Current Practice of Abdominal Wall Closure in Elective Surgery - Is There Any Consensus?

Abstract

Abstract

Background: Development of incisional hernia after open abdominal surgery remains a major cause of post-operative morbidity. The aim of this study was to determine the current practice of surgeons in terms of access to and closure of the abdominal cavity in elective open surgery.
Methods: Twelve surgical departments of the INSECT-Trial group documented the following variables for 50 consecutive patients undergoing abdominal surgery: fascial closure techniques, applied suture materials, application of subcutaneous sutures, subcutaneous drains, methods for skin closure. Descriptive analysis was performed and consensus of treatment variables was categorized into four levels: Strong consensus >95%, consensus 75–95%, overall agreement 5075%, no consensus <50%.
Results: 157 out of 599 patients were eligible for analysis (85 (54%) midline, 54 (35%) transverse incisions). After midline incisions the fascia was closed continuously in 55 patients (65%), using slowly absorbable (n = 47, 55%), braided (n = 32, 38%) sutures with a strength of 1 (n = 48, 57%). In the transverse setting the fascia was closed continuously in 39 patients (72%) with slowly absorbable (n = 22, 41%) braided sutures (n = 27, 50%) with a strength of 1 (n = 30, 56%).
Conclusion: In the present evaluation midline incision was the most frequently applied access in elective open abdominal surgery. None of the treatments for abdominal wall closure (except skin closure in the midline group) is performed on a consensus level.

Background

Approximately 700.000 open abdominal procedures are performed annually in Germany and 4.000.000 in the United States.^[1] Development of incisional hernia remains the major postoperative wound complication after open abdominal surgery with a stable incidence of 5% to 24% over the last decades.^[2,3] Regarding pathogenesis of incisional hernias, the incision type (midline vs. transverse vs. oblique) and the strategy of fascia closure, i.e. the combination of applied suture technique (interrupted vs. continuous) and suture material (monofilament vs. braided; absorbable (rapidly, intermediately, slowly) vs. non-absorbable) are the main factors amenable to the surgeon.

There is still controversy about the best strategy for abdominal wall closure due to inconsistent and incomplete evidence provided by several randomized controlled trials (RCT)^[4–8] as well as meta-analyses.^[9–12] Based on the lack of data from well-designed long-term surgical trials, a large multi-centre randomized controlled trial (interrupted or continuous slowly absorbable sutures evaluation of abdominal closure techniques, INSECT-Trial) recruited 624 patients between 2004 and 2006 with the rationale to compare the most relevant surgical practices for abdominal fascia closure after primary midline laparotomy.^[13] Participating surgeons raised the following two questions during conduction of the INSECT-Trial:

1. Is midline incision still the most frequently applied access to the abdominal cavity in elective situations?

2. Has consensus for abdominal wall closure already been established in surgical routine?

The primary objective of this cross sectional study was therefore to identify current practice of abdominal cavity access and closure in elective surgery.

BMC Surg © 2009 

Cite this: Current Practice of Abdominal Wall Closure in Elective Surgery - Is There Any Consensus? - Medscape - May 15, 2009.