Abdominal Wall Closure Techniques Research Articles

A study to compare abdominal wall closure with interrupted vs. continuous sutures using polydioxanone in patients undergoing emergency exploratory laparotomy

Background: Wound closure in emergency surgeries can be done either by interrupted or by continuous sutures with each having its own advantages and disadvantages. In this paper we shall try to compare the advantages and adverse effects of both these methods of wound closure. Methods: A prospective comparative study involving 50 patients undergoing emergency laparotomies was conducted in Department of General Surgery, MMIMSR, Mullana from October 2022 to April 2024 (18 months). We compared two abdominal wall closure techniques using polydioxanone (PDS), patients, aged 18-75 years, were alternatively assigned to one of two groups: Group I received interrupted PDS sutures, while Group II received continuous PDS sutures. Postoperatively, pain and complications like infections were observed and analysed statistically. Results: In our study, we compared abdominal wall closure techniques in emergency exploratory laparotomy patients. The mean age was similar in the two groups, 43.68 years vs 43.08 years respectively in group I and II. Wound infection occurred in 44% of patients in the interrupted suture group and 60% in the continuous suture group, with a significant difference favouring the interrupted method. The mean wound closure time (33.24 vs 18.32 minutes) and post operative pain were more in the interrupted suture group as compared to the continuous suture group. Conclusions: The interrupted suturing method proved to be more effective in preventing complications, it did require more time to perform. However, after thoroughly reviewing the available data, no definitive evidence was found to support the superiority of either techniques.

Comparison of continuous versus modified continuous SMEAD jones “far-near-near-far” suturing technique for abdominal wall closure in emergency midline laparotomy wound in terms of wound dehiscence.

Objective: To compares the frequency of wound dehiscence in emergency midline laparotomy wound closure using the modified continuous Smead-Jones technique to the continuous method. Study Design: Randomized Controlled Trial. Setting: Department of Surgery, Allied Hospital Faisalabad. Period: December 20, 2022, to June 20, 2023. Methods: Every one of the one hundred patients having an emergency exploratory laparotomy gave written informed consent. They were split into two groups at random: Group A received continuous closure using prolene #01 suture bites placed 1 cm from the margin and 1 cm apart, and Group B received a modified Smead-Jones technique where suture bites were taken 1.5 cm from the wound margin and 0.5 cm linea alba on either side with prolene # 01 with suture placed 2cm apart. Wound dehiscence was checked following operational definitions. Results: The study's mean age was determined to be 40.18+13.53 years for Group A and 41.18+13.33 years for Group B. Males made up 58.0% (n = 29) of Group A and 72.0% (n = 36) of Group B, while females made up 42.0% (n = 21) of Group A and 28% (n = 14) of Group B. The mean wound dehiscence was 28% in Group B and 10% in Group 2. The p-value for this study was 0.022. Conclusion: When compared to the traditional continuous abdominal wound closure technique, the wound dehiscence rate was significantly lower with the modified continuous smead-jones abdominal wound closure method.

Advances and Techniques in Subcuticular Suturing for Abdominal Wall Closure: A Comprehensive Review.

Subcuticular suturing has emerged as a prominent technique for abdominal wall closure, offering notable benefits in cosmetic outcomes, infection reduction, and patient satisfaction. This comprehensive review delves into the evolution and current state of subcuticular suturing, examining its principles, techniques, and advancements. Traditional methods like continuous and interrupted suturing are compared with modern innovations like barbed sutures and knotless techniques. Clinical outcomes, including healing efficacy, complication rates, and cost-effectiveness, are analyzed to highlight the technique's advantages. The review also explores specific applications in various surgical specialities, presenting case studies and clinical trials to substantiate its effectiveness. Despite certain challenges and limitations, the future of subcuticular suturing appears promising with ongoing research and technological advancements. This review aims to thoroughly understand subcuticular suturing, emphasizing its significance in improving surgical outcomes and patient care in abdominal wall closure.

A SYSTEMATIC REVIEW AND META-REGRESSION OF FACTORS AFFECTING INCISIONAL HERNIA RATES IN MIDLINE INCISIONS OVER A 10-YEAR PERIOD

Abstract Aims The Incisional hernia (IH) rate after midline incisions was reported to be 12.8% in a systematic review of literature published in 2015. With updated guidance on abdominal wall closure techniques, the landscape of abdominal wall closure has changed. We aimed to update this literature to assess any change in the rates and any new identifiable risk factors for IH in midline incisions. Methods We undertook a systematic review of literature according to PRISMA guidelines and registered on PROSPERO. All papers reporting IH rates in midline incisions with primary suture closure between April 2013 — October 2022 were included. Papers with two or more arms suitable for inclusion were extracted independently. Results Sixty three papers (21 RCTs, 36 cohort studies and 6 case-control studies), comprising 18,126 patients were included. The mean IH rate was 16.8% at a weighted mean follow up of 31.3 months. Meta-regression identified two study level variables that correlated with an increase in IH rates (Use of radiology for diagnosis of IH and inclusion of patients undergoing a contaminated procedure) and one operative variable that corresponded with a decrease in rates (Small bites closure technique). Conclusions The Incisional hernia rate in midline incisions reported in the literature have increased over the last decade. A change in detection method and an increase in patient complexity may account for the majority of risk, suggesting standardisation of trial technique is essential in IH prevention trials. Small bites technique is associated with a significant reduction in IH rates, and future work should focus on strengthening the evidence base around this technique.

Anterior component separation technique for abdominal wall closure among patients undergoing colorectal surgery: Short-term outcomes and initial experience

IntroductionThe anterior component separation (ACS) is a technique used for abdominal wall closure performed by dissecting and medially advancing the musculature to achieve tension-free closure. Methodsand Materials:This study reviewed our experience with this procedure as used for complex abdominal wall defects encountered during colorectal surgery in a 7-year period. ResultsSixteen patients were included, with 12 having malignancies and the rest for infectious or inflammatory conditions. Defects ranged from 16–400 cm2 and were mostly located at the midline (56%, n = 9). Five cases required additional flaps for closure, attributed either to the size or area of abdominal involvement where benefits of component separation is more limited. Complications include surgical site infection (n = 4), hematoma (n = 2), seroma (n = 1), and wound dehiscence (n = 2). None required ICU admission or assisted ventilation post-operatively. One patient died who had a preexisting cardiac pathology, and the rest were discharged improved. ConclusionThis study demonstrates use of this modality for autologous reconstruction of complex appropriately sized abdominal wall defects from multiple etiologies. Adjunct flaps may be used to achieve reconstruction particularly in areas wherein the effectiveness of ACS is limited. While the study is able to describe immediate outcomes, long-term follow-up is recommended.

Continuous versus interrupted abdominal wall closure after emergency midline laparotomy: CONTINT: a randomized controlled trial [NCT00544583

BackgroundHigh-level evidence regarding the technique of abdominal wall closure for patients undergoing emergency midline laparotomy is sparse. Therefore, we conducted a randomized controlled trial (RCT) to evaluate the efficacy and safety of two commonly applied abdominal wall closure strategies after primary emergency midline laparotomy.Methods/designCONTINT was a multi-center pragmatic open-label exploratory randomized controlled parallel trial. Two different abdominal wall closure strategies in patients undergoing primary midline laparotomy for an emergency surgical intervention with a suspected septic focus in the abdominal cavity were compared: the continuous, all-layer suture and the interrupted suture technique. The primary composite endpoint was burst abdomen within 30 days after surgery or incisional hernia within 12 months. As reliable data on this composite primary endpoint were not available for patients undergoing emergency surgery, it was planned to initially recruit 80 patients and conduct an interim analysis after these had completed the 12 months follow-up.ResultsFrom August 31, 2009, to June 28, 2012, 124 patients were randomized of whom 119 underwent surgery and were analyzed according to the intention-to-treat (ITT) principal. The primary composite endpoint did not differ between the continuous suture (C: 27.1%) and the interrupted suture group (I: 30.0%). None of the individual components of the primary endpoint (reoperation due to burst abdomen after 30 days (C: 13.5%, I: 15.1%) and reoperation due to incisional hernia (C: 3.0%, I:11.1%)) differed between groups. Time needed for fascial closure was longer in the interrupted suture group (C: 12.8 ± 4.5 min, I: 17.4 ± 6.1 min). BMI was associated with burst abdomen during the first 30 days with an OR of 1.17 (95% CI 1.04–1.32).ConclusionThis RCT showed no difference between continuous suture with slowly absorbable suture versus interrupted rapidly absorbable sutures after primary emergency midline laparotomy in rates of postoperative burst abdomen and incisional hernia after one year. However, the trial was stopped after the interim analysis due to futility as there was no chance to show superiority of one suture technique.

Reconstruction following full-thickness excision of abdominal wall tumors: A prospective observational study conducted in a tertiary care Government Hospital in Eastern India

Background: Reconstruction of abdominal wall defects following full-thickness excision of large tumors (primary or metastatic) has always been a challenge for the treating surgeon. A number of reconstructive techniques have been described in the literature, including different types of meshes, flaps, and component separation techniques (anterior and amp; posterior), with varying results. We conducted a prospective observational study of our three-layer technique of abdominal wall closure at Medical College Hospital, Kolkata, to assess the long-time success of the procedure, especially in terms of hernia rates. Aims and Objectives: Reconstruction of abdominal wall defects following full-thickness excision of large tumors (primary or metastatic) has challenged surgeons for long, with several reconstructive techniques being described, with varying results. We conducted a prospective observational study of our three-layer technique of abdominal wall closure at Medical College Hospital, Kolkata, to assess the long-time success of our procedure, especially in terms of hernia rates. Materials and Methods: Thirteen patients with abdominal wall primary and isolated metastatic tumors were included from January 2017 to January 2022 with follow-up period from 8 to 60 months. Tumors were dermatofibrosarcoma protuberans, sarcomas, desmoid tumors, and two abdominal wall metastases. All patients in our study underwent computed tomography scan, core needle biopsy, and immunohistochemistry for better surgical planning. Results: Eight patients were male and five were female with mean age of 39 years and mean defect size of 10 cm. Polypropylene mesh was used, size varying from 15×15 to 30×30 cm with average operative time of 210 min. Post-operative superficial wound infection in 2 (15%), partial flap necrosis in 1 (7.6%), and tumor recurrence in one patient (7.6%) were seen. Conclusion: For closure of such large abdominal wall defects, our three-layer reconstructive technique has shown good results in terms of zero hernia rates. We recommend our method of closure, where affordability of biological meshes, availability of expensive meshes, accessibility to plastic and reconstructive surgeons or non-acquaintance with complex closure techniques are present.

P-111 TAR (TRANSVERSUS ABDOMINIS MUSCLE RELEASE) AS AN ALTERNATIVE IN PATIENTS WITH INCISIONAL HERNIA AND COMPLEX ABDOMINAL WALL. ANALYSIS OF OUR EXPERIENCE

Abstract Aim To analyze the results of patients with complex abdominal wall surgery using TAR(transversus abdominis muscle release) technique in our center. Material and Methods An observational, descriptive, retrospective study of patients operated using TAR technique in a second level hospital in the last three years was carried out. Demographic variables, classification of incisional hernias according to the EHS(European Hernia Society), and complications after the intervention were recorded. Statistical analysis was performed with IBMSPSS-Statistics-25. Results 13 patients were operated using TAR. Medium age was 56 years. 54% of patients were men and 46% women. Median BMI was 30. According to the EHS classification, the most frequent incisional hernia was M3(84.6%), followed by M4(61.5%) and M2(53.8%). W2(61.5%) and W3(30.8%). Median distance between the rectus in the CT prior the intervention was 85 mm. 100% had median laparotomy. 53.8% subcostal or stomal incision. 46% of the patients suffered some type of complication, 38.5% surgical. The complications were wound dehiscence secondary to skin necrosis(23%), abscess(15%), mesh infection(7%), hematoma(7%). Recurrence(7%). Subcostal or other laparotomy showed higher risk of complications of any type(p 0,048). Distance between rectums was associated with high risk of skin necrosis and wound dehiscence(p 0,015). No ileus, UTI, pneumonia, stroke or DVT. Conclusions TAR is a technique used in complex abdominal wall with good results in relation to closure of hernia defect. However, in our cohort some postoperative complications were observed with a low rate of hernia recurrence. This highlights the effectiveness of TAR as a technique for complex abdominal wall closure.

P-032 FASCIOTENS: FIRST CASE IN THE HOSPITAL OF MéRIDA

Abstract Aim Anterior abdominal wall incisional hernias are a problem present in approximately 11–20% of patients undergoing laparotomy. Incisional hernias with loss of right of abode are associated with many physical, physiological and psychological problems. In order to surgically repair these incisional hernias with loss of right of abode, we need to perform a prehabilitation of the incisional hernias. Effective prehabilitation is required in order to close the aponeurotic defect without tension and to return the hernial contents to the abdominal cavity. Material and methods A 59-year-old female patient with a history of open cholecystectomy and incisional hernia repaired on three occasions, presenting with multisaccular midline incisional hernia (M1-M4 W3) containing colon and greater omentum. Results After application of botulinum toxin and Fasciotens, it is possible to perform Rives-Stoppa retrorectus repair, being able to reduce the hernial content without tension and without increasing intra-abdominal pressure. Conclusions Prehabilitation in complex abdominal wall surgery is essential to repair large aponeurotic defects without tension. In addition, the application of Fasciotens after administration of botulinum toxin allows closure of the aponeurotic defect using standard abdominal wall closure techniques.

Comparison of post-operative pain in short versus long stitch technique for abdominal wall closure after elective laparotomy: a double-blind randomized controlled trial.

Conventional mass closure uses suture-to-wound length ratio of 4:1 ('long stitch', LS). 'Short stitch' (SS) has a suture-to-wound length ratio of more than 4 and incorporates only the linea alba, which may reduce tension and pain. We compared the post-operative pain after laparotomy closure using LS and SS. Patients undergoing elective midline laparotomy through standardized incisions in two tertiary hospitals from February 2017 to September 2018 were randomized to either LS or SS. The primary outcome was post-operative patient-controlled analgesia morphine usage at 24 h. Secondary outcomes were presence of surgical site infection and length of hospital stay (LOHS). Categorical variables were analysed using chi-squared analysis. Outcomes of study were tested for normal distribution. Skewed data were analysed using Mann-Whitney U-test. Eighty-six patients were recruited (42 SS and 44 LS). The median age was 66 (interquartile range (IQR) 15). Majority were males (62.8%) and Chinese (50%). The median incision length was 17 cm in both groups. The median patient-controlled analgesia morphine usage 24 h post-operatively did not differ significantly (SS 21 mg, IQR 28.3; LS 18.5 mg, IQR 33.8, P=0.829). The median pain score at rest (SS 1, IQR 1; LS 1, IQR 2, P=0.426) and movement (SS 3, IQR 1; LS 3, IQR 2, P=0.307) did not differ significantly. LOHS was shorter in the SS group (SS 6, IQR 4; LS 8, IQR 5, P=0.034). The rate of surgical site infection trended lower in the SS group with no statistical difference. There were no differences in post-operative pain between SS and LS but we found that there were shorter LOHS in SS arm as secondary outcome.

Variation in abdominal wall closure techniques in lower transverse incisions: a nationwide survey across specialties.

Lower transverse abdominal incisions are typically used by obstetricians/gynecologists and colorectal surgeons. The suture technique and choice of material when closing the abdomen is an essential factor to decrease the risk of incisional hernia. We conducted a nationwide survey among obstetricians/gynecologists and colorectal surgeons investigating the surgical handling of the fascia, rectus muscle, subcutis, peritoneum, and skin, in lower transverse incisions. All departments of obstetrics/gynecology and departments of surgery performing colorectal surgery in Denmark were invited to participate. An online questionnaire was sent to consultant obstetricians/gynecologists and colorectal surgeons. The survey consisted of demographic information together with questions on surgical details. The study was reported according to STROBE guidelines. A total of 252 (64.5%) consultants provided a complete response to the survey. We found that 98.0% of the colorectal surgeons and 65.8% of the obstetricians/gynecologists used monofilament suture when closing the fascia. The majority of the colorectal surgeons used continuous suture and small bites technique. This was only the case for half of the obstetricians/gynecologists. Approximately two thirds of the colorectal surgeons and one third of the OB/GYN used the suture length to wound length ratio > 4:1. Furthermore, we found significant differences between the groups in the handling of subcutis, peritoneum, and skin. We found significant variation in abdominal wall closure techniques in lower transverse incisions. Disagreement between the current guidelines within the specialties together with insufficient evidence on the closure of lower transverse incisions emphasizes the need for education as well as further studies.

Randomised-controlled feasibility trial on abdominal wall closure techniques in patients undergoing relaparotomy (ReLap study; DRKS00013001)

BackgroundPatients undergoing relaparotomy are generally underrepresented in clinical trials, despite how common the procedure is in clinical practice. Specifically, techniques for re-do abdominal wall closure have never been evaluated in a randomised-controlled trial. The aim of this trial was to identify the optimal abdominal wall closure technique in patients undergoing relaparotomy.MethodsIn this monocentric, randomised feasibility trial, patients scheduled for elective relaparotomy were randomised to abdominal wall closure with either the small stitches technique, using Monomax® 2-0, or the large stitches technique, using PDS II® 1 loop. Patients’ postoperative courses were followed for 1 year after the index operation. Effectiveness and safety outcomes were compared at a level of significance of 5% between the two techniques.ResultsA total of 100 out of 131 patients (76.3%) were evenly randomised to the small stitches and large stitches groups. The time for abdominal wall closure did not differ between the two techniques (small stitches 27.5 ± 9.5 min versus large stitches 25.3 ± 12.4 min; p = 0.334). The overall comprehensive complication index was 14.4 ± 15.5 in the small stitches group and 19.9 ± 23.4 in the large stitches group (p = 0.168). Specifically, rates of surgical site infection (small stitches 30.0% versus large stitches 36.0%; p = 0.524) and burst abdomen (small stitches 4.0% versus large stitches 0.0%; p = 0.495) did not differ. After 1 year, incisional hernia rate was 7.5% in the small stitches group and 10.0% in the large stitches group (p > 0.999).DiscussionBoth abdominal wall closure techniques investigated in this trial were feasible in relaparotomy patients. This exploratory trial revealed no noticeable difference in the effectiveness or safety of the small stitches technique with Monomax® 2-0 versus the large stitches technique with PDS II® 1 loop. Therefore, surgeons should stay with their preferred suture technique in relaparotomy patients.Trial registrationDeutsches Register Klinischer Studien (www.germanctr.de): DRKS00013001

Technique of Midline Abdominal Incision Closure Among Surgical Trainees

Background: Technique of anterior abdominal wall closure (AAWC) determines wound-related surgical complications. Residents in obstetrics and gynecology and surgery departments perform most midline abdominal wall closure; data is lacking on how it is being done. This study identifies abdominal wall closure techniques used.
 Methods: A descriptive study was carried out from October 2015 to May 2016.
 Results: 71 (35 surgical, 36 ObGyn) residents completed a self-administered questionnaire. Knowledge of midline abdominal closure was acquired from medical officers (58.6%) or consultants before residency (28.6%). Absorbable suture was preferred for clean wounds by 75% of residents; 70% used size 1 suture for fascial closure. Most residents (95.7%) closed fascia in clean wound by continuous suturing. Interrupted suturing was preferred in contaminated and dirty wounds. Half of the residents in both groups would close skin in contaminated wounds, while 16% of surgery and 9.4% ObGyn will close skin in dirty wounds.
 Conclusion: Inconsistencies exist in anterior abdominal wall closure between groups of residents despite presence of clear guidelines. It is important to harmonize training on AAWC at the tertiary hospital.
 Keywords: Abdominal closure, Midline incision, Wound complications

Hernia reduction following laparotomy using small stitch abdominal wall closure with and without mesh augmentation (the HULC trial): study protocol for a randomized controlled trial

BackgroundIncisional hernias are among the most frequent complications following abdominal surgery and cause substantial morbidity, impaired health-related quality of life and costs. Despite improvements in abdominal wall closure techniques, the risk for developing an incisional hernia is reported to be between 10 and 30% following midline laparotomies. There have been two recent innovations with promising results to reduce hernia risks, namely the small stitches technique and the placement of a prophylactic mesh. So far, these two techniques have not been evaluated in combination.MethodsThe HULC trial is a multicentre, randomized controlled, observer- and patient-blinded surgical effectiveness trial with two parallel study groups. A total of 812 patients scheduled for elective abdominal surgery via a midline laparotomy will be randomized in 12 centres after informed consent. Patients will be randomly assigned to the control group receiving closure of the midline incision with a slowly absorbable monofilament suture in the small stitches technique or to the intervention group, who will receive a small stitches closure followed by augmentation with a light-weight polypropylene mesh in the onlay technique. The primary endpoint will be the occurrence of incisional hernias, as defined by the European Hernia Society, within 24 months after surgery. Further perioperative parameters, as well as patient-reported outcomes, will be analysed as secondary outcomes.DiscussionThe HULC trial will address the yet unanswered question of whether a combination of small stitched fascial closure and onlay mesh augmentation after elective midline laparotomies reduces the risk of incisional hernias. The HULC trial marks the logical and innovative next step in the development of a safe abdominal closure technique.Trial registrationGerman Clinical Trials Register, DRKS00017517. Registered on 24th June 2019.

Evaluation of a new technique for abdominal wall closure in midline laparotomies

Background: An efficient technique for abdominal wall closure should provide strength and be a barrier against infection. Method of closure and type of suture material are critical aspects of an effective abdominal wall closure after midline laparotomy. Dehiscence of abdominal wounds after closure is a serious complication especially in emergency laparotomies. Our study was done to know whether our method of abdominal closure was helpful in reducing incidence of wound dehiscence.Methods: Present study was carried out as a retrospective randomized clinical study in the department of general surgery, Menoufia University Hospitals for one year starting from March 2017 to March 2018. 168 patients had midline laparotomies (either elective or emergent) for inflammatory, traumatic or neoplastic indications.Results: In present study for this new technique of abdominal wall closure after midline laparotomies, wound infection was noticed in 12/168 (7.2%) cases and 2/168 (1.2%) patients developed wound dehiscence.Conclusions: Present study demonstrates that our new technique (Moharam Repair) of abdominal wall closure after midline laparotomies) is efficient in reducing post-operative wound dehiscence (burst abdomen). So, this technique is applicable, safe, and can minimize morbidities and mortalities related to wound dehiscence (as a short-term complication) after midline exploratory laparotomies (MEL).

Hughes Abdominal Repair Trial (HART)—abdominal wall closure techniques to reduce the incidence of incisional hernias: feasibility trial for a multicentre, pragmatic, randomised controlled trial

ObjectivesIncisional hernias are common complications of midline abdominal closure. The ‘Hughes Repair’ combines a standard mass closure with a series of horizontal and two vertical mattress sutures within a single...

Searching for the safest abdominal closure technique after emergency laparotomy for Hinchey III and IV peritonitis

Background: The optimal strategy for abdominal wall closure has been an ongoing issue of debate and convincing evidence is still lacking. The INLINE systematic review and meta-analysis published on annals of surgery 2010 suggested that a running suture with a slowly absorbable suture material was the gold standard technique for abdominal wall closure after elective surgery, while there’s no general agreement in the emergency setting.Methods: Retrospective study regarding patients who underwent emergency surgery for a generalized peritonitis due to colonic perforation from 2002 to 2014 at San Gerardo hospital (Monza, Italy). Particularly study analyzed differences between continuous suture (Maxon loop, Covidien ©) and interrupted suture (Safil, B. Braun ©) for fascial closure and between metallic clips and second intention healing for incision management. After completion of data retrieval, 110 patients were included in the statistical analysis.Results: Incisional hernia rate was 15/101 (14.9%) and surgical site infection rate was 29/110 (26.4%). No significant statistical differences were found between incidence of incisional hernia and surgical site infection in the two groups, although there was a higher prevalence of incisional hernia in the running suture group (25% vs 11,7%). There was no difference between skin-stapler’s and second-intention’s wound closure groups in terms of surgical site infection and incisional hernia development.Conclusions: We consider reasonable to use an interrupted long time absorbable suture for fascial closure after emergency midline laparotomy for Hinchey III and IV peritonitis, at least in high-risk patients. Considering skin closure, suggestion is to perform a primary skin closure.

Hughes Abdominal Repair Trial (HART) - Abdominal wall closure techniques to reduce the incidence of incisional hernias: study protocol for a randomised controlled trial.

BackgroundIncisional hernias are common complications of midline closure following abdominal surgery and cause significant morbidity, impaired quality of life and increased health care costs.The ‘Hughes Repair’ combines a standard mass closure with a series of horizontal and two vertical mattress sutures within a single suture. This theoretically distributes the load along the incision length as well as across it. There is evidence to suggest that this technique is as effective as mesh repair for the operative management of incisional hernias; however, no trials have compared the Hughes Repair with standard mass closure for the prevention of incisional hernia formation following a midline incision.Methods/designThis is a 1:1 randomised controlled trial comparing two suture techniques for the closure of the midline abdominal wound following surgery for colorectal cancer. Full ethical approval has been gained (Wales REC 3, MREC 12/WA/0374). Eight hundred patients will be randomised from approximately 20 general surgical units within the United Kingdom. Patients undergoing open or laparoscopic (more than a 5-cm midline incision) surgery for colorectal cancer, elective or emergency, are eligible. Patients under the age of 18 years, those having mesh inserted or undergoing musculofascial flap closure of the perineal defect in abdominoperineal wound closure, and those unable to give informed consent will be excluded. Patients will be randomised intraoperatively to either the Hughes Repair or standard mass closure. The primary outcome measure is the incidence of incisional hernias at 1 year as assessed by standardised clinical examination. The secondary outcomes include quality of life patient-reported outcome measures, cost-utility analysis, incidence of complete abdominal wound dehiscence and C-POSSUM scores. The incidence of incisional hernia at 1 year, assessed by computerised tomography, will form a tertiary outcome.DiscussionA feasibility phase has been completed. The results of the study will be used to inform current and future practice and potentially reduce the risk of incisional hernia formation following midline incisions.Trial registrationTrial Registration Number: ISRCTN 25616490. Registered on 1 January 2012.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-016-1573-0) contains supplementary material, which is available to authorized users.

Effect of suture technique on the occurrence of incisional hernia after elective midline abdominal wall closure: study protocol for a randomized controlled trial.

BackgroundBased on a recent meta-analysis, a continuous suture technique with a suture to wound length ratio of at least 4:1, using a slowly absorbable monofilament suture material, is recommended for primary median laparotomy closure. Incisional hernia, which develops in 9 to 20% of patients, remains the major complication of abdominal wall closure. Current clinical data indicate that the incidence of incisional hernias increases by 60% between the first and the third year after median laparotomy, implicating that a follow-up period of 1 year postoperatively is too short with regard to this common complication. Trauma to the abdominal wall can be reduced by improvements in suture technique as well as suture material. Several factors, such as stitch length, suture tension, elasticity, and tensile strength of the suture material are discussed and currently under investigation. A Swedish randomized controlled trial showed a significant reduction in the incisional hernia rate by shortening the stitch length. However, a non-elastic thread was used and follow-up ended after 12 months. Therefore, we designed a multicenter, international, double-blinded, randomized trial to analyze the influence of stitch length, using an elastic, extra-long term absorbable monofilament suture, on the long term clinical outcome of abdominal wall closure.MethodsIn total, 468 patients undergoing an elective, median laparotomy will be randomly allocated to either the short stitch or the long stitch suture technique for abdominal wall closure in a 1:1 ratio. Centers located in Germany and Austria will participate. The primary endpoint measure is the incisional hernia rate 1 year postoperatively, as verified by ultrasound. The frequency of short term and long term complications as well as costs, length of hospital stay and patients’ quality of life (EQ-5D-5 L) will be considered as secondary parameters. Following hospital discharge, patients will be examined after 30 days and 1, 3, and 5 years after surgery.DiscussionThis study will provide further evidence on whether a short stitch suture technique in combination with an elastic, extra-long term absorbable monofilament suture can prevent incisional hernias in the long term, compared with the long stitch suture technique.Trial registrationNCT01965249.

Porcine acellular dermal matrix for delayed abdominal wall closure after pediatric liver transplantation.

Children are one of the groups with the highest mortality rate on the waiting list for LT. Primary closure of the abdominal wall is often impossible in the pediatric population, due to a size mismatch between a large graft and a small recipient. We present a retrospective cohort study of six pediatric patients, who underwent delayed abdominal wall closure with a biological mesh after LT, and in whom early closure was impossible. A non-cross-linked porcine-derived acellular dermal matrix (Strattice(™) Reconstructive Tissue Matrix; LifeCell Corp, Bridgewater, NJ, USA) was used in all of the cases of the series. After a mean follow-up of 26 months (21-32 months), all patients were asymptomatic, with a functional abdominal wall after physical examination. Non-cross-linked porcine-derived acellular dermal matrix (Strattice(™) ) is a good alternative for delayed abdominal wall closure after pediatric LT. Randomized controlled trials are necessary to determine the best moment and the best technique for abdominal wall closure.