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5 Wound Closure and Postoperative Hernia Prevention Strategies
43
is preferred based on the fact that this method is
faster, easier, and can, thus, save operating time
[ 25 , 32 , 33 ].
Suture Length to Wound Length Ratio
The suture length to wound length ratio has been
an underestimated variable of abdominal wall
closure. It comprises the length of the suture
material in relation to the length of the wound and
it relates the size of the stitches and the interval
between them [ 34 ]. In general, many surgeons
have been trained to use large stitches (tissue
bites) for abdominal wall closure. Large stitches
have been described as sutures placed at 10 mm
distance from the wound edge and at intervals of
10 mm. Small stitches, on the other hand, are
placed at 5–8 mm distance from the wound edge
and stitch intervals of less than 5 mm [ 34 ].
It has been shown in several animal experiments that high suture tension is associated
with impaired collagen synthesis, wound weakness, and increased tissue necrosis and infec-
tion. There is strong evidence that a suture
length to wound length ratio of at least 4:1
should be used for closure of the abdominal
wall to minimize the risk of incisional hernia
[ 34 , 35 ]. A suture to wound length ratio of less
than 4:1 has been associated with a threefold
increased risk of developing incisional hernia
[ 35 ]. Millbourn et al. also described that a lin-
ear correlation exists between the stitch length
and the risk of developing wound infection. In
order to achieve a suture length to wound length
ratio of at least 4:1, it has been recommended to
measure and document the achieved ratio for
each patient [ 36 ].
This ratio can be achieved by placing many
bites at close intervals, or by placing fewer bites
at greater intervals. As a simple rule, the length
between stitches must not exceed the distance
between the fascia edge and the stitch (Fig. 5.1 ).
An experimental study in animals by Cengiz
et al. showed higher wound tensile strength after
4 days when small stitches were used [ 37 ]. Other
clinical studies performed on this topic by
Israelsson, Millbourn, and the STITCH study
group also supported that wound closure should
Fig. 5.1 Examples of
small bites and large
bites techniques
44
A. Jairam et al.
Fig. 5.2 Median laparotomy wound in obese patient, closure of aponeurosis with small stitches using PDS
antibacterial (polydioxanone) 2-0 suture (Courtesy of Dr.
A.G. Menon, surgeon, Havenziekenhuis Rotterdam,
Rotterdam, the Netherlands)
®
Plus
be performed with small stitches [ 34 , 35 , 38 , 39 ].
A clinical example of the small stitches technique
is shown in Figs. 5.2 and 5.3 . Small stitches have
been associated with a decre ased risk of incisional hernia and surgical site infections. In the
Swedish randomized trial by Millbourn et al.,
incisional hernia was found in 49/272 patients
(18.0%) in the large stitch group and in 14/250
patients (5.6%) in the small stitch group
( p < 0.001). Also, 1/381 patients with large bites
developed abdominal wound dehiscence compared to none of the 356 allocated to the small
bites technique (0.3% vs. 0%, p > 0.99) [ 34 ].
The STITCH trial (Suture Techniques to
reduce the Incidence of The incisional Hernia)
was a randomized controlled trial, in which the
large bites technique was compared with the
small bites technique. In the large bite technique
the bite width was 1.5 cm and the intersuture
space 1 cm. In the small bites technique, bite
Fig. 5.3 Result after closure of median laparotomy
wound with small bites; a SL:WL ratio of 6:1 was
achieved (Courtesy of Dr. A.G. Menon, surgeon,
Havenziekenhuis Rotterdam, Rotterdam, the Netherlands)
widths and inter suture spacing of 0.5 cm were
applied. The primary endpoint of the study was
incisional hernia after 1 year postoperatively. The
study showed that the incidence of incisional hernia at 1 year was statistically signifi cantly lower
(13% vs. 21%) in the small bites group. In addition, 2/284 patients in the large bites group developed abdominal wound dehiscence vs. 4/276
patients in the small bites group (0.7% vs. 1.4%,
p = 0.392) [ 38 ]. In the Swedish study, multivari-
ate analysis showed that patients treated with
large stitches were exposed to a relative risk of 2
for infection and 4 for incisional hernia. In the
STITCH trial, small stitches were not associated
with decreased rate of surgical site infection and
neither study was adequately powered for detection of a statistically signifi cant difference in the
incidence of abdominal wound dehiscence.
However, the STITCH trial confi rmed that the
small bites technique is superior compared to
5 Wound Closure and Postoperative Hernia Prevention Strategies
45
the large bites technique in the prevention of
incisional hernia after closure of abdominal
midline wounds.
The positive effects of small stitches on wound
healing can be explained as follows: the aponeurosis has limited possibilities for regeneration and
cannot bridge over a large defect [ 6 ]. With a large
stitch, not only aponeurosis tissue is included, but
also fat and muscle. In combination with increased
intra-abdominal pressure, soft tissue can be compressed and damaged. This can result into slackening and separation of wound edges, tissue
devitalization, and infection. A separation of
wound edges of more than 12 mm during the fi rst
postoperative period has been strongly associated
with development of incisional hernia [ 3 ]. Closing
patients with the use of small stitches has been
associated with longer operation time of 4–5 min
[ 34 , 36 ]. However, if the reduced incidence of
incisional hernia (repairs) is taken into account,
using small stitches should be considered a safe,
easy, and cost-effective method [ 39 ]. In conclu-
sion, the ideal suture technique for closing of the
fascia should be with performed with a continuous mass technique, using slowly absorbable
suture material and suture to wound length ratio
of 4 to 1 [ 40 ].
Preventive Abdominal Binders
Prevention of abdominal wound dehiscence and/
or incisional hernia by using preventive abdominal binders is highly surgeon-dependent. In
some countries, abdominal binders and/or corsets are widely used in spite of the fact that the
effects of these medical aids have been disputed
[ 41 ]. The prescription of these binders is moti-
vated by the conception that externally applied
pressure may help in diminishing chances of
developing postoperative seroma and dehiscence
of fascial edges, thereby preventing abdominal
wound dehiscence and incisional hernia. In midline laparotomy, fascial edges are tended toward
separation instead of approximation by the
forces exerted by contractions of the oblique and
transverse abdominal muscles. In theory, it
seems unlikely that lateral forces separating fascia edges will be diminis hed by externally
applied forces exercised by abdominal binders.
Clinical studies on the use of abdominal binders
are scarce, but in one study patients reported to
have abandoned wearing supportive corsets and/
or binders due to perceived discomfort, whereas
another study reported increased patient comfort
[ 42 , 43 ]. Moreover, it is imaginable that dimin-
ished elasticity of the abdominal wall could
result in lower abdominal—and thereby, thoracic
volume, with less possibility for lung expansion.
The use of abdominal binders should, therefore,
be considered carefully and weighed against
potential risks of lung atelectasis and possible
pneumonia.
Primary Mesh Augmentation
Placement of mesh to prevent incisional hernia has
been investigated in several studies since the mid1990s of the previous century. Its use has primarily
been investigated in high-risk patient groups, such
as patients with abdominal aortic aneurysms and
obesity. In these patient groups, incidences of incisional hernia of up to 38% and 50% have been
found, respectively [ 2 , 9 , 12 , 44 , 45 ]. Different
mesh positions are possible in primary mesh augmentation. In the onlay position, mesh is placed on
the anterior rectus fascia. The sublay technique
comprises the positioning of the mesh on the posterior rectus fascia and peritoneum (Figs. 5.4 , 5.5
and 5.6 ). In the preperitoneal technique, mesh is
placed directly on the peri toneum.
Bhangu et al. published a systematic review
in which randomized controlled trials and prospective cohort studies were included [ 46 ].
Recently, Timmermans et al. conducted a metaanalysis which included randomized controlled
trials only [ 47 ]. All studies featured in the
review by Bhangu et al. were high-risk patients
for incisional hernia, such as patients with connective tissue disorders (including abdominal
aortic aneurysm), obesity, or other relevant
comorbidity. Bhangu et al. concluded that the
rate of incisional hernia was signifi cantly
reduced (OR 0.15, p < 0.001) after primary mesh
placement (3.9%, 9/238), compared with primary suture repair (22%, 67/305). There was,
however, an increased rate of postoperative
46
A. Jairam et al.
Fig. 5.4 Preparation of closure of median laparotomy
with prophylactic mesh: continuously sutured posterior
rectus fascia using PDS
(Courtesy of Dr. I. Dawson, surgeon, Ijsselland Ziekenhuis,
Capelle aan den Ijssel, the Netherlands)
®
(polydiaxonone) 0 suture
seroma formation in the mesh group (12.9%,
26/201 vs. 6.9%, 18/262 in the suture group),
with a borderline signifi cant p -value of 0.050.
With a random effect model, no signifi cant
increase in seroma rate was found (OR 1.86,
p = 0.210). Incidences of surgical site infections
and hematomas were comparable for both
groups. There was an increased rate in chronic
pain for the mesh group, although this increase
was non-signifi cant [ 46 ].
In the meta-analysis by Timmermans et al.,
fi ve randomized controlled trials were included.
In one of these trials, primary (polypropylene)
mesh augmentation was compared to primary
suture repair. The outcome data were pooled, and
the authors also concluded that incisional hernia
occurred signifi cantly less in the group with primary mesh augmentation (RR 0.25, 95% CI
0.12–0.52, p < 0.001). There were no statistically
signifi cant differences between the groups of primary mesh augmentation and primary suture
repair with regard to wound infection, seroma
formation, and chronic pain. However, a trend
was found of more chronic pain in the primary
mesh augmentation group. Some important outcome measurements, such as hematoma, operation
Fig. 5.5 Prophylactic
Progrip™ mesh in
retrorectus position. The
mesh is fi xated using
interrupted polyglactin
910 3-0 sutures
(Courtesy of Dr.
I. Dawson, surgeon,
Ijsselland Ziekenhuis,
Capelle aan den Ijssel,
the Netherlands)
5 Wound Closure and Postoperative Hernia Prevention Strategies
Fig. 5.6 Closure of
anterior rectus fascia
over Progrip™ mesh
in retrorectus
position using PDS
(polydiaxonone) 0
suture (Courtesy of
Dr. I. Dawson, surgeon,
Ijsselland Ziekenhuis,
Capelle aan den Ijssel,
the Netherlands)
®
47
time, quality of life, and cost-effectiveness, were
not reported in all of the included studies [ 47 ].
Not included in the aforementioned metaanalyses was a randomized clinical study by Caro
Tarrago et al. This study included (mainly) oncological patients with elective midline laparotomies. In this RCT, published in March 2014, it
was shown that placement of prophylactic mesh
in supra-aponeurotic position was associated
with a reduction of incisional hernia. The likelihood of incisional hernia at 12 months for patients
with mesh placement was 1.5%, compared to
35.9% in the group without mesh ( p < 0.0001)
[ 12 ]. Signifi cantly, more seromas were found in
the mesh group (29% vs. 11%, p < 0.01).
There are no studies available in which different mesh types have been compared. In one study,
biological mesh was used (Alloderm, Lifecell,
Branchburg, NJ, USA), whereas in all other studies polypropylene mesh was used. In the study by
Caro-Tarrago et al., a large pore/lightweight
polypropylene mesh was used (Biomesh Light,
Cousin), but in all other studies small pore,
heavyweight meshes were used. Different meth-
ods of mesh position and mesh fi xation were
used. In none of the studies different mesh positioning techniques were compared. The onlay
technique is, in general, the easiest and quickest
way, but has been associated with increased
seroma formation and wound infections.
With regard to primary mesh augmentation,
limited data are available concerning secondary
outcomes such as quality of life or cost- effectiveness
of mesh placement. Placement of a preventive
mesh could potentially lead to complications or
re-operations with adverse effects on quality of life.
Long-term follow-up results of these studies will
provide the surgical community with more evidence regarding the possible benefi ts of primary
mesh augmentation in selected patient group s.
Future Perspectives
Several trials are currently in progress, and the
results of these studies are expected to infl uence
daily practice in hernia surgery. The Dutch
PRIMA trial will be the fi rst trial to be published
48
A. Jairam et al.
comparing different mesh positioning techniques: primary mesh augmentation in onlay
or sublay position, compared to primary suture.
Other upcoming trials include the PRIMAAT
trial from Belgium, the results of which are
expected shortly as well. The ProphMesh group
from Switzerland compares Dynamesh IPOM
with primary suture in high-risk patients. The
Austrian Hernia Study group set up another
RCT, comparing onlay mesh with primary
suture, and the fi ndings of this study are expected
in 2016.
The use of preventive mesh with abdominal
wound dehiscence as primary end point has not
been studied extensively. The methods reported
in older literature include intraperitoneal polyglactin 910 mesh compared to either polyamide
mesh glued to the skin or extraperitoneal retention sutures. Three studies published on this
topic were of poor quality, including small or
incomparable patient groups or had non-randomized designs [ 48 – 50 ]. Recently, an interna-
tional multicenter study was ended prematurely
mainly due to low patient enrollment. Patients
with fascial dehiscence were randomized
between Strattice ® Reconstructive Tissue
Matrix (Lifecell) placed either as an intraperitoneal underlay or as retro-rectus sublay, or
standard repair by re-approximating wound
edges using sutures with or without absorbable
(polyglactin) mesh. The endpoints of the study
were occurrence of incisional hernia, fascial
redehiscence, and other adverse events.
Eventually, 18 patients were treated with
Strattice ® and 19 patients with standard repair.
The incidence of fascial redehiscence was sig-
®
nifi cantly lower after Strattice
repair (5.6%
vs. 36.8%, p = 0.015), whereas no increase in
adverse events was found. In spite of low
patient numbers, the results of this study plead
for use of biological mesh in patients with fascial dehiscence, in spite of the implicated high
costs (Jeekel J, presented at congress of
European Hernia Society 2014 in Edinburgh).
Personal Thought on Patient, Technique and Mesh Selections
On principle, minimally invasive techniques should
be considered in every patient undergoing abdominal surgery. If minimally invasive techniques cannot be used, a transverse or paramedian incision
should be considered. If a midline laparotomy is
chosen, the abdominal fascia should be closed in a
continuous fashion using slowly absorbably suture
material with small bites and a suture length to
wound length ratio of 4:1. In high-risk patients,
such as patients with abdominal aortic aneurysms
or obesity, primary mesh augmentation should be
considered. Poly propylene mesh in sublay position
might be preferred over onlay position based on a
lower risk of wound morbidity. Figure 5.7 shows a
fl ow chart which can be followed for patients
undergoing abdominal surgery.
Personal Tips and Tricks: Small Bites and Prophylactic Mesh Placement
All patients diagnosed with an aneurysm of the
abdominal aorta, undergoing a midline laparotomy, should receive a mesh to prevent an incisional hernia. For the small bites technique , a
slowly absorbable 2–0 single suture with a
36-mm needle should be chosen. It should be
recommended to have sterile rulers included in
all laparotomy instrument sets to facilitate sterile
measuring of the wound length and length of
suture remnants. Standard measurement and documentation of the achieved suture length to
wound length ratio could contribute to shortening of the learning curve and to the process of
quality monitoring.
5 Wound Closure and Postoperative Hernia Prevention Strategies
Fig. 5.7 Flowchart for
patients undergoing
abdominal surgery
49
Abdominal surgery
Minimally invasive
possible?
Yes
No
Midline incision
avoidable?
Yes No
High Risk
Patient?
Yes
Prophylactic
Mesh
No
Small
stitches
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