1) The document provides guidelines for closing abdominal incisions to decrease the risk of incisional hernias and burst abdomen. 2) It recommends using a non-midline incision whenever possible, as well as continuous suturing with a slowly absorbable monofilament suture in a single layer for midline incisions. 3) The optimal technique remains unclear due to lack of high-quality evidence, but guidelines aim to optimize closure methods based on current best evidence.

1. Closure of elective
midline abdominal
incision:
European Hernia Society
2014 guidelines
Jibran Mohsin
Resident, Surgical unit I
SIMS/Services Hospital, Lahore

2. – Joint official journal of the
– European Hernia Society (GREPA), established in 1979,
– American Hernia Society (AHS) established in 1997 and
– Asia Pacific Hernia Society (APHS) established in 2004.
Hernia. 2015 Feb;19(1):1-24

3. ‘‘Maybe we should first learn and teach how to prevent incisional
hernias, rather than how to treat them?’’
SPERLONGA STATEMENT
(autumn board meeting of the EHS in September 2013 in Sperlonga, Italy)

4. 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

5. 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.

6. 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 sequelae of incisional hernia repairs

7. 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.

8. Objective
– Guidelines refer to patients undergoing any kind of abdominal wall incision, including
– visceral surgery,
– gynecological surgery,
– aortic vascular surgery,
– urological surgery or
– orthopedic surgery.
– Both open and laparoscopic surgeries are included in these guidelines.

10. Area open for
research

11. Query # 1
Which diagnostic modality is the most suitable to detect incisional hernias?

12. Ultrasound
(Dynamic abdominal sonography for hernia (DASH)
technique)
CT scan
MERIT • more accessible in most health care settings • reliable and reproducible
DEMERIT • more operator-dependant • radiation load
Which diagnostic modality is the most suitable to detect incisional
hernias?

13. Which diagnostic modality is the most suitable to detect incisional
hernias?

14. Which diagnostic modality is the most suitable to detect incisional
hernias?

15. Query # 2
Does the type of abdominal wall incision influence the incidence of
incisional hernias or burst abdomen?

16. 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

17. Does the type of abdominal wall incision influence
the incidence of incisional hernias or burst
abdomen?

18. Query # 3
What is the optimal technique to close a laparotomy
incision?

19. 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 of low quality. e.g.
– Different populations studied
– midline only or including other incisions,
– emergency or elective surgery, and
– different operative indications

20. What is the optimal technique to close a
laparotomy incision?

21. What is the optimal technique to close a
laparotomy incision?

22. Continuous suturing versus interrupted sutures
– Continuous suturing for closure of midline laparotomies was beneficial compared to
interrupted closure
– Significant lower incisional hernia rate for continuous suturing (p = 0.001) in elective surgery.
– No difference in case of emergency laparotomies.
– Continuous suturing was recommended in ER because it was significantly faster.
What is the optimal technique to close a
laparotomy incision?

23. What is the optimal technique to close a
laparotomy incision?

24. 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?

25. What is the optimal technique to close a
laparotomy incision?

26. 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 definitions 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?

27. Mass closure versus single layer closure
– For future research EHS proposes the following definitions
Mass closure Incision is closed with a suture bite including all layers of the abdominal wall
except the skin.
Layered closure Incision is closed with more than one separate layer of fascial closure
Single layer aponeurotic closure Incision is closed by suturing only the abdominal fascia in one layer.
What is the optimal technique to close a
laparotomy incision?

28. What is the optimal technique to close a
laparotomy incision?

29. 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 ratio of 4/1 (Jenkins’ Rule)
What is the optimal technique to close a
laparotomy incision?

30. What is the optimal technique to close a
laparotomy incision?

31. What is the optimal technique to close a
laparotomy incision?

32. 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?

33. What is the optimal technique to close a
laparotomy incision?

34. Query # 4
What is the optimal suture material to close a laparotomy incision?

35. 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).

36. What is the optimal suture material to close a
laparotomy incision?

37. 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 suture material to close a
laparotomy incision?

38. What is the optimal suture material to close a
laparotomy incision?

39. Monofilament
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?

40. What is the optimal suture material to close a
laparotomy incision?

41. – Concerning the size of the suture,
– no studies comparing directly the size of the sutures used to close abdominal wall incisions were
identified
– For the ‘‘small bites’’ technique, isrealsson et al. suggest to use a suture size USP 2/0 (USP = united
states pharmacopeia).
What is the optimal suture material to close a
laparotomy incision?

42. What is the optimal suture material to close a
laparotomy incision?

43. 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?

44. What is the optimal suture material to close a
laparotomy incision?

45. 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?

46. What is the optimal suture material to close a
laparotomy incision?

47. Query # 5
Is there a place for retention sutures when closing a laparotomy?

48. 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 sutures

49. Is there a place for retention sutures when closing a
laparotomy?

50. Query # 6
Post Operative Care
– Subcutaneous drain placement
– Post operative abdominal binders
– Post operative restriction of activity

51. 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 the occurrence of incisional
hernias of prescribing abdominal binders or restricting postoperative activity.

52. Post Operative Care
Subcutaneous drains in laparotomy incisions
– Prophylactic routine placement of subcutaneous
drains after laparotomy is occasionally used to
decrease wound complications:
– Infection,
– hematoma,
– seroma or
– wound dehiscence
– Disadvantages of routine use of subcutaneous
drains
– patient discomfort and pain at removal,
– hinder early mobilisation and
– demand additional nursing care.
Therefore, their use should be driven by a proven benefit.

53. 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.

54. Post Operative Care

55. Post Operative Care
Postoperative binders
– 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 dehiscence

56. Post Operative Care
Postoperative binders
– RCTS……….No significant improvement for the short-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.

57. Post Operative Care

58. 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.

59. Post Operative Care

60. Query # 7
– Prophylactic Mesh Augmentation
– Mesh Type
– Mesh Position
– Mesh fixation method

61. 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.

62. Prophylactic Mesh Augmentation

63. – Polypropylene mesh
– small pore/heavy weight mesh:
– prolene; ethicon
– premilene; B. Braun
– Large pore/light weight mesh: biomesh light P8; cousin biotech. (1 study)
– Polyglactin mesh (vicryl; ethicon) (1 study)
– Biological mesh (alloderm; lifecell) (1study)
Prophylactic Mesh Augmentation

64. Prophylactic Mesh Augmentation

65. which mesh position?
Prophylactic Mesh Augmentation
Mesh Position Number of studies done
Onlay 2
Retro-muscular 2
Pre-peritoneal 2
Intra-peritoneal (absorbable synthetic mesh) 1
Intra-peritoneal (non absorbable synthetic mesh) 0

66. Prophylactic Mesh Augmentation

67. 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 a self-fixating mesh
Prophylactic Mesh Augmentation

68. Prophylactic Mesh Augmentation

69. Query # 8
– Trocar wounds for laparoscopic surgery
– Trocar size
– Trocar type
– Closure of trocar wound

70. 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 validity of
results.
– No RCT’s or case-control studies available

71. Trocar wounds for laparoscopic
surgery

72. 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

73. Closure of trocar incisions
– No good quality comparative studies investigating different suture materials or
techniques for closure of trocar fascia defects.
– Prophylactic intraperitoneal placement of a ventral patch at the umbilical site in high-risk
patients
– reduces the incidence of trocar-site hernia from 18.5 to 4.4 %
Trocar wounds for laparoscopic surgery

74. Closure of trocar incisions
– 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

75. Trocar wounds for laparoscopic surgery

76. Trocar wounds for laparoscopic surgery

77. 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.

78. Single Incision Laparoscopic
Surgery

79. Validity of the guidelines
– 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.

80. Limitations

81. Limitations

82. 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.

83. Conclusions
– It is suggested that
– the use of a slowly absorbable monofilament suture
– in a single layer aponeurotic closure technique
– without separate closure of the peritoneum and
– using a small bites technique
– with a sl/wl ratio at least 4/1
is the current recommended method of fascial closure.

84. Conclusions
– Currently, no recommendations can be given on the optimal technique to close
emergency laparotomy incisions.
– Prophylactic mesh augmentation appears effective and safe and can be suggested in
high risk patients like, aortic aneurysm surgery and obese patients.

85. Available at surgicalpresentations