Midline Fascial Closure Research Articles

Prevention of component separation in complex abdominal wall surgery by Botox prehabilitation: a propensity-matched study.

To facilitate midline fascial closure in complex abdominal wall surgery, component separation techniques (CST) are usually required. However, CST is associated with an enlarged morbidity. Prehabilitation could increase the compliance of the abdominal wall and thereby decrease the necessity of myofascial release. This can be accomplished by administration of botulinum toxin type A (BTA) in the lateral abdominal wall musculature. The aim of this study was to determine the effect of BTA on the subsequent necessity to perform CST in patients with complex abdominal wall hernias. Patients with a complex abdominal wall hernia, planned to undergo CST between July 2020 and November 2022 were included. Outcome of procedures with 300U of BTA 4 (2-6) weeks prior to surgery, were retrospectively analyzed by comparison with propensity matched subjects of an historical group. Hernia width difference was assessed by CT and operative details were included. A total of 13 patients with a median hernia width of 12cm (IQR 9-14, range 24) were prehabilitated with BTA between July 2020 and November 2022. A CST was planned for all, however not required in 6/13 patients (46%) to accomplish midline fascial closure. A mean elongation of lateral abdominal wall musculature of 4.01cm was seen in patients not requiring CST. Compared to the propensity score matched control group, a 27% reduction (p = 0.08) in the need for CST was observed. There is a tendency for decrease of necessity for CST by preoperatively administered BTA in patients with complex abdominal wall defects. Although small, as this study used propensity matched comparison, further exploration of BTA should be encouraged.

V-020 Botulinum Toxin: not just aesthetics anymore

Abstract Introduction Surgical repair of recurrent abdominal incisional hernia can be challenging. The aim should be a tension-free, mesh reinforced midline fascial closure. Different methods have been described to achieve this primary fascial closure. Botulinum toxin (BT) is a neurotoxin that when injected into muscle tissue, causes a temporary flaccid muscle paralysis. This effect can be applied to the lateral abdominal wall muscles, thereby facilitating midline rectus muscles re-approximation and defect closure. Clinical Case We present a case of a 58 year old female, with a history of right hemicolectomy and ileostomy, that underwent subsequent stoma closure one year after. She presented with a 12 cm defect width incisional hernia and right rectus muscle atrophy. We demonstrate the preoperative injection of BT using the Zielinski technique in a consultation room with no need for patient monitoring or anesthesia. Four weeks later, the patient underwent open repair with bilateral transversus abdominis release and retromuscular mesh reinforcement. The defect was closed without tension and the postoperative period was uneventful. Patient was discharged on postoperative day 4. Conclusion Preoperative BT injection as a selective muscle chemical component paralysis is a safe, easy to perform and effective technique that aims to counteract the chronic muscle retraction observed in large ventral hernias. BT in combination with advanced ventral hernia repair techniques, may help provide the crucial extra tissue mobility required to achieve primary closure, with the added advantage of less postoperative pain, thereby contributing to early patient discharge.

The effect on incisional hernia of absorbable barbed suture for midline fascial closure in minimally invasive surgery for colorectal and gastric cancers: study protocol for a randomized controlled trial

BackgroundIncisional hernia following abdominal surgery is a frequent complication of midline laparotomy. This complication is strongly associated with the technique and material used for suture. While a monofilament absorbable suture is recommended to prevent incisional hernia, it can lead to suture loosening or surgical-knot breakage. Although barbed sutures can be an alternative suture material in abdominal fascial closure, evidence for its safety and effectiveness is lacking. Therefore, we designed a prospective randomized trial to evaluate the safety and efficacy of absorbable barbed sutures for midline fascia closure in minimally invasive surgery for colorectal and gastric cancers in comparison with conventional absorbable monofilament sutures.MethodsA total of 312 patients who underwent minimally invasive surgery for colorectal and gastric cancers will be randomly allocated to either the absorbable barbed or monofilament suture group for abdominal fascia closure in a 1:1 ratio. The primary outcome is incisional hernia rate within 3 years after surgery, as verified by physical examination and computed tomography. Postoperative complications, including surgical site infection, postoperative pain, and quality of life, will be compared between two groups as secondary outcomes. The investigator will examine the patients until discharge and at 6, 12, 18, 24, and 36 months postoperatively.DiscussionThis is the first randomized controlled trial to compare absorbable barbed sutures with monofilament sutures for midline fascia closure in minimally invasive surgery. If absorbable barbed sutures demonstrate superior results to those of monofilament sutures, this type of suture material may be recommended as an alternative option for abdominal fascia closure.Trial registrationKCT0007069. Registered on January 30, 2023

Abdominal wall reconstruction using biosynthetic absorbable mesh in high-risk complex ventral hernia.

Biosynthetic mesh may represent an improvement on biological and large pore synthetic meshes for high-risk complex ventral hernia repair. This study aimed to evaluate the performance of polyglycolic acid (PGA):trimethylene carbonate (TMC) biosynthetic mesh for reinforcement of the midline fascial closure in a single-stage repair of complex ventral hernias in high-risk patients. A retrospective review was undertaken for patients who underwent a planned open single-stage complex ventral hernia repair with a single unit of PGA:TMC biosynthetic mesh between May 2013 and August 2017. Data on outcome variables were recorded and quality of life assessed using the Short Form-12 (SF-12) instrument. Overall, 56 patients underwent abdominal wall reconstruction for complex ventral hernias. All meshes were placed in the retrorectus position. Some 39% underwent component separation. The majority of patients (86%, n = 48) had high risk (grade 2 or 3) hernias according to the Ventral Hernia Working Group classification. Overall hernia recurrence rate was 3.6% (n = 2). Postoperative surgical site infection occurred in 26.8% (n = 15). Median follow-up by clinical examination was 6 months (range 4–17). Median telephone follow-up was 21 months (range 4–54). Pre- and post-treatment SF-12 quality of life assessments demonstrated significant improvements in both the physical and mental components. This study reports a large series of abdominal wall reconstructions using biosynthetic mesh in complex ventral hernia. The findings indicate promising early outcome data associated with use of biosynthetic mesh. Larger well-controlled studies with longer follow-up are needed for confirmation of these findings.

The prevention of extraction site incisional hernia after robotic-assisted radical prostatectomy.

Extraction site incisional hernia (IH) has been recognized as an important complication in minimally invasive procedures but has not been as well characterized following robotic-assisted laparoscopic prostatectomy (RALP). Approximately 29% of IH required surgical repair. A number of techniques have been utilized to reduce the rates of IH following minimally invasive procedures. First, off-midline extraction was investigated, this did not demonstrate a reduction in incisional hernia rates. Recently, supra-umbilical transverse incisions have been utilized to extract prostate specimen and this method decreased the extraction site IH rate compared to the vertical midline incision. In addition, the choice of fascial closure technique and choice of the suture may influence the incidence of extraction site IH. For example, studies showed that abdominal fascial closure using a nonabsorbable suture and a continuous running suture technique decreased IH rate from 32 to 17%. Finally, "the small bites technique" has been recommended to reduce hernia incidence after midline fascial closure following a randomized controlled trial (RCT) which demonstrated the superiority of the small-bite technique. In summary, a supra-umbilical transverse incision to extract the specimen was shown to decrease the rate of extraction site IH. In vertical midline incisional closure, the small bites technique with slowly- or non-absorbable suture, such as #0 or 2-0 PDS II with SH or CT-2 needle (26mm arch length), reduces the IH rate. Urologists should consider this data to reduce the risk of IH following RALP.

The worst-case scenario: Bridging repair with a biologic mesh in high-risk patients with very large abdominal wall hernias–a prospective multicenter study

BackgroundWhile modern techniques allow midline fascial closure for most abdominal hernias, a bridge repair with mesh may be the only alternative in very large defects. When the risk of infection is high, the use of prosthetic mesh is controversial. We aim to examine outcomes after bridge repair of very large abdominal hernias at high risk for postoperative infection with a second-generation biologic mesh. MethodsProspective, multicenter, single-arm study of patients with very large abdominal hernias who received bridge repair with a neonatal bovine dermis mesh. Primary outcome was hernia recurrence, as identified on computed tomography 1 year after the operation. Secondary outcomes included mesh laxity, surgical site occurrences, and any other mesh-related complications. Independent risk factors of the outcomes were determined by univariate and multivariable analyses. ResultsA total of 117 bridge repair patients were enrolled with a mean defect size of 442.5 ± 254.2 cm2. The patients were predominantly obese (mean body mass index 36.5 ± 10.5) and with multiple comorbidities (Charlson comorbidity index 3 ± 2.5). Hernia recurrence was identified in 24 (20.5%) patients. An infected mesh at the index operation was an independent predictor of hernia recurrence, whereas obesity was an independent predictor of the pooled endpoint of recurrence and mesh laxity. Surgical site occurrences were recorded in 36.8% of the patients, and no independent risk factors were identified. ConclusionIn patients with very large abdominal hernias and at high risk for postoperative infection, who cannot undergo midline fascial closure, a bridge repair with neonatal bovine dermis mesh offers an acceptable profile in terms of hernia recurrence and wound occurrences.

Interrupted Midline Fascial Closure to Prevent Burst Abdomen in Emergency Laparotomy: Comparison between Continuous and Interrupted closure

Burst abdomen represents one of the most frustrating and difficult postoperative complication that concerns every abdominal surgeon. It occurs because of various predisposing factors which can be prevented to some extend by having knowledge regarding them. Despite many years of experience, the optimal technique of laparotomy closure remains controversial. The varieties of surgical excess as well as the varieties of abdominal closure techniques are the main difficulties in the proper standardization of this procedure. In this paper a randomized prospective study was designed to compare with a interrupted and continuous technique for closing a midline abdominal fascia in emergency laparotomy. A total of 300 patients of acute abdominal condition who underwent laparotomy were randomized into two groups of 150 patients in each group. Total 22(7.33%) of 300 patients developed burst in the postoperative period. Fourteen (14) (9.33%) in continuous arms and eight (08) (5.33%) patients in interrupted arms developed burst. Burst abdomen occurring mostly 40-60 years age group with a male to female ratio of 1.68: 1. Cough, anemia, malnutrition, DM, intraperitoneal sepsis, wound infection, uremia and abdominal distension were the important predisposing factors for the incidence of burst abdomen. Interrupted suturing was associated with significantly reduced the burst abdomen when comparing with continuous closure.TAJ 2017; 30(2): 69-75

Prophylactic Retention Sutures in Midline Laparotomy in High-Risk Patients for Wound Dehiscence: a Randomised Prospective Case Control Study

Abdominal wound dehiscence (AWD) is one of the most notorious complication after laparotomy and associated with high morbidity and mortality. The retention suture is used in the re-operated cases of wound dehiscence to reduce the disruption of fascia. To study the effect of prophylactic retention sutures in patients with high risk for wound dehiscence who underwent midline laparotomy. Random selection of 200 midline laparotomy cases was done divided into two groups. In the one group (Cases- group A) Conventional mass closure of midline fascial wound closure with incorporation of prophylactic retention sutures. In other group (Control group - group B) midline line fascial closure by conventional mass closure without incorporation of prophylactic retention sutures. Comparison of both the techniques regarding preoperative status and postoperative complication such as incisional hernia, wound dehiscence and chronic wound pain was done according to clinical examination and recorded in the pro forma prepared. Incorporation of prophylactic retention sutures reduce the occurrence of WD following midline laparotomy in high-risk patients with multiple risk factors for impaired wound healing without imposing remarkable post-operative complications.

Initial UK experience with transversus abdominis muscle release for posterior components separation in abdominal wall reconstruction of large or complex ventral hernias: a combined approach by general and plastic surgeons.

Introduction Large, complicated ventral hernias are an increasingly common problem. The transversus abdominis muscle release (TAMR) is a recently described modification of posterior components separation for repair of such hernias. We describe our initial experience with TAMR and sublay mesh to facilitate abdominal wall reconstruction. Methods The study is a retrospective review of patients undergoing TAMR performed synchronously by gastrointestinal and plastic surgeons. Results Twelve consecutive patients had their ventral hernias repaired using the TAMR technique from June 2013 to June 2014. Median body mass index was 30.8kg/m2 (range 19.0-34.4kg/m2). Four had a previous ventral hernia repair. Three had previous laparostomies. Four had previous stomas and three had stomas created at the time of the abdominal wall reconstruction. Average transverse distance between the recti was 13cm (3-20cm). Median operative time was 383 minutes (150-550 minutes) and mesh size was 950cm2 (532-2400cm2). Primary midline fascial closure was possible in all cases, with no bridging. Median length of hospital stay was 7.5 days (4-17 days). Three developed minor abdominal wall wound complications. At median review of 24 months (18-37 months), there have been no significant wound problems, mesh infections or explants, and none has developed recurrence of their midline ventral hernia. Visual analogue scales revealed high patient satisfaction levels overall and with their final aesthetic appearance. Conclusions We believe that TAMR offers significant advantages over other forms of components separation in this patient group. The technique can be adopted successfully in UK practice and combined gastrointestinal and plastic surgeon operating yields good results.

PWE-410 Initial UK experience with transversus abdominus muscle release for posterior components separation in abdominal wall reconstruction of large or complex ventral hernias. a combined approach by general and plastic surgeons

Introduction Large complicated ventral hernias are an increasingly common problem following laparotomy and particularly laparostomy. Moreover, they are often seen in patients with significant co-morbidities who may have or need to have stomas. Repair with bridging is associated with high recurrence rates and makes surgical risk unattractive. The transversus abdominis muscle release (TAMR) is a recently described modification of posterior components separation for repair of such hernias. We describe our initial experience with TAMR and sublay mesh to facilitate abdominal wall reconstruction. Method A retrospective review of consecutive patients undergoing TAMR performed synchronously by colorectal and plastic surgeons since June 2013. Results Twelve consecutive patients had their ventral hernias repaired using the TAMR technique from June 2013 to June 2014. Median body mass index was 30.8 kg/m 2 (range 19.0–34.4 kg/m 2 ). Four had a previous ventral hernia repair. Three had previous laparostomies. Four had previous stomas and three had stomas created at the time of the abdominal wall reconstruction. Average and range of transverse distance between the recti was 13 cm (3–20 cm). Median operative time was 383 min (range 150–550 min), and mesh size was 950 cm 2 (532–2400 cm 2 ). Primary midline fascial closure was possible in all cases with no bridging. Median length of hospital stay was 7.5 days (4–17 days). Three developed minor abdominal wall wound complications. At short-term review (median 3.5 months), there have been no significant wound problems, no mesh infections or explants and none have developed recurrence of their ventral hernia. Conclusion We believe TAMR offers significant advantages over other forms of components separation in this patient group. The technique can be adopted successfully in UK practice and combined gastrointestinal and plastic surgeon operating yields good early results. Disclosure of interest None Declared.

PREBIOUS trial: A multicenter randomized controlled trial of PREventive midline laparotomy closure with a BIOabsorbable mesh for the prevention of incisional hernia: Rationale and design

BackgroundDevelopment of an incisional hernia is one of the most frequent complications of midline laparotomies requiring reoperation. This paper presents the rationale, design, and study protocol for a randomized controlled trial, the aim of which is to evaluate the efficacy and safety of prophylactically placing a bioabsorbable synthetic mesh for reinforcement of a midline fascial closure. MethodsThe PREBIOUS trial (PREventive midline laparotomy closure with a BIOabsorbable mesh) is a multicenter randomized controlled trial in which adult patients undergoing elective or urgent open abdominal operations through a midline laparotomy incision are assigned to one of two groups based on the laparotomy closure procedure: an intervention group in which a continuous polydioxanone (PDS) suture is reinforced with a commercially available GORE® BIO-A® Tissue Reinforcement prosthesis (W.L. Gore & Associates, Flagstaff, AZ, USA), or a control group with continuous PDS suture only. Both groups are followed over 6months. OutcomesThe primary outcome is the appearance of incisional hernias assessed by physical examination at clinical visits and radiologically (CT scan) performed at the end of follow-up. Secondary outcomes are the rate of complications, mainly infection, hematoma, burst abdomen, pain, and reoperation. The PREBIOUS trial has the potential to demonstrate that suture plus prosthetic mesh insertion for routine midline laparotomy closure is effective in preventing incisional hernias after open abdominal surgery, to avoid the effects on those affected, such as poor cosmesis, social embarrassment, or impaired quality of life, and to save costs potentially associated with incisional hernia surgical repair.

Improved Outcomes in the Management of High‐Risk Incisional Hernias Utilizing Biological Mesh and Soft‐Tissue Reconstruction: A Single Center Experience

Repair of incisional hernias is complex in the setting of previous/current infection, loss of domain and bowel involvement, and is often on the background of significant co-morbidities. Reported repair techniques are associated with significant morbidity and led our unit to develop a novel technique for complex incisional hernia repair. A retrospective case notes review of all high-risk (Ventral Hernia Working Group grade 2-4) incisional hernia repairs was undertaken. Standardized repair involved resection of attenuated soft tissue and hernia sac (bioburden reduction), component separation (where necessary), intra-peritoneal Strattice™ biological mesh insertion, midline fascial closure, and soft-tissue reconstruction, performed in combination with a plastic surgeon as a single-stage procedure. A total of 58 patients underwent hernia repair between February 2009 and September 2012 (median age 59 years; 59 % female). Eleven patients (19 %) were grade 4, 19 (33 %) were grade 3, and 28 (48 %) were grade 2. Nineteen (33 %) were recurrent hernias, and midline fascial closure was achieved in 52 (90 %). Early complications included 15 (26 %) surgical-site occurrences, three (5 %) respiratory complications, two (3 %) cardiac complications, and two (3 %) urinary tract infections. Follow-up has revealed three (5 %) asymptomatic hernia recurrences and no patients requiring mesh explantation. This technique was associated with a low risk of surgical site occurrences and hernia recurrence, with no requirements for mesh explantation. Repair of such complex incisional hernias remains challenging, and further randomized controlled trials are required to elucidate the optimal method of closure and mesh type.

Evolution of Abdominal Wall Reconstruction

Ventral hernia repair (VHR) continues to evolve and now frequently includes some form of component separation (CS) for large defects. To determine the optimal technique for VHR, we evaluated our outcomes before and after we refined and simplified our algorithm for repair. One hundred five consecutive patients undergoing VHR for large midline hernias over 9 years were examined. Patients were divided into those operated on after (group 1) and before (group 2) the institution of our simplified algorithm. Our algorithm emphasizes careful patient selection and a stepwise approach including, but not limited to, bilateral CS if appropriate, preservation of large perforators, retrorectus mesh placement as appropriate, linea alba or midline fascial closure, and vertical panniculectomy. Primary outcomes evaluated included wound infection, dehiscence, and hernia recurrence. Seventy-eight (74.3%) patients underwent repair using our algorithm (group 1), whereas 27 (25.7%) underwent repair before utilization of this algorithm (group 2). Ninety-eight (93.3%) underwent CS, whereas 7 (6.7%) underwent another form of VHR. There was no significant difference in patient age or defect size. The mean follow-up period in days for patients in group 1 and group 2 were 184.02 and 526.06, respectively (P < 0.001). Hernia recurrence in group 1 was 2.6% versus 29.6% in group 2 (P < 0.001). The incidence of wound infection in group 1 was 10.3%, whereas that in group 2 was 33.3% (P < 0.001). The rate of wound dehiscence in group 1 was 17.9% versus 25.9% in group 2 (P < 0.001). Simplifying and unifying our algorithm for VHR, notably with utilization of CS, has yielded improved results. Recurrence and wound healing complications using this approach are favorable compared with published outcomes.

Are Commercial Negative Pressure Systems Worth the Cost in Open Abdomen Management?

A commercial negative pressure product is compared with the Barker technique (sterile x-ray cassette cover, lap pads, adhesive drape with negative pressure) for temporary abdominal closure in open abdomen management. We performed a retrospective review of 37 open abdomen patients who had temporary abdominal closure with a commercial negative pressure device (ABThera, KCI) from 2010 to 2011. These patients were compared with the most recent 37 patients having open abdomen management using the Barker technique from 2009 to 2010. Patient demographics, body mass index (BMI), preoperative albumin, indication for open abdomen management, number of operations, use of sequential closure, and success with closure were analyzed. Patients were compared using chi square, t-test, and logistic regression analysis with significance of p < 0.05. Mean age and BMI were significantly higher in the ABThera patients. No statistically significant differences were seen in male:female ratio, indication for open abdomen management, preoperative albumin, number of operations, and use of sequential closure. In 33 patients (89%) ultimate midline fascial closure was achieved with the ABThera vs in 22 patients (59%) using the Barker technique (p < 0.05). Logistic regression analysis was performed on the 3 significant variables identified on bivariate analysis. Only the type of temporary abdominal closure proved significant, with an odds ratio of 7.97 favoring ABThera (95% CI 1.98 to 32.00). A commercially available negative pressure device for temporary abdominal closure had significantly greater success with ultimate closure after open abdomen management compared with the Barker technique. The added cost of the device is offset by improved patient results and savings from successful closure.

Abdominal wall reconstruction: a case series of ventral hernia repair using the component separation technique with biologic mesh

BackgroundSixty-eight consecutive patients from October 2008 until February 2012 were selected for this retrospective review. MethodsA midline fascial closure with component separation was completed using biologic mesh onlay in all cases. Recurrence rates of the hernias, complication rates, patient satisfaction, and time to return to work/normal activities were investigated. ResultsThe recurrence rate was 1.5% (n = 65) with ongoing follow-ups (mean = 20 months). The average age was 57 years, and the average body mass index was 36 kg/m2 (range 22 to 60). The average hernia defect was 20 cm (range 12 to 26) transversely. Wound infection and/or breakdown occurred in 32%, and seroma formation occurred in 9% of patients. Patient satisfaction was 3.63 of 4. The average time to return to work/normal activities was 16 weeks (range 1 to 76 weeks). ConclusionsLarge complex ventral hernias can be reliably repaired using the component separation technique. The short-term recurrence rate is significantly reduced in this case series using a biologic mesh onlay.

Study of two techniques for midline laparotomy fascial wound closure.

To study the results of two techniques, simple interrupted closure and continuous with intermittent Aberdeen knot technique for midline laparotomy fascial wound closure. A random selection of 200 midline laparotomy cases was done. In one group (group A) of 100 cases, midline fascial wound closure was done with continuous sutures with intermittent Aberdeen knot technique using Prolene No. 1 suture material. In the other group (group B) of 100 cases, closure was done with the technique of simple interrupted sutures with Prolene No.1 suture material. Comparison of both the techniques regarding preoperative status and postoperative complication such as incisional hernia, wound dehiscence, suture sinus formation, stitch granuloma, and chronic wound pain was done according to clinical examination and recorded in the pro forma prepared. In group A, postoperative complications were incisional hernia 3%, wound dehiscence 4%, and suture sinus formation 1%. In group B, postoperative complication were incisional hernia 5%, wound dehiscence 4%, and suture sinus formation 1%. All these complications were statistically insignificant, in both group comparisons. While the complication such as stitch granuloma 3%, chronic wound pain 3%, and wound infection 4% in group A was significantly less than in group B where the complication of stitch granuloma was 12%, chronic wound pain 13%, and wound infection 13% (P value 0.03, P value 0.018, and P value 0.048, respectively). Both the techniques, simple interrupted suture closure and continuous with intermittent Aberdeen knot closure for midline laparotomy fascial wounds, show a similar rate of postoperative complication such as incisional hernia, wound dehiscence, and suture sinus formation. But the continuous suturing with intermittent Aberdeen knot technique is a better option to prevent complications such as stitch granuloma, chronic wound pain, and wound infection, which are higher in the simple interrupted fascial wound closure technique.

Abdominal Wall Reconstruction

To determine the efficacy and describe the evolution of the "components separation" technique for abdominal wall repair in 200 consecutive patients. Retrospective medical record review. Northwestern Memorial Hospital, Chicago, Illinois. Two hundred consecutive patients who underwent ventral hernia repair using the components separation technique. Biological and permanent meshes were used in select patients to augment the repair of the midline fascial closure but were not used as "bridging" materials. Hernia recurrence rates and major and minor complication rates for the overall series and for the different techniques. Primary components separation (n = 158) yielded a 22.8% recurrence rate. Closure of the midline tissues with augmentation of the repair using an acellular cadaveric dermis underlay (n = 18) had a 33.3% recurrence rate requiring a second operation, whereas intra-abdominal soft polypropylene mesh (n = 18) had 0% recurrence (P = .04). Elevated body mass index was a significant risk factor predicting hernia recurrence (P = .003). Contamination (P = .04) and enterocutaneous fistula (P = .02) at the time of surgery were associated with increased major complications, whereas body mass index (P = .01) and diabetes mellitus (P = .04) were associated with increased minor complications. Large complex hernias can be reliably repaired using the components separation technique despite the presence of open wounds, the need for bowel surgery, and numerous comorbidities. The long-term strength of the hernia repair is not augmented by acellular cadaveric dermis but seems to be improved with soft polypropylene mesh.

Wound closure technique and acute wound complications in gastric surgery for morbid obesity: a prospective randomized trial

Background: During the past 10 years, numerous clinical studies have supported the use of continuous monofilament fascial closure after laparotomy. Because of the increased incidence of surgical-site infections and other acute wound complications in the morbidly obese, these patients are well suited for a study of technical factors that may affect the frequency of these wound complications. Study Design: A prospective, randomized study of the midline fascial closure technique in gastric bariatric operations was conducted between 1991 and 1998 in 331 consecutive morbidly obese patients. At the time of closure of the upper midline laparotomy wound, the patients were randomized into two groups: Group I patients (n = 172) underwent continuous fascial closure and group II patients (n = 159) underwent interrupted fascial closure. All patients received prophylactic antibiotics in a similar fashion. Wounds were monitored for 30 days postoperatively, and acute wound complications were classified as superficial or deep. Superficial complications included superficial surgical-site infections, seromas, and hematomas. In all superficial complications, the fascia remained uninvolved and intact. Deep wound complications included deep surgical-site infections and fascial dehiscence. Results: A total of 49 acute wound complications occurred (15%). There were 22 superficial (7%) and 27 deep (8%) wound complications in the 331 in the patients studied. Group I patients experienced fewer total wound complications than group II patients (18 versus 31; p = 0.021). Group I patients also experienced fewer deep wound complications than group II (5 versus 22; p = 0.003). Conclusions: Continuous fascial closure reduces major acute wound complications in morbidly obese patients undergoing gastric operations for obesity.

Prospective, randomized evaluation of midline fascial closure in gastric bariatric operations

Severe obesity is cited as a major risk factor for fascial wound dehisence and late incisional hernia after major abdominal surgery. The purpose of this study was to prospectively compare two methods of closure of the linea alba after gastric restrictive operations performed for treatment of morbid obesity. During a 6-year period 229 patients were randomized to have closure of the midline fascia using either a double-stranded #1 PDS suture placed in a continuous fashion or #1 Ethibond suture placed using an interrupted figure-eight technique. Two of 109 patients who had closure with Ethibond suffered an acute dehiscence of the midline fascia vs no cases of fascial dehiscence in the PDS group. There were no wound infections in either group. There were 20 late incisional hernias (18%) in the Ethibond group vs 11 late hernias (10%) in the PDS group (P < or = 0.04). Mean postoperative follow-up time for all patients was 29.4 months. The cost of suture material and the time required to completely close the linea alba were also calculated for each group. The mean closure time in the Ethibond group was 13.3 vs 9.1 minutes in the PDS group (P < 0.0001). Although the cost per suture pack of #1 PDS was $4.63 vs $1.76 per pack for #1 Ethibond, the mean cost of sutures per patient was $4.81 for PDS vs $11.09 for Ethibond. We conclude that #1 PDS placed in a continuous fashion provides a more secure and cost-effective closure of the midline fascia in morbidly obese patients than #1 Ethibond placed using an interrupted figure-eight technique.