EUROPEAN HERNIA SOCIETY (EHS) 2014

GUIDELINES:
CLOSURE OF ABDOMINAL WALL
INCISIONS
(MIDLINE ELECTIVE)

JIBRAN MOHSIN
RESIDENT, SURGICAL UNIT I
SIMS/SERVICES HOSPITAL, LAHORE
 “MAYBE WE SHOULD FIRST LEARN AND
TEACH HOW TO PREVENT INCISIONAL
HERINIAS, RATHER THAN HOW TO TREAT
THEM?”
SPERLONGA STATEMENT
(Autumn board meeting of the EHS in
September 2013 in Sperlonga, Italy)
INTRODUCTION
• Incisional hernias are a frequent complication of abdominal wall incisions
( incidence 12.8 to 69%)

• Risk factors for incisional hernias include

 Postoperative surgical site infection
 Obesity and
 Abdominal aortic aneurysm

• Nevertheless, the suture material and the surgical technique used to close an
abdominal wall incision, are the most important determinants of the risk of
developing an incisional hernia
INTRODUCTION
• Development of an incisional hernia has an important impact on the
patients’ quality of life and body image

• Repair of incisional hernias still has a high failure rate with long term
recurrence rates above 30%, even when mesh repair is performed
INTRODUCTION
• Mean direct and indirect costs for the repair of an average incisional
hernia in an average patient in France in 2011 was € 7,089 (PKR
827090, PGR yearly stipend)

• Optimizing the surgical technique to close abdominal wall

incisions using evidence based principles, holds a potential to
prevent patients suffering from incisional hernias and the potential
sequelas of incisional hernia repairs
OBJECTIVE
• To provide guidelines for all surgical specialists who perform
abdominal incisions in adult patients on the optimal materials and
methods used to close the abdominal wall

In order to
• To decrease the occurrence of both burst abdomen and incisional
hernia
OBJECTIVE
• Guidelines refer to patients undergoing any kind of abdominal wall
incision, including
 Visceral surgery
 Gynecological surgery
 Aortic vascular surgery
 Urological surgery
 Orthopedic surgery

• Both open and laparascopic surgeries are included in the guidelines

Which diagnostic modality is the most suitable to detect
incisional hernias?
 WHICH DIAGNOSTIC MODALITY IS THE MOST
SUITABLE TO DETECT INCISIONAL HERNIAS?
• No systematic reviews were found

• Only 4/15 were retained as high quality

• No studies compared different diagnostic modalities in a similar

methodology and with the similar study arms
 no pooling of data was useful or possible
WHICH DIAGNOSTIC MODALITY IS THE MOST
SUITABLE TO DETECT INCISIONAL HERNIAS?
• Most studies show that medical imaging will increase the rate of
detection incisional hernias compared to physical examination

• In an everyday clinical setting this is usually not important, because

most asymptomatic hernias do not require treatment and their
diagnosis is thus not necessary
WHICH DIAGNOSTIC MODALITY IS THE MOST
SUITABLE TO DETECT INCISIONAL HERNIAS?
WHICH DIAGNOSTIC MODALITY IS THE MOST
SUTABLE TO DETECT INCISIONAL HERNIAS?
WHICH DIAGNOSTIC MODALITY IS THE MOST
SUTABLE TO DETECT INCISIONAL HERNIAS?
Does the type of abdominal wall incision influence the
incidence of incisional hernias or burst abdomen ?
Does the type of abdominal wall incision influence the
incidence of incisional hernias or burst abdomen ?
• laparotomy incisions can be classified as midline, transverse, oblique
or paramedical incisions

• 2/6 systematic reviews comparing midline laparotomies to alternative

incisions were considered high quality
Does the type of abdominal wall incision influence the
incidence of incisional hernias or burst abdomen?
• Incisional hernia rates after non-midline (transverse and paramedian)
incisions were significantly lower compared to the incisional hernia
rates after midline incisions

• However, data on Burst abdomen (deep wound dehiscence or fascial

dehiscence) were not significantly different between the different
incisions types
Does the type of abdominal wall incision influence the
incidence of incisional hernias or burst abdomen?
What is the optimal technique to close a laparotomy
incision ?
 What is the optimal technique to close a
laparotomy incision?
• 4/10 systematic reviews on the techniques and/or the materials to
close abdominal wall incisions were identified as high quality

• Data from the different systematic reviews are very incoherent and
conclusions are often completely contradictory and low quality e.g
 different populations studied
 Midline only or including other incisions
 Emergency or elective surgery and
 Different operative indications
What is the optimal technique to close a laparotomy
incision?
• Most studies on closure of laparotomies in the failure to monitor the
technical details of the suturing technique, like the SL/WL ratio and
the stitch size

• Protocol for an ongoing Cochrane review was published in 2006 but

the final data have not yet been published
What is the optimal technique to close a
laparotomy incision?
What is the optimal technique to close a
laparotomy incision?
What is the optimal technique to close a
laparotomy incision?
CONTINUOUS SUTURING VERSUS INTERRUPTED SUTURES
• Continuous suturing for closure of midline laparotomies was
beneficial compared to interrupted closure

 Significant lower incisional hernia rate for continuos suturing (p=0.001) in

elective surgery.
 No difference in case of emergency laparotomies
 Continuous suturing was recommended in ER because if was significantly
faster
What is the Optimal technique to close a
laparotomy incision?
CONTINUOUS SUTURING VERSUS INTERRUPTED SUTURES
• High risk of bias in most studies because

• Interrupted study arm used rapidly absorbable multifilament suture and

• Continuous arm used either non absorbable or slowly absorbable

monofilament sutures
What is the optimal technique to close a
laparotomy incision?
What is the Optimal technique to close a
laparotomy incision?

CLOSURE VERSUS NON-CLOSURE OF THE PERITONEUM

• No short-term or long-term benefit in peritoneal closure

What is the optimal technique to close a
laparotomy incision?
What is the optimal technique to close a
laparotomy incision?
MASS CLOSURE VERSUS SINGLE LAYER CLOSURE
• Search for the most appropriate layers to be sutured when closing a
laparotomy
• Hampered by the lack of good definition on what constitutes a
• Mass closure
• Layered closure or
• Single layer closure

• No clinical studies directly comparing different closure methods were

found
What is the optimal technique to close a
laparotomy incision?
MASS CLOSURE VERSUS SINGLE LAYER CLOSURE

• For future research EHS proposes the following definitions

What is the optimal technique to close a
laparotomy incision?
What is the optimal technique to close a
laparotomy incision?
SUTURE LENGTH TO WOUND LENGTH RATIO (SL/WL)

• Evidence from clinical prospective studies remains scarce

• Most of the work addressing the topic comes from the clinic of sundsvall in
Sweden

• Demonstrated the importance of the SL/WL ratio in reducing incisional hernia rate

• Critical value was determined to be at a ration of 4/1

What is the optimal technique to close a
laparotomy incision?
What is the optimal technique to close a
laparotomy incision?
 What is the optimal technique to close a
laparotomy incision?
SMALL BITES VERSUS LARGE BITES
• Closure of a midline laparotomy with a”small bites” technique
resulted in
• Significant less incisional hernias (5.6 vs 18.0%; p=0.001) and
• Less surgical site infections (5.2 vs 10.2%; p=0.02)

• Small bite technique

• Laparotomy wound closed with a single layer aponeurotic suturing technique
taking bites of fascia of 5-8 mm and placing stitches every 5 mm
What is the optimal technique to close a
laparotomy incision?
What is the optimal suture material to
close a laparotomy incision?
 What is the optimal suture material to
close a laparotomy incision?
RAPIDLY ABSORBABLE SUTURE
VERSUS
NON-ABSORBABLE OR SLOWLY ABSORBABLE SUTURES

• Significantly more incisional hernias with rapidly absorbable sutures

compared to non-absorbable sutures (p=0.001) and compared to
slowly absorbable sutures (p=0.009)
What is the optimal technique to close a
laparotomy incision?
What is the optimal suture material to
close a laparotomy incision?
NON-ABSORBABLE
VERSUS
SLOWLY ABSORBABLE SUTURES

• No difference in incisional hernia rate for continuous suturing of midline

incisions with slowly absorbable versus non-absorbable sutures (p=0.75)

• However, an increased incidence of prolonged wound pain( p=0.005) and

suture sinus formation(p=0.02) with non-absorbable sutures
What is the optimal technique to close a
laparotomy incision?
What is the optimal suture material to
close a laparotomy incision?
MONIFILAMENT
VERSUS
MULTIFILAMENT SUTURES

• Monofilament sutures are believed to be associated with a lower

surgical site infection rate than multifilament sutures

• However, none of the systematic reviews commented on this issue

specifically
What is the optimal suture material to
close a laparotomy incision?
What is the optimal suture material to
close a laparotomy incision?
• Concerning the size of the suture.

• Monofilament sutures are believed to be associated with a lower surgical site

infection rate than multifilament sutures

• However, none of the systematic reviews commented on this issue specifically

What is the optimal suture material to
close a laparotomy incision?
What is the optimal suture material to
close a laparotomy incision?
SUTURES IMPREGNATED WITH ANTIBIOTICS (TRICLOSAN)

• Meta-analysis of 5 studies
• Significant decrease in surgical site infection

• No data on incisional hernias are available from these studies

What is the optimal suture material to
close a laparotomy incision?
What is the optimal suture material to
close a laparotomy incision?
SUTURE NEEDLES

• 1 systematic review

• 1 RCT
• No difference in SSI rate between blunt and sharp needles
What is the optimal suture material to
close a laparotomy incision?
 What is the optimal suture material to
close a laparotomy incision?
Limitations of the statements in these guidelines on suture technique
and suture materials
 What is the optimal suture material to
close a laparotomy incision?
Limitations of the statements in these guidelines on suture technique
and suture materials
Is there a place for retention sutures when
closing a laparotomy?
 Is there a place for retention sutures when
closing a laparotomy?
• No systematic review on the use of retention sutures

• 3 RCTs on prevention of burst abdomen using either retention sutures

or a reinforced tension line suture in patients with increased risk for
wound dehiscence and burst abdomen

• 2 studies showed favorable results

• But one study reported a high number of adverse events when using
retention sututres
Is there a place for retention sutures when
closing a laparotomy?
 Post operative care
• Postoperative management and instructions for patients
• Not supported by high quality prospective data
• Rely mostly on surgeons’ habits, tradition and common beliefs

• Long-term-follow-up studies are needed to research the impact on

occurrence of incisional hernias of prescribing abdominal binders or
restricting postoperative activity
 Post operative care
SUBCUTANEOUS DRAINS IN LAPAROTOMY INCISIONS

• Prophylactic routine placement of • Disadvantages of routine use of

subcutaneous drains after subcutaneous drains
laparotomy is occasionally used to • Patient discomfort and pain at removal
decrease wound complications: • Hinder early mobilization and
• Infection • Demand additional nursing care
• Hematoma
• Seroma or
• Wound dehiscence
Therefore, their use should be driven by a proven benefit
 Post operative care
SUBCUTANEOUS DRAINS IN LAPAROTOMY INCISIONS

• With few exceptions, most studies did not show a benefit for the use of
subcutaneous drains

• However, none of these studies had incisional hernias or burst abdomen as

primary or secondary endpoint
Post operative care
 Post operative care
POSTOPERATIVES

• 1 systematic review = 4 RCTS+ French Survey

• French Survey
• Common practice after major laparotomies in many surgical departments (94% use
them in some patients)
• Expected to reduce postoperative pain and to improve early mobilization
• 83% of users expect a benefit in the prevention of abdominal wall degiscence
 Post operative care
POSTOPERATIVE BINDERS

• RCTS…………. No significant improvement for the sort-term benefits

• VERSUS
• Significant lower visual analogue scale (VAS) score for pain at 5th postoperative day
and no adverse effect on postoperative lung function
• No studies were found that had burst abdomen or incisional hernias as
primary or secondary endpoints
Post operative care
 Post operative care
POSTOPERATIVE RESTRICTION OF ACTIVITY

• No prospective studies
• Advocated by some surgeons to decrease the risk of incisional hernias
• But there is no consensus on the level or the duration of the restriction
• Adverse impact on the return to normal activity and delay the return to
work
Post operative care
 Prophylactic Mesh Augmentation
• 6 RCTs
• Effective in the prevention of incisional hernias
• But associated with increased incidence of postoperative seroma

• Limitation
• Larger trials are needed to make a strong recommendation to perform
prophylactic mesh augmentation for all patients within certain risk groups
Prophylactic Mesh Augmentation
 Prophylactic Mesh Augmentation
• Polyproplene mesh
• Small pore/heavy weight mess
• Proline; ethicon
• Premilence; B. Braun

• Large pore/light weight mass: bio mesh light P8; cousin biotech (1
study)
• Polyglactin mesh (vicryl; ethicon) (1 study)
• Biological mesh (all orders; lifecell) (1 study)
Prophylactic Mesh Augmentation
Prophylactic Mesh Augmentation
WHICH MESH POSITION?
Prophylactic Mesh Augmentation
 Prophylactic Mesh Augmentation
WHICH TYPE OF MESH FIXATION?

• Mesh was in all studies fixed with sutures to the fascia

• Except for 1 study which used no fixation

• No studies on mesh augmentation with glue or self-fixating mes

Prophylactic Mesh Augmentation
 Trocar wounds for laparoscopic surgery
TROCAR SIZE

• Several studies comment on the incidence of trocar-site hernia for

various trocar sizes

• However, the quality of many studies is insufficient and challenges the

validly of results

• No RCT’s or case-control studies availab le

Trocar wounds for laparoscopic surgery
 Trocar wounds for laparoscopic surgery
TROCAR TYPE

• No RCT’s have investigated the incidence of trocar-site hernia after

insertion of blunt versus bladed trocars
 Trocar wounds for laparoscopic surgery
RISK FACTORS
• Obesity
• Age above 60 years
• Diabetes
• Long duration of surgery
• The need for fascia enlargement for specimen extraction
 Trocar wounds for laparoscopic surgery
CLOSURE OF TROCAR INCISION
• No good quality comparative studies investigating different suture
materials or techniques for closure of trocar fascia defects

• Prophylactic intraperitoneal placement of ventral patch at he

umbilical site in high-risk patients
• Reduces the incidence of trocar-site hernia from 18.5 to 4.4%
 Trocar wounds for laparoscopic surgery
CLOSURE OF TROCAR INCISION

• Larger sample-sized studies with a good risk-benefit assessment and

longer follow-up are needed to confirm and support a stronger
recommendation
Trocar wounds for laparoscopic surgery
Trocar wounds for laparoscopic surgery
 Single incision Laparoscopic Surgery
• 3 HIGH QUALITY META ANALYSES
• 2 meta-analyses of RCT’s have found no difference in the incidence of trocar
site hernia between single port and multiple port surgery
• Although a trend in favor of multiple port surgery was demonstrated

• Most recent meta-analysis included 19 RCTs involving 676 patients and found
a higher incidence of trocar site hernia following single port surgery
Single incision Laparoscopic Surgery
 LIMITATIONS
• Not many strong recommendations could be made due to lack of
sufficient evidence

• It is somewhat confusing to notice that

• The first string recommendation in these guidelines is to avoid midline
laparotomies in favor of alternative incisions
• That all other recommendations are only valid for elective midline incisions
 LIMITATIONS
• A midline laparotomy is till the favored approach for most surgeon

• MERITS
• Allows quick entrance to the abdominal cavity and
• Extension of the incision is easy if this is required for the operation
• DEMERITS
• Lines alba is probably the most vulnerable and least vascularizes part of the
abdominal wall
• Some refer to incisional hernias as” a midline crisis)/
 VALIDITY OF THE GUIDLINES

• Guidelines development Group has decided to update these

guidelines in 2017 and present the results during the 39th annual
congress of the EHS in Vienna in may 2017
 CONCLUSIONS
• To decrease the incidence of incisional hernias it is recommended to
utilize a non-midline approach to a laparotomy whenever possible

• For elective midline incisions, it is strongly recommended to perform

a continuous suturing technique and to avoid the use of rapidly
absorbable sutures
 CONCLUSIONS
• It is suggested that
• The use of a slowly absorbable monofilament suture
• In a single layer aponeurotic closure technique
• Without separate closuren of the peritoneum and
• Using a small bites technique
• With a sw/wl ratio at least 4/1

Is the current recommended method of fascia closure

 CONCLUSIONS
• Currently, no recommendations can be given on the optimal
technique to close emergency laparotomy incisions

• Prophylactic mesh augmentation appears affective and safe and can

be suggested high risking patients like, aortic aneurysm surgery and
obese patients