice we have experienced difficulty due to concerns regarding sutures below 1–0 grade allowing increased rates of early dehiscence and incisional hernia. We sought to demonstrate the safety of this method of wound closure. Method Un-selected patients undergoing abdominal surgery (elective and emergency) were prospectively collected from within the practice of a single surgeon in a regional teaching hospital. All wounds greater than four centimetres (fascia defect length) were included. All patients underwent closure of abdominal fascial wounds using a suture to wound length ratio of at least 4:1. Suture material was 2–0 PDS. Risk of death from surgery was preoperatively calculated using the P-POSSUM score. Initial follow up period was 30 days from procedure. Study end points were length of stay, morbidity and mortality within 30 days, dehiscence and hernia formation rate. Results 34 patients underwent fascial closure as described above, 17 cases were patients undergoing emergency laparotomy. Average fascial defect length was 13.8 cm (median 14.5 cm); average length of suture used was 98.5 cm (median 82 cm). Average ratio of suture length to wound length was 7.5. Mean length of stay in this group was 5.4 days. Average BMI was 28.9; average calculated risk of death was 11.6%. A single patient died from overwhelming sepsis shortly after emergency laparotomy. Three patients developed chest sepsis post operatively (emergency group) and two elective patients were readmitted within 30 days with chest infection and hypocalcaemia respectively. Conclusion We have demonstrated that using a small, frequent suture does not give rise to increased rates of early dehiscence, incisional hernia or major wound complications in the early post operative period. Disclosure of interest None Declared. Reference Israelsson L, Millbourn D. Prevention of incisional hernias. How to close a midline incision. Surg Clin North Am. 2013;93:1027–1040

Short‐ and Long‐Term Results of Open Versus Laparoscopic Appendectomy

BackgroundClinical advantages of laparoscopic appendectomy have been shown in numerous trials and reviews. Most of these advantages are small and of limited clinical relevance, while laparoscopic operation costs are reported to be higher. The present study compares short- and long-term results of conventional appendectomy with or without diagnostic laparoscopy (OA), and laparoscopic appendectomy (LA).MethodsAll adult patients who underwent appendectomy in our institution from 1995 to 2005 were included retrospectively. Patient data were retrieved from medical records, questionnaires sent by mail, and records of general practitioners. Primary outcome parameters were long-term complications, readmissions, and reinterventions (>30 days postoperatively). Secondary outcome parameters were short-term complications, readmissions, and reinterventions (≤30 days postoperatively).ResultsA total of 755 patients were included, 545 of whom underwent OA, with the remaining 210 undergoing LA. In the long term there were few complications noted, and there were no significant differences in complications between the two groups. Within 30 days postoperatively, LA was associated with a significantly higher incidence of abdominal abscesses with consequent diagnostic investigations, interventions, and readmissions.ConclusionsAlthough laparoscopic appendectomy is known to deliver clinical advantages, it is associated with a higher incidence of abdominal abscesses. Because the procedure is about to become the standard of care, future research must be directed at solving this issue. The expected lower incidence of incisional hernia and small bowel obstruction after laparoscopic appendectomy was not shown in the present study.

Reducing the incidence of incisional hernia after liver transplantation

Two important issues must be considered when deciding the abdominal incision for a liver transplant (LT): a good access to both liver lobes and a reduced rate of wound-related morbidity. Historically, two incisions have been recommended for a LT: the classic Mercedes incision [1] and the subcostal bilateral incision [2]. Nevertheless, in recent years, the right subcostal incision with medial extension to xyphoid process (J-shaped incision) has arisen as a good option for liver surgery [3]. The reported frequencies of incisional hernia after LT range from 4.9% to 17.2% and several factors such as older age, acute rejection with steroids treatment, ascites or wound infection seem to be associated [4-7]. In a recent article from UCLA, an incidence of 4.6% of incisional hernia was reported after LT through a Mercedes incision [4]. The authors found that reoperation, pulmonary complications and the male gender were associated risk factors for incisional hernia. Comparing the outcome using the J-shaped incision and the classic Mercedes incision for LT, Heisterkamp et al. [8] found a significantly lower incidence of incisional hernia after the J-shaped incision (7% vs. 24%P = 0.002) with a relaparotomy rate that was not significantly different between the two groups (31% and 45% respectively P = 0.487). From January 1998 to December 2007, we performed 626 consecutive orthotopic liver transplantations. All patients were transplanted using a bilateral subcostal incision that was closed with two layers of running sutures of absorbable monofilament (Maxon 1; Synature, Covidien, Mansfield, USA). Child-Pugh score was A in 141 patients (22.5%), B in 242 (38.7%), and C in 243 (38.8%). Immunosuppression was based on tacrolimus, and steroids from the first post-transplant day (20 mg/day of prednisone). A 3-day course of methylprednisolone was used in 83 patients (13.2%) to treat a moderate or severe acute cellular rejection. Post-transplant relaparotomy was needed in 29 patients (4.6%). No patient was lost to follow-up. An incisional hernia was diagnosed, and subsequently treated in 11 patients, which means an incidence of 1.7%. The Chi-squared test was used to compare our results with the two reports already mentioned [4, 8]. Our incidence of incisional hernia was significantly lower with a P value ranging from 0.03 to 0.003 depending on the type of incision, J-shaped or Mercedes. In our opinion, this significantly low incidence of incisional hernia may be explained by several circumstances: (i) the avoidance of Mercedes incision and its relative ischemic area at the trifurcation point, (ii) the low accumulated steroid dose in our patients because of our immunosuppressive protocol and the low rate of steroids-treated acute cellular rejection, and (iii) the significant low incidence of post-transplant relaparotomy (P < 0.001 when compared with the reports previously mentioned [4, 8]). According to our results, subcostal bilateral incision may be considered for liver transplantation provided other risk factors for incisional hernia are prevented. Incisions with upward midline extension may be reserved for liver transplants with difficult suprahepatic vein reconstruction, as they allow a vertical access to the suprahepatic vena cava rather than from a caudal view [9]. No funding sources support this work. Authors have no commercial associations.

Incisional hernia after open versus laparoscopic sigmoid resection

Incisional hernia after open surgery is a well-known complication with an incidence of up to 20% after a 10-year period. Data regarding the long-term hernia risk after laparoscopic colonic surgery are lacking in the literature. In the present study we compared the long-term hernia incidence after laparoscopic versus open sigmoid resection. The study included patients undergoing laparoscopic sigmoid resection in the period January 1995 to December 2004 in the eastern part of Denmark. This group was matched with a consecutive group of patients undergoing open surgery in our department in the same period. Patients were contacted by telephone, and a questionnaire was completed for each patient. If the patient was believed to have a hernia or if there was any suspicion of a hernia, a consultant surgeon examined the patient and completed the questionnaire. Factors related to the primary operation, the hernia and general risk factors were registered for all patients. A total of 201 patients answered the questionnaire (95.3%). The laparoscopy group was comprised of 58 patients and 143 patients were included in the laparotomy group. The patients had a median follow-up of 4.6 years (range 2.4-11.7 years) and 4.9 years (range 2.4-8.5 years) after laparoscopic and open surgery, respectively (P = 0.326). Incisional hernia was found in two of 58 patients (3.4%, 95% CI -1.4-7.4) in the laparoscopic surgery group compared with 21 of 143 patients (14.7%, 95% CI 8.9-20.5) in the open surgery group (P = 0.026). There were no significant differences in demographic data or the occurrence of risk factors between the two groups. Laparoscopic sigmoid resection leads to a significantly lower incidence of incisional hernia compared with the open surgical technique.

Making the case for the radially expanding access system

ObjectiveTo report data on the case of the radially expanding access device for laparoscopic surgery.DesignA narrative based on personal and industry‐wide evidence‐based outcome data on abdominal injuries caused by sharp trocars, compared with the safety associated with the radially expanding access system.SubjectsPatients undergoing laparoscopic gynaecological and general surgical procedures.ConclusionsUse of the radially expanding access device is associated with far fewer abdominal injuries, reduced pain and a much lower incidence of incisional hernia.