Midline Closure Research Articles

Does randomised evidence alter clinical practise? The react qualitative study

BackgroundIn 2015, the results of the ‘Small bites versus large bites for closure of abdominal midline incisions (STITCH) Trial’ were published in The Lancet. This demonstrated the superiority of small bite laparotomy closure over mass closure for the reduction of incisional hernias; despite this most surgeons have not changed their practice. Previous research has shown the time taken for the implementation of evidenced based practise within medicine takes an average of 17 years. This study aims to understand the reasons why surgeons have and have not changed their practice with regards to closure of midline laparotomy.MethodsSemi-structured interviews were completed with surgical consultants and registrars at a single institution in South West England. The interview topic guide was informed by a review of the published literature, which identified barriers to adopting evidence into surgical practice. Interview transcripts underwent thematic analysis with themes identified following discussions within the research team, exploring views on published data and clinical practise.ResultsNine interviews with general surgical and urological consultants as well as registrars in training were performed. Three themes were identified; ‘Trusting the Evidence & Critical Appraisal’, ‘Surgical Attitude to Risk’ and ‘Adopting Evidence in Practise’, that reflected barriers to the introduction of evidenced based practise to clinical work.ConclusionIdentification of the themes highlights possible areas for intervention to decrease the adoption time for evidence, for example from randomised controlled trials. The continued updating of clinical practise allows clinicians to provide best evidenced based care for patients and improve their outcomes.

Posterior components separation with transversus abdominis release and sublay mesh reinforcement in large ventral hernia repair

AbstractAimVentral abdominal hernia is a prevalent condition among surgical patients. Large ventral hernias with defects >10 cm that cannot be closed primarily, often with loss of domain requiring abdominal wall reconstruction, pose a surgical challenge. Our study aimed to evaluate the outcomes of posterior components separation (PCS) with transversus abdominis release (TAR) and sublay mesh reinforcement in large ventral hernia repair, particularly in terms of surgical site occurrences (SSOs) and hernia recurrence.Patients and MethodsOur study included 40 adult patients presented to Tanta University Hospitals with a large ventral hernia (defect width ≥10 cm) from December 2021 to January 2023. All patients were submitted to PCS with TAR and sublay mesh reinforcement.ResultsThe mean age of the study population was 47.32 (standard deviation [SD] 9.31) years (range 36–65 years) with a mean body mass index of 33.55 (SD 3.42) kg/m2 (range 28.35–38.72 kg/m2). The major risk factors were obesity (95.00%), smoking (45.00%), and multiparity (45.00%). Midline incisional hernia was the most common type in 28 patients (70.00%). Thirty‐four patients (85%) achieved successful midline closure, while six patients required additional anterior components separation technique to achieve tensionless midline closure and an onlay mesh for functional reconstruction. Post‐operative SSOs occurred in 12 patients (30.00%), with subcutaneous seroma in 8 patients (20.00%) and wound dehiscence and necrosis in 4 patients (10.00%). Two patients (5.00%) experienced recurrence after a mean follow‐up period of 19.25 (SD 3.52) months.ConclusionsPCS with TAR and sublay mesh reinforcement is a reliable and durable technique for complex ventral hernia repair with low morbidity and recurrence rates. However, long‐term clinical outcomes with more cases are required to properly evaluate this technique.

Effect of Thiocolchicoside on Midline Closure in Early Chicken Embryos

Effect of Thiocolchicoside on Midline Closure in Early Chicken Embryos

Prophylactic slowly resorbable mesh in midline laparotomy to limit incisional hernia incidence: the prospective ‘Mesh Augmented Reinforcement of Abdominal Wall Suture Line (MARS)’ cohort study protocol

Background: Incisional hernia (IH) after abdominal surgery is a frequent surgical complication. Risk factors associated with IH are midline incisions, patients with an abdominal aneurysm of the aorta, and high BMI. Preventive measures include the use of the small-bites suture technique and/or placing a prophylactic mesh for reinforcement of the midline closure. Although recommended for high-risk patients, many surgeons are still reluctant to place a prophylactic mesh due to related complications. To counter these concerns, new synthetic resorbable meshes are being developed, such as the Deternia Self-Gripping Resorbable Mesh (“investigational device”). However, the effectiveness of this mesh in IH prevention has not been proved. Methods: The Mesh Augmented Reinforcement of Abdominal Wall Suture Line (MARS) study is a European, multicentre, prospective, single-arm study. A total of 120 patients scheduled for elective midline laparotomy, and for that reason at risk of developing IH, will be recruited in ~12 sites after informed consent. The sample size was estimated based on greater than 80% power, two-sided alpha of 0.05, an expected 12 month IH rate of 8% and a predefined performance goal of 18% (10% clinical margin). Midline incisions will be closed by the small bites closure technique with a minimum 4:1 suture-to-wound length ratio and reinforced by mesh placement in the retrorectus position. The primary outcome will be IH occurrence at 12-month postoperatively, evaluated both clinically and by ultrasound. Secondary outcomes will include mesh-related and postoperative complications, surgical characteristics, IH incidence at 2 and 3 years after surgery, and quality of life. Discussion: Currently, no conclusive evidence is available for synthetic resorbable meshes in a prophylactic setting to prevent IH. The MARS study will be the first prospective cohort study to investigate resorbable synthetic meshes and small bites closure to reduce IH incidence.

INITIAL EXPERIENCE WITH AN INTRAOPERATIVE FASCIAL STRETCHING DEVICE TO REPAIR COMPLEX INCISIONAL HERNIAS

Abstract Aim Midline closure is a target of incisional hernia (IH) repair and poses a surgical challenge, especially in W3 IH. Therefore, measures such as surgical prehabilitation (Botulinum Toxin -BT- or progressive pneumoperitoneum -PN-) have been adopted. We present our initial results with a fascial traction (FT) device for treating large IH. Material and Methods Single-centre, observational, retrospective study (April 2022–December 2023), including patients treated with FT (transverse defect greater or equal to 15 cm). Epidemiological characteristics, comorbidity, prehabilitation, type of IH, bridging, surgical time, hospital stay, morbidity, mortality and recurrence were studied. Results Patients characteristics (N = 5) Male/Female 3/2 Age 57(43-63) Diabetes mellitus 2(40%) Arterial hypertension 4(80%) Body mass index 34,4 (30,7–41,5) CeDAR 32,6% (17-47) IH classification (EHS): 3 M2-3-4-5 (60%), 1 M2-3-4 (20%), 1 bilateral L1 (20%), all W3 (15–27 cm). 2 cases R0 (40%), 2 R1 (40%), 1 R2 (20%). All received preoperatively TB and 4 PP, mean insufflated volume 8150 cc (4000–14400).Surgery related parameters (N = 5)TechniqueRives-StoppaBilateral TAR3(60%)2(40%)MeshesPVDF2(40%)Biosynthetic +PPL3(60%)Primary fascial closure4(80%)Bridging(size)1(15 × 5 cm)Surgical time(minutes)278(210–330)IFSD use30 minutesHospital stay(days)12,8 (6–29)Related postoperative painLow2Medium2High1ComplicationsWound-related (N = 4,80%)Infection3 (60%)Seroma2 (40%)Haematoma2 (20%)General (N = 0)Mortality0Recurrences0 Conclusions FTD are useful to treat IH, but a rational use must be made through proper preselection of candidates (W3 defects wider than 15 cm), due to economic cost, increased surgical time and the possible complications they entail.

Increased risk of incisional hernia after stoma closure in patients with colorectal cancer.

Stoma construction and closure are common surgical strategies in patients with colorectal cancer. The present study evaluated the influence of multiple incisional sites resulting from stoma closure on incisional hernia after colorectal cancer surgery. The study included 1681 patients who underwent colorectal cancer surgery. Multiple incisional sites were defined as the coexistence of incisions at the midline and stoma closure sites. We retrospectively investigated the relationship between the presence of multiple incisional sites and incisional hernia development in patients with colorectal cancer. Among the 1681 patients, 420 (25%) underwent stoma construction, with a stoma closure-to-construction ratio of 33% (139/420), and 155 (9.2%) developed incisional hernias after colorectal cancer surgery. In the multivariate analysis, female sex (p < 0.001), body mass index (p < 0.001), multiple incisional sites (p = 0.001), wound infection (p = 0.003), and postoperative chemotherapy (p = 0.030) were independent predictors of incisional hernia. In the multiple incisional sites group, the age (p < 0.001), surgical approach (laparoscopic) (p = 0.013), wound infection rate (p = 0.046), small bowel obstruction rate (p < 0.001), and anastomotic leakage rate (p = 0.008) were higher in those in the single incisional site group. Multiple incisional sites resulting from stoma closure are associated with the development of incisional hernia following colorectal cancer surgery.

A new midline closure technique without skin sutures: Long-term outcomes of primary repair of pilonidal sinus disease.

Currently, the focus regarding pilonidal sinus disease is put on the treatment techniques. The aim of the study is to compare postoperative long-term complications and recurrence of two surgical techniques. From February 2015 to December 2020, male patients with pilonidal sinus disease attended at two general surgery outpatient centers were randomly assigned to either Group 1 (n=80; excision and primary closure) or Group 2 (n=80; excision and midline closure without skin sutures). Patients with recurrent or complicated pilonidal sinus or with prior surgical procedures were excluded from the study. Intergroup postoperative results and recurrence throughout the follow-up period were analyzed. Significant decrease (p<0.001) in the duration of the surgical procedure (35 to 25 minutes), length of hospital stay (one day to the day of the surgery), and of the time required to return to work (15 to 12 days) was seen for Group 2 patients. The complication rate (wound infection and seroma) was lower in Group 2 compared to Group 1 (n = 3; 3.7% vs n = 10; 12.5%; p = 0.014). During the five-year mean follow-up, five patients (6.2%) in Group 1 had recurrence compared to none in Group 2 (p = 0.023). Midline primary closure method without skin sutures - easy to learn and implement and has no complication or recurrence in the long-term follow-up - may be an ideal method in cases where excision and primary repair is planned, especially in patients with sinus orifices located in the midline.

Three-year follow-up analysis of the short-stitch versus long-stitch technique for elective midline abdominal closure randomized-controlled (ESTOIH) trial

BackgroundClinical trials have shown reduced incisional hernia rates 1 year after elective median laparotomy closure using a short-stitch technique. With hernia development continuing beyond the first postoperative year, we aimed to compare incisional hernias 3 years after midline closure using short or long stitches in patients from the ESTOIH trial.MethodsThe ESTOIH trial was a prospective, multicenter, parallel-group, double-blind, randomized-controlled study of primary elective midline closure. Patients were randomized to fascia closure using a short- or long-stitch technique with a poly-4-hydroxybutyrate-based suture. A predefined 3-year follow-up analysis was performed with the radiological imaging-verified incisional hernia rate as the primary endpoint.ResultsThe 3-year intention-to-treat follow-up cohort consisted of 414 patients (210 short-stitch and 204 long-stitch technique) for analysis. Compared with 1 year postoperatively, incisional hernias increased from 4.83% (20/414 patients) to 9.02% (36/399 patients, p = 0.0183). The difference between the treatment groups at 3 years (short vs. long stitches, 15/198 patients (7.58%) vs. 21/201 (10.45%)) was not significant (OR, 1.4233; 95% CI [0.7112–2.8485]; p = 0.31).ConclusionHernia rates increased significantly between one and 3 years postoperatively. The short-stitch technique using a poly-4-hydroxybutyrate-based suture is safe in the long term, while no significant advantage was found at 3 years postoperatively compared with the standard long-stitch technique.Trial registryNCT01965249, registered on 18 October 2013.

State of the Art: Advances in Hernia Care.

The field of hernia surgery has seen many recent advances and continues to evolve. Care of the hernia patient begins preoperatively by ensuring adequate preparation for surgery with surgeons now having the opportunity to accurately predict risk which can aid with informed consent. Imaging studies can now help surgeons diagnose and plan hernia surgery on an individual level based on hernia characteristics as well as abdominal wall musculature. In the operating room, new technology and surgical techniques have allowed surgeons to become increasingly sophisticated with goals of reducing tension on midline closures, utilizing minimally invasive and robotic techniques, and availability of new and varied mesh prosthetics. While modest improvements in outcomes have been witnessed by these advances, there is still opportunity for improvement which will be realized by continued research, use of registries, and education and training. Hernia prevention strategies focusing on minimally invasive surgery, laparotomy closure, and the use of prophylactic mesh will also help with the burden of incisional hernias. These advances in hernia surgery have led to the new field of Abdominal Core Health which helps represent this evolving and growing new subspecialty of general surgery.

Surgical Treatment of Uncomplicated Pilonidal Sinus with the Simple Closed Technique - New Findings of Pilonidal Sinus Treatment from Albania.

Dear Editor,&#x0D; Concerning the article of Bollano E et al. “Surgical treatment of uncomplicated Pilonidal Sinus with a simple closed technique” has been gathering our attention. In this LTE, we would like to critically discuss some of the author's statements. Firstly, the stated pathophysiology of PSD is an outdated theory. Furthermore, primary midline closure, as postulated by the author, is not the surgical procedure of first choice, as several large reviews have shown.&#x0D; The letter discusses the rationale behind adopting the simple closed technique, highlighting its efficacy and potential advantages. By presenting data from our experiences in Albania, we aim to contribute valuable insights to the global discourse on pilonidal sinus treatment.&#x0D; This letter is a noteworthy addition to AJTES, offering fresh insights into the treatment landscape of pilonidal sinus. We trust the editorial team will find the content aligned with the journal's objectives and scope.&#x0D; Your consideration of this submission is highly appreciated, and we look forward to the possibility of contributing to the journal's ongoing dialogue on innovative surgical approaches.&#x0D;

Investigation of the Effect of Tenoxicam on Neural Tube Defect Using Chick Embryo Model.

To evaluate tenoxicam's effects on embryonic neural tube formation to identify potential teratogenicity and determine the underlying mechanisms leading to neural tube defects (NTDs). This study was conducted at our University's Neuro-embryology Laboratory. A total of 100 fertile chicken eggs were opened using the windowing method after 24 hours of incubation. The embryo models were divided into four groups based on tenoxicam dosage: 0.01, 0.02, 0.10 μg, and control group (0.9% SF was administered). The tenoxicam groups were administered 20 μL volume sub-blastodermally. The eggs were incubated for another 24 hours after being covered with sterile draping. All the eggs were opened at the 48th hour, and the embryos were evaluated. Each group consisted of 25 chicken embryos. Normal neural tube development was observed in Group 1 (0.01μg) with 23 out of 25 embryos, Group 2 (0.02 μg) with 20 out of 25 embryos, Group 3 (0.10μg) with 16 out of 25 embryos, and Group 4 (control group) with 24 out of 25 embryos. Additionally, the rates of absence of embryo development were 8%, 8%, 12%, and 4% in Groups 1, 2, and 3 and the control group, respectively. We observed that tenoxicam use caused midline closure defects in early chicken embryos in a dose-dependent manner. Further studies are required to determine the mechanisms underlying the embryonic damage and teratogenic effects due to genetic and environmental factors and minimize the development of congenital defects.

Impact of anterior component separation technique on lowering the incidence of abdominal wall dehiscence and incisional hernia after emergent laparotomy: a feasibility study

Introduction Abdominal wall dehiscence is one of the critical postoperative complications following abdominal surgeries. Emergency surgery highly contributes to the incidence of a burst abdomen due to a lack of proper preoperative preparation and the presence of intraabdominal sepsis. Anterior component separation was primarily evolved in abdominal wall reconstruction in the open abdomen and huge ventral hernia repair. Methods This prospective study included 50 patients operated by midline laparotomy for non-traumatic abdominal emergencies. Anterior component separation technique was randomly applied in 25 patients before laparotomy closure, the other 25 patients were closed using the traditional midline closure method. Preoperative patient’s demographics, operative time, and different postoperative complications were reported. Incidence of burst abdomen in both groups was reported. Results Preoperative patient’s demographic data showed no significant difference between both groups; the mean age of the patients was 53.69±7.34. Operative time was significantly longer in the Anterior Components Separation (ACS) group (P&lt;0.001). The incidence of abdominal wall dehiscence after ACS technique (4.3%) was significantly less than after traditional technique (24%). Postoperative seroma and hematoma were the common postoperative complications after ACS however the incidence was not statistically significant. Incisional hernia was detected in (13.04%) in ACS group and in (32%) in traditional group. Conclusion Application of ACS technique during laparotomy closure in abdominal emergencies seems to lower the incidence of abdominal wall dehiscence with no increase in different postoperative complications.

Management strategy and outcomes of sacrococcygeal teratoma — an Egyptian multicenter experience

ObjectivesNationwide criteria regarding patients with sacrococcygeal teratoma (SCT) are still lacking in Egypt. We aimed to present a multicenter study regarding the management and outcomes of this tumor to evaluate our national treatment strategy.MethodsA retrospective analysis including all patients with SCT who were managed at four major Egyptian centers between 2013 and 2023. Clinical data, surgical approaches, and short- and long-term outcomes were discussed.ResultsThe study included 95 patients (74 were females). Antenatal diagnosis was reported in 25% of patients. Seventy-one patients (74.7%) were classified as Altman type I/II. Surgery was performed via a perineal approach in 75 patients, whereas the remaining 20 underwent a combined abdominoperineal approach. Vertical elliptical incision with midline closure was conducted in 51.5% of patients, followed by classic or modified chevron incisions. Benign mature teratoma was detected in 82% of patients. At a median follow-up of 57 months, eight patients (8.5%) had relapsed. The 5-year overall survival (OS) and event-free survival (EFS) of all patients were 94% and 91%, respectively. In the after-care monitoring, 19 patients (20%) had urinary or bowel dysfunctions. Nine of them were managed using medications. Clean intermittent catheterization was practiced in another five patients. The remaining five underwent further surgical interventions.ConclusionFavorable outcomes were achieved in our country during the last decade. Diverse perineal incisions were performed for resection, and vertical elliptical with midline closure was the commonest. During follow-up, 20% of patients developed urological or bowel dysfunctions that required medical and surgical treatment modalities to improve their quality of life.

A survey of treatment preferences of UK surgeons in the treatment of pilonidal sinus disease.

Pilonidal sinus is a common surgical condition which impacts a young and economically active population. There are limited data to guide treatment in this condition. The aim of this work was to assess current practice. A survey was developed as part of the PITSTOP study. It included questions on volume of practice, treatment preferences and training. The survey was delivered to consultant surgeons with a UK practice through social media, specialty surgical societies and through PITSTOP sites. Descriptive statistics were reported. Of the 200 people who received a link to the questionnaire, 109 completed it (response rate 54.5%). Respondents treated a median of 15 patients per year, with 20% of these having recurrent disease. Estimates of recurrence were higher than reported in the literature and higher than in a survey 10 years ago. Nearly 50% of surgeons advocate nonsurgical treatment in some patients despite limited evidence. Two thirds practised interventions not favoured by guidelines, including excision and leave open and midline closure techniques. Invasive procedures tended to be favoured when minimally invasive procedures may be appropriate. Surgical training programmes were the key training setting for commonly offered procedures, with few other training opportunities reported. For some procedures, no formal training had been given. This survey highlights issues with quality in pilonidal surgery in the UK, with persistence of potentially outdated techniques, no consistent treatment escalation plan, a suggestion of under- or overtreatment of disease and a high perception of failure. This may relate to the current system of training and lack of evidence-based guidance.

V-046 LIRA (LAPAROSCOPIC INTRACORPOREAL RECTUS APONEUROPLASTY) WITH A MANUAL ROBOTIC LAPAROSCOPIC ARM: TECHNICAL STEPS

Abstract Introduction LIRA (Laparoscopic Intracorporeal Rectus Aponeuroplasty) is a minimally invasive technique for the tension-free repair of incisional hernias from M2 to M4, with low recurrence rate and less postoperative bulging and seroma formation than classic IPOM lap repair. Objective To describe the main steps of the LIRA focusing on the tension-free midline closure. The use of a robotic laparoscopic arm1 improved the surgeon's mobility range and ergonomy, facilitating the procedure. Methods A 42-year-old obese woman (BMI 34 Kg/m2), presented with a recurrent umbilical hernia M3W2, Hernia defect: 6cm.in width, (previous onlay repair with polypropylene mesh in 2020). Access: 3 Trocars at the midaxillary line. Posterior rectus sheaths were divided, and the defect was closed with a running 2/0 barbed suture. Then, the repair was reinforced with a tailored, round-shaped 15 cm. composite mesh2 fixed with a double crown of absorbable tacks3. No drain was used. Results Operating time: 85 minutes. The procedure was performed in an outpatient setting. The postoperative course was uneventful. Follow-up: 9 months. The patient remains asymptomatic and highly satisfied (9/10). No recurrence nor bulging has been observed. Conclusions The LIRA technique allowed a tension-free reconstruction of the abdominal midline when dealing with ventral hernias, without remarkable complications. LIRA provides the advantages of laparoscopic surgery in terms of less postoperative pain, morbidity (e.g. seroma, and less risk of infection), and no bulging. The use of robotized laparoscopic arms facilitates these quite complex procedures.

P-038 BOTULINUM TOXIN IN THE TREATMENT OF COMPLEX ABDOMINAL HERNIAS: A REVIEW OF CLINICAL OUTCOMES

Abstract Aim Adjuvant use of botulinum toxin (BTX), which causes temporary paralysis of the lateral abdominal wall muscles, may have a roll in achieving a functional abdominal wall reconstruction when treating complex hernias, without the need of component separation techniques (CST). Methods Retrospective analysis of all patients with complex hernia between April 2021 and October 2022 in which BTX was used. Patients that would have to go through CST regardless and patients with other adjuvant treatments were excluded. Results 22 patients had BTX, with a total of 13 patients included in this study. The median age was 64 and BMI 30,7kg/m2. The average CT imaging measurement of the transverse defect was 13,7cm. The median of Cedar's calculation was 27%. 7 patients (54%) only needed a Rives Stoppa Wantz (RSW) for midline closure, but 6 patients still needed a CST. The median time of the surgery for the RSW was 233 min and for the CST 330 min. Of the patients submitted to RSW, 1 complicated with a deep incisional infection and 2 CST patients had surgical complications. No recurrences in the RSW group and one hernia persistence after a major complication on the CST group. Conclusion The BTX can have an important role as an adjuvant in the treatment of large incisional hernias and in some patients may allow its repair with a less invasive surgical technique, with less operative time and less complications. More studies are needed in this area.

P-029 USE OF INTRAOPERATIVE FASCIAL TRACTION DEVICE (FASCIOTENS®). INITIAL EXPERIENCE IN A WALL SURGERY UNIT

Abstract Aim We present the use of the Fasciotens-abdomen® fascial traction device for the closure of large eventrations in three patients treated in our department. Material &amp; Methods Description of three cases of large eventration in which we used the Fasciotens-abdomen® device. Results The first patient is a 61-year-old woman with a history of anterior ultra-low rectal resection. She presents an M2-M4W3 10 cm eventration. A Rives eventroplasty was performed with placement of a 25×10cm retromuscular PPL mesh. Fasciotens-abdomen® device was applied with a 14–16 kg load during 25 minutes. The second case is a 45-year-old female patient with a previous umbilical hernioplasty in 2016. She presents an M2-M4W3R1 11 cm eventration. During the eventroplasty, fascial approach with Fasciotens-abdomen® device was performed for 25 minutes/14–16 kg, and a mesh of 22×11 cm was placed onlay. Thirdly, a 60-year-old female patient with a previous eventroplasty in 2015. She presented an M2-M3W3 14 cm eventration. During the Rives eventroplasty, 70 cm of small bowel were resected due to firm adhesions. The closure was performed with retromuscular mesh placement and fascial approximation with Fasciotens-abdomen®, for 25 minutes/14kg. All three patients received an infiltration of 15 IU of botulinum toxin weeks before the reconstruction surgery and were discharged from the hospital uneventflul. Conclusions Large incisional hernias pose a challenge to the surgeon. Adjunctive procedures for abdominal wall reconstruction, like the Fasciotens®fascial traction device, help to achieve tension-free midline closure.

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.

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.

6:1 Suture or Wound length ratio with the short stitch technique – a reality check on practicability and short term outcome

Aim: To analyze laparotomy closure of conventional midline and transverse abdominal incisions in elective and emergency laparotomies with a longterm, absorbent, elastic suture material. Method: Prospective, single centre, non randomised, controlled cohort study on short stitches with a longterm resorbable, elastic suture (material: poly-4-hydroxybutyrate) aiming at a 6:1 suture to wound (SL/WL) length ratio in midline and transverse, primary &amp; secondary laparotomies for elective &amp; emergency surgery. Results: We included 351 patients (♂: 208; ♀: 143), midline (n=194), transverse (n=103) and a combined midline/transverse L-shaped (n=54) incisions. There was no stitch performance quality difference between elective (n=296) and emergency (n=55) operations, while results in the first 150 patients showed a significantly reduced SL/WL-ratio to the following 200 suture closures (SL/WLratio: 5.64±2.5 vs 6.1±2.3, p&lt;0.001). Average SL/WL-ratio in general was better for midline than transverse incision sutures (6.62±2.5 vs 4.3±1.51, p&lt;0.001). SL/WL-ratio varied among the 6 surgeons participating, although results steadily improved and eventually approximated each other. Conclusions: We could show that a 6:1 SL/WL-ratio with a 2-0 single, ultra-long term, absorbent, elastic suture material can be significantly performed better in midline than transverse incisions. Transverse incisions should preferably be closed in 2 layers in order to achieve a sufficient SL/WL-ratio equivalent to the median incision. While on an individual level, results varied between surgeons, quality will improve and eventually approximate.