Journal club's lecture, department of General surgery 13th of september, 2018 By: Yousef El-Ayman, Master degree

1. guidelines on the
closure of abdominal
wall incisions
And decreasing incidence of incisional hernia

2. Magnitude of the problem
‘‘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)

3. Incidence rate:
• Incidence of incisional hernia (IH) after 2 years was 12.8% in a systematic review and
meta-regression study (2014).
• Rises up to 69 % in high-risk patients with long term follow-up!
• Incidence is determined by several factors: the study population, the type of incision,
the length of follow-up and the method of diagnosis.
• Risk factors for IH include postoperative surgical site infection (SSI), obesity and
abdominal aortic aneurysm.
• Nevertheless,
it seems that 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
Magnitude of the problem

4. • The development of IH has a big negative impact on the patients’ quality of life and
body image.
• Furthermore, the repair of IH still has a high failure rate with long term recurrence rates
above 30%, even with mesh repair is performed.
• Optimizing the surgical technique to close abdominal wall incisions holds a potential to
prevent patients suffering from incisional hernias and the potential sequelae of their
repairs
• The mean direct and indirect costs for the repair of an average incisional hernia in an
average patient in France in 2011 was € 7,089
Magnitude of the problem

5. Classification
The predicament of classification
‘‘Despite the magnitude of the problem, we do not have a classification that is simple, repro
ducible and internationally accepted’’
Schumpelick, 2000
• Without a unified classification of Hernia, studies on the subject were like comparing
“apples and oranges”.
• Severel classifications were proposed, none was widely accepted. They widely varied
regarding parameters that should be included in classification:
Size of defect (width or length or diameter or suface area??), size of sac, number of
defects, BMI, Abdominal wall/defect ratio, abdominal volume/sac volume ratio, primary
or incisional, recurrence, previous mesh, indication of first operation, type of incision,
symptoms, reducibility, other risk factors…..

6. Classification

7. Classification: The EHS
The European Hernia Society (EHS) Classification of 2009
Separating hernia into two entities, each with a different classification:
• Primary abdominal wall hernias
• Incisional abdominal wall hernias
A recurrent hernia after primary hernia repair is considered an incisional hernia (The term
“Primary incisional hernia” shouldn’t be used)
Parastomal hernias – although by definition are incisional hernias – are excluded from this
classification, being a distinct group with specific properties and treatment options

8. Classification: The EHS
The European Hernia Society (EHS) Classification of 2009

9. Classification: The EHS
The European Hernia Society (EHS) Classification of 2009
Definition of Incisional Hernia:
Any abdominal wall gap with or without a bulge in the area of a
postoperative scar perceptible or palpable by clinical examination or
imaging.

10. Classification of IH
Localization

11. Classification of IH
Size

13. The EHS guideline
European Hernia Society guidelines on the closure of
abdominal
wall incisions (2014)

14. Clinically irrelevant
All evidence regarding optimal diagnostic method is low evidence
CT is more reliable X radiation load
US is more accessible X operator dependant
Dynamic Abdominal Sonography for Hernia (DASH) technique: done by the surgeon
not radiologist – currently believed to be the best diagnostic modality
Discrepancy between clinical and radiological detection matters only for follow up
incidence studies.
Diagnosis

15. Non mid-line
Non-midline (Transverse or Para-median) carry a significantly lower risk of IH
Transverse incisions: (RR = 1.77; 95 % CI:1.09–2.87)
paramedian incisions (RR = 3.41; 95 % CI: 1.02–11.45),
but not burst abdomen
Type of incision

16. “Abdominal closure: if it looks all right, it’s too tight – if it looks
too loose, it’s all right.”
Matt Oliver
Closure technique

17. Layers:
No Clear definitions of layered or Mass closure
Proposed definitions by the Guidelines Development Group
• Mass closure: the incision is closed with a suture bite including all layers of the abdominal
wall except the skin
• Layered closure: the incision is closed with more than one separate layer of fascial closure
• Single layer aponeurotic closure: the incision is closed by suturing only the abdominal
fascia in one layer.
Closure technique

18. Continuous suture show significantly lower rates of IH. (OR 0.59: p = 0.001)
But with high risk of bias – continuous favored for speed
No short or long term benefits from closure of peritoneum
Closure technique

19. Suture Length (SL): Wound Length (WL)
The beneficial effect of high SL/WL ratio has been long recognized, but scarcely studied
The critical value was determined as 4:1
Although this value is often mentioned in studies, many fail the actual documentation on
study subjects
Closure technique

20. Bites:
‘‘small bites’’ technique resulted in significant less IH (5.6% vs 18.0%; p<0.001),
and less surgical site infections (5.2% vs 10.2%; p = 0.02).
In the small bite technique the wound is closed with a single aponeurotic layer, taking bites of
fascia of 5–8 mm and placing stitches every 5 mm.
Closure technique

21. Absorbability:
Slowly or non-absorbable sutures are associated with significantly less risk of IH than rapidly
absorbable sutures (OR 0.65: p = 0.009)
No difference in risk between slowly and non-absorbable sutures regarding IH, but there is
higher risk of prolonged wound pain and sinus formation with non-absorbable sutures.
Suture material

22. Structure:
Monofilament suture material are believed to be associated with lower risk of Surgical Site
Infection SSI than multifilament suture
ALL slowly absorbable sutures are monofilament sutures
No studies compared sutures’ size directly,
But for the “small bites technique, suture size of 2/0 was recommended
Suture material

23. Antibiotic “Triclosan” coated sutures:
Triclosan coated sutures have a significantly beneficial effect in prevention of SSI, but no data
on incidence of IH can are available on this studies.
Suture material

24. Suture needles and tension “retention” sutures:
Suture material

25. These recommendations regarding techniques and sutures can not be generalized over emergency or
non mid-line laparotomies.
Limitations

26. List of suture materials

27. Postoperative management and instructions for patients are not supported by high quality data,
but rely mostly on surgeons’ habits, tradition and common beliefs.
Long-term follow-up studies are needed to research the impact of abdominal binders or
restricting postoperative activity.
Some studies found Abdominal binders to be beneficial for pain reduction and mobilization, but
no data on burst abdomen or IH
There is no evidence of any benefit from post-operative restriction of activity on incidence of IH,
nor there is consensus in practice on the level or duration of restriction.
Post-operative care

28. The use of prophylactic mesh for closure of elective laparotomies in high risk group (e.g. obese
or aortic aneurysm patients) is suggested,
However this suggestion is founded mainly on a single trial, and larger trials are needed.
There is no data available favouring one mesh type, position or fixation method over the other
for prophylactic closure.
Prophylactic Mesh

29. N.B:
A recent Meta-analysis (Payne et al. 2017) was published, adding two
more studies (109 patients) to the previously collected studies, and
strengthening the evidence in favour for prophylactic mesh
augmentation in high risk groups.
Prophylactic Mesh

30. Most data regarding incidence of trocar site hernia after laparoscopic operations are deficient in
quality and have many limitations hampering generalization of their results.
However, available studies favor the use of smaller trocars and fascial closure for trocars ≥
10mm.
The most recent meta-analysis shows higher incidence of Trocar site hernia after single incision
compared to multiple incision laparoscopic operation, as well as fascial enlargement for
specimen extraction.
Trocar site hernia

31. Trocar site
There is no good quality data regarding the optimal closure technique for trocar defect.
One study demonstrated the benefit of using a prophylactic mesh at the umbilical site in high
risk patients for reducing the incidence of trocar site hernia from 18.5 to 4.4 % (OR 10.1: CI 2.15
–47.6; p<0.001).
Larger studies with longer follow-up are needed in that area.

32. Current research areas
NPWT
Many RCTs and Meta-analysis studies are currently being published regarding the use of
“Negative Pressure Wound Therapy (NPWT)” or “Vacuum Assisted Closure (VAC)” for patients
at high risk of surgical site complications after laparotomy e.g. contaminated GIT surgery or
obese patients:
• Meta-Analysis of Comparative Trials Evaluating a Prophylactic Single-Use Negative
Pressure Wound Therapy System for the Prevention of Surgical Site Complications.
(2017)
• Prophylactic negative-pressure wound therapy after cesarean is associated with
reduced risk of surgical site infection: a systematic review and meta-analysis. (2018)
• A systematic review and meta-analysis including GRADE qualification of the risk of
surgical site infections after prophylactic negative pressure wound therapy compared
with conventional dressings in clean and contaminated surgery. (2016)
• Does negative pressure wound therapy applied to closed incisions following ventral

33. Current research areas
Hughes abdominal repair:
The “Hughes repair,” also known as the “Cardiff repair,” is a standard mass closure combined
with a series of horizontal and 2 vertical mattress sutures within a continuous suture.
It is thought to distribute the load both along and across the incision length and so, theoretically
avoids ischemia and suture pull-through.
The Hughes Abdominal Repair (HART) Trial is a protocol for a prospective, randomized
controlled trial at 28 centers throughout the United Kingdom that will compare the
“Hughes closure” to the surgeons’ customary suture techniques.

34. Current research areas
Hughes abdominal repair:

35. Current research areas
Hughes abdominal repair:
Demonstration Video:
https://www.youtube.com/watch?v=pn1Yq_ID3w0&hd=1
Or
https://www.facebook.com/yousef.elayman/videos/pcb.283280505618407/10215184447997820/
?type=3&theater&ifg=1

36. Current research areas
T-line mesh:
Conventional mesh often fails at the suture-line. This may be because the suture slices through
mesh or tissue because the tensile stress of the abdominal wall exceeds the tensile strength of
the anchoring sutures.
Levinson and colleagues have developed a novel mesh prosthetic. The T-line hernia mesh
contains seamless, uninterrupted extensions continuous with the mesh body that are 15-fold the
surface area of standard suture.

37. Current research areas
T-line mesh:

38. Take-home message
1. Utilize a non-midline incision whenever possible.
2. Perform a continuous suturing technique.
3. Avoid rapidly absorbable sutures.
4. Use a slowly absorbable monofilament suture in a single layer closure technique
without separate closure of the peritoneum.
5. Use a small bites technique with a SL / WL ratio at least 4/1. (with actual
measuring and documentation of the ratio.)
1. Prophylactic mesh augmentation appears effective and safe and suggested in
high-risk patients like aortic aneurysm surgery and obese patients.
7. In laparoscopic surgery: use small trocars when possible, close defects≥10mm,
multiple incision technique is preferred over single incision.

39. References
1. Muysoms, F. E., Antoniou, S. A., Bury, K., Campanelli, G., Conze, J., Cuccurullo, D.,
Berrevoet, F. (2015). European Hernia Society guidelines on the closure of abdominal
wall incisions. Hernia, 19(1), 1–24. https://doi.org/10.1007/s10029-014-1342-5
2. Muysoms, F. E., Miserez, M., Berrevoet, F., Campanelli, G., Champault, G. G.,
Chelala, E., … Kingsnorth, A. (2009). Classification of primary and incisional
abdominal wall hernias. Hernia, 13(4), 407–414. https://doi.org/10.1007/s10029-009-0
518-x
3.Payne, R., Aldwinckle, J., & Ward, S. (2017). Meta-analysis of randomised trials
comparing the use of prophylactic mesh to standard midline closure in the reduction
of incisional herniae. Hernia, 21(6), 843–853. https://doi.org/10.1007/s10029-017-165
3-4
4.Harris, H. W., Hope, W. H., Adrales, G., Andersen, D. K., Deerenberg, E. B., Diener, H
.,Young, D. M. (2018). Contemporary concepts in hernia prevention: Selected
proceedings from the 2017 International Symposium on Prevention of Incisional
Hernias. Surgery, 164(2), 319–326. https://doi.org/10.1016/j.surg.2018.02.020
5. Ibrahim, M. M., Poveromo, L. P., Glisson, R. R., Cornejo, A., Farjat, A. E., Gall, K., &
Levinson, H. (2018). Modifying hernia mesh design to improve device mechanical
performance and promote tension-free repair. Journal of Biomechanics, 71, 43–51.
https://doi.org/10.1016/j.jbiomech.2018.01.022