ABDOMINAL WALL CLOSURE CLINICAL EVIDENCE – POCKET GUIDE

ABDOMINAL WALL CLOSURE CLINICAL EVIDENCE – POCKET GUIDE

SUPPORTING CLINICAL EVIDENCE FOR...

AIM

RESULTS

TECHNIQUES AND MATERIALS

TRANSVERSE VS. MIDLINE

Identify the optimal suture technique and suture material after abdominal wall closure (AWC).

Determine which incision might be the best option for elective abdominal surgery.

Continuous technique produced lower incisional hernia rate (IHR),1-5 however, interrupted technique was superior regarding wound pain, suture sinus1 and wound infection. 2 Absorbable material was better than non-absorbable sutures regarding IHR1, being the slowly absorbable sutures more effective.1,3 Nevertheless, van’t Riet et al. and Rucinski et al. did not find differences between slowly absorbable3 and monofilament absorbable sutures 4 compared to non-absorbable material regarding IHR and Weiland et al. 2 and Hodgon et al. 5 found that continuous non-absorbable sutures produced lower IHR. INSECT Trial 6,7 failed to demonstrate any reduction of IHR with continuously absorbable monofilament and interrupted rapidly absorbable suture material.

Most of studies did not show any differences in the IHR, 8,9 however, Halm et al.10 found lower hernia incision in transverse surgery.

Moreover, transverse incisions lead to a lower pain rate, 8,10 lower frequency of pulmonary complications 8 and better cosmetic results.10 On the other side, transverse group presented more wound infections. Furthermore, no significant differences were found in consumption of analgesia, length hospital stay and mortality rate. 9,10

In respect to secondary outcome, absorbable suture is better than non-absorbable regarding suture sinus, whereas no difference is found in regard to wound infection, dehiscence and wound pain.1,4,5

CONCLUSIONS

Optimal solution for midline closure after elective median laparotomy: slowly absorbable suture material with the continuous technique.

Both incision direction are comparable regarding the clinical outcome.

Nowadays, no consensus is available regarding the strategy of the opening of the abdomen.

ULTRA-LONG VS. LONG TERM

STITCH LENGTH

HIGH RISK PATIENTS

Investigate the safety and efficacy of Monomax ® for AWC.

Assess the influence of the stitch length on wound infection and IHR.

Define if a prophylactic mesh is the best choice to reduce the IHR vs. suture repair in high risk patients.

The incidence of burst abdomen and wound infection until day of discharge was 7.3 % in patients receiving Monomax ® and 11.3 % in control patients receiving MonoPlus ® or PDS TM.

Deerenberg et al.13 defended that short stitches technique is more effective than long stitches in prevention of incisional hernia and it is not associated with higher rate of adverse events.

Other authors found out similar results, Harlaar et al.14 said that the tensile force was significantly higher with short stitches than with large stitches, and Milbourn et al. studies demonstrated that surgical site infection and IHR were significantly lower in short stitch group15,16 and that a suture length to wound length ratio >4 reduces the incidence of hernia and saves costs.17 The risk of wound infection was at least twice as high and the risk of incisional hernia was four times as high in the long stitch group,15,18 being in some cases not identified in the short stitch group.16 Moreover, wound infection were more common in overweight patients receiving long stitches,16 although Deerenberg et al.13 did not found any significant difference.

The mesh repair significantly reduced the IHR vs. suture group.19-23 Moreover, in suture group, the incisional hernia developed earlier.19 An increased mean time to close the abdominal wall was observed in the mesh group. 20

The length of postoperative hospital stay was similar in both, as well as the rate of protruding sac. The rate of incisional hernia and the number of fascial gaps was reduced in Monomax ® group, although not significantly.11,12

Ultra-long term absorbable, elastic, monofilament suture Monomax® is safe and efficient for AWC after primary midline laparotomy.11,12

Short stitches (<10 mm) has been related by majority with a reduction of the wound infection rate and IHR compared to long stitches (>10 mm).

El-Khadrawy et al. 21 defended that subcutaneous seroma and chronic pain were more common in the mesh group.

On the other hand, suture site infection decreased in these patients. Conversely, Stryzelcyk and colleagues 22 did not found any difference in the incidence of seromas and minor wound leakage between groups.

PRIMA Trial24 detected more seromas in mesh group placed in onlay position, vs. mesh group placed in sublay position and suture group. However, this trial did not find differences in surgical site infection, hematoma, reintervention, or readmission.

The use of a prophylactic polypropylene mesh in high risk patients (obesity and abdominal aortic aneurysm) seems to be beneficial and effective to prevent incisional hernias.

The product trademarks “PDSTM”, “PDSTM II”, “PDSTM Plus” and “VicrylTM” are registered trademarks of Ethicon.

RECENT CLINICAL STUDIES

AIM

METHODS

RESULTS

KEY MESSAGE

INLINE1

STITCH13

PROUD25

Optimal technique and material.

Incisional hernia rate using small bites vs. large bites.

Surgical Site Infection (SSI) ocurrence using PDS TM Plus vs. PDS TM II.

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Meta-analysis of randomized controlled trials.

5 systemic reviews, 14 trials including 7711 patients.

Elective Midline Abdominal Laparotomy (EMAL).

Significantly lower incisional hernia (IH) rate for continuous suture technique vs. interrupted.

Significantly lower IH rate for slowly-absorbable material vs. rapidlyabsorbable.

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Lower chance of developing IH when using a continuous technique and slowly absorbable suture material for abdominal closure.

Multicentric, doubleblinded, randomized controlled trial.

10 Dutch hospitals.

EMAL, 560 patients.

Patients received small bites (stitch intervall of 5 mm, lateral distance of 5 mm), or large bites (stitch intervall of 1 cm, lateral distance of 1 cm).

IH 1 yr. postop.: 21 % (large) vs.

13 % (small).

Multicentric, randomized controlled study.

24 German hospitals.

EMAL, 1185 patients.

SSI 1 month postop.: 14.8 % (PDS TM Plus) vs. 16.1 % (PDS TM II).

No significant differences.

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Small bites are more effective than large bites for reduction of IH. No increase of adverse events.

PDS TM Plus did not reduce SSI after EMAL.

INSECT 6,7

ISSAAC11,12,26

ESTOIH18

IH rate between continuous (MonoPlus®/PDS TM) and interrupted (VicrylTM) suture technique, 1 yr. postop.

Safety and efficacy of Monomax ®.

Incisional hernia rate using small bites vs. large bites.

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No significant reduction of IH within 1 yr. after abdominal closure.

Monomax ® is safe and efficient for abdominal wall closure.

Hypothesis: Short stitch + elastic extra-long term absorbable monofilament might prevent IH.

Multicentric, three-armed, randomized, controlled trial.

4 German centres.

EMAL, 625 patients.

Groups: Interrupted Vicryl TM, continuous PDS TM, continuous MonoPlus ® suture technique.

IH incidence of 15.9 % (Vicryl TM), 8.4 % (PDS TM), 12.5 % (MonoPlus ®).

Time for abdominal wall closure was significantly shorter in the continuous suture group.

Multicentric, single-armed, historically-controlled, prospective trial.

4 German centres.

EMAL, 775 patients from ISSAAC and INSECT studies.

Monomax ® vs. INSECT Groups PDS TM and MonoPlus ® as control.

Burst abdomen and wound infection: 7.3 % ISSAAC vs. 11.3 % INSECT. Wound dehiscence (30 days postop.): 2 % SSAAC, 7 % INSECT. IH rate 1yr. postop: 14 % ISSAAC, 21 % INSECT (not significant). IH rate 3 yr. postop: Monomax ® 19.2 %, MonoPlus ® 23.2 %.

International, multicentric, double-blinded, randomized controlled study.

9 centers in Germany and Austria.

EMAL, 468 patients.

Hypothesis: Reduction of the IH 1 yr. postop. up to 50 % using small bite technique with Monomax ® USP 2/0 vs. large bite technique with Monomax ® USP 1.

The product trademarks “PDSTM”, “PDSTM II”, “PDSTM Plus” and “VicrylTM” are registered trademarks of Ethicon.

REFERENCES 1. Diener MK, Voss S, Jensen K, Büchler MW, Seiler CM. Elective midline laparotomy closure: the INLINE systematic review and meta-analysis. Ann Surg. 2010 May;251(5):843-56.

2. Weiland DE, Bay RC, Del Sordi S. Choosing the best abdominal closure by meta-analysis.

Am J Surg. 1998 Dec;176(6):666-70.

3. Van’t Riet M, Steyerberg EW, Nellesteyn J, Bonjer HJ, Jeekel J. Meta-analysis of techniques for closure of midline abdominal incisions. Br J Surg. 2002 Nov;89(11):1350-6.

4. Rucinski J, Margolis M, Panagopoulos G, Wise L. Closure of the abdominal midline fascia: meta-analysis delineates the optimal technique. Am Surg. 2001 May;67(5):421-6.

5. Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg. 2000 Mar;231(3):436-42.

6. Knaebel HP, Koch M, Sauerland S, Diener MK, Büchler MW, Seiler CM. INSECT Study Group of the Study Centre of the German Surgical Society. Interrupted or continuous slowly absorbable sutures – design of a multi-centre randomized trial to evaluate abdominal closure techniques INSECT – trial [ISRCTN24023541]. BMC Surg. 2005 Mar;8(5):3.

7. Knaebel HP, Kirschner MH, Reidel MA, Büchler MW, Seiler CM. Operative Standardisation in randomized controlled surgical trials. Meeting of the INSECT trial. Chirurg. 2006 Mar; 77(3):267-72.

8. Brown SR, Goodfellow PB. Transverse versus midline incisions for abdominal surgery.

Cochrane Database Syst. Rev. 2005 Oct;(4):CD005199.

9. Seiler CM, Deckert A, Diener MK, Knaebel HP, Weigand MA, Victor N, et al. Midline versus transverse incision in major abdominal surgery: a randomized, double-blind equivalence trial (POVATI: ISRCTN60734227). Ann Surg. 2009 Jun;249(6):913-20.

10. Halm JA, Lip H, Schmitz PI, Jeekel J. Incisional hernia after upper abdominal surgery: a randomised controlled trial of midline versus transverse incision. Hernia. 2009 Jun; 13(3):275-80.

11. Fischer L, Baumann P, Hüsing J, Seidlmayer C, Albertsmeier M, Franck A, et al. A historically controlled, single-arm, multi-centre, prospective trial to evaluate the safety and efficacy of Monomax suture material for abdominal wall closure after primary midline laparotomy.

ISSAAC-Trial [NCT005725079]. BMC Surg. 2008 Jul;8:12.

12. Albertsmeier M, Seiler CM, Fischer L, Baumann P, Hüsing J, Seidlmayer C, et al. Evaluation of the safety and efficacy of Monomax® suture material for abdominal wall closure after primary midline laparotomy-a controlled prospective multicentre trial: ISSAAC [NCT005725079]. Langenbecks Arch Surg. 2012 Mar;397(3):363-71.

13. Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, et al.

Small bites versus large bites for closure of abdominal midline incisions (STITCH): a doubleblind, multicentre, randomised controlled trial. Lancet. 2015 Sep;386(10000):1254-60.

14. Harlaar JJ, van Ramshorst GH, Nieuwenhuizen J, Ten Brinke JG, Hop WC, Kleinrensink GJ, et al. Small stitches with small suture distances increase laparotomy closure strength.

Am J Surg. 2009 Sep;198(3):392-5.

15. Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg. 2009 Nov; 144(11):1056-9.

16. Millbourn D, Cengiz Y, Israelsson LA. Risk factors for wound complications in midline abdominal incisions related to the size of stitches. Hernia. 2011 Jun;15(3):261-6.

17. Millbourn D, Wimo A, Israelsson LA. Cost analysis of the use of small stitches when closing midline abdominal incisions. Hernia. 2014;18(6):775-80.

18. Fortelny RH, Baumann P, Thasler WE, Albertsmeier M, Riedl S, Steurer W, et al. Effect of suture technique on the occurrence of incisional hernia after elective midline abdominal wall closure: study protocol for a randomized controlled trial. Trials. 2015 Feb;16:52.

19. Bevis PM, Windhaber RA, Lear PA, Poskitt KR, Earnshaw JJ, Mitchell DC. Randomized clinical trial of mesh versus sutured wound closure after open abdominal aortic aneurysm surgery.

Br J Surg. 2010 Oct;97(10):1497-502.

20. Muysoms FE, Detry O, Vierendeels T, Huyghe M, Miserez M, Ruppert M, et al. Prevention of Incisional Hernias by Prophylactic Mesh-augmented Reinforcement of Midline Laparotomies for Abdominal Aortic Aneurysm Treatment: A Randomized Controlled Trial. Ann Surg. 2016 Apr;263(4):638-45.

21. El-Khadrawy OH, Moussa G, Mansour O, Hashish MS. Prophylactic prosthetic reinforcement of midline abdominal incisions in high-risk patients. Hernia. 2009 Jun;13(3):267-74.

22. Strzelczyk JM, Szymański D, Nowicki ME, Wilczyński W, Gaszynski T, Czupryniak L. Randomized clinical trial of postoperative hernia prophylaxis in open bariatric surgery. Br J Surg. 2006 Nov; 93(11):1347-50.

23. Gutiérrez de la Peña C, Medina Achirica C, Domínguez-Adame E, Medina Díez J. Primary closure of laparotomies with high risk of incisional hernia using prosthetic material: analysis of usefulness. Hernia. 2003 Sep;7(3):134-6.

24. Timmermans L, Eker HH, Steyerberg EW, Jairam A, de Jong D, Pierik EG, et al. Short-term results of a randomized controlled trial comparing primary suture with primary glued mesh augmentation to prevent incisional hernia. Ann Surg. 2015 Feb;261(2):276-81.

25. Diener MK, Knebel P, Kieser M, Schüler P, Schiergens TS, Atanassov V, et al. Effectiveness of triclosan-coated PDS Plus versus uncoated PDS II sutures for prevention of surgical site infection after abdominal wall closure: the randomised controlled PROUD trial. Lancet.

2014 Jul 12;384(9938):142-52.

26. Fink C, Baumann P, Wente MN, Knebel P, Bruckner T, Ulrich A, et al. Incisional hernia rate 3 years after midline laparotomy. Br J Surg. 2014 Jan;101(2):51-4.

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