Tag Archives: Abdominal Wound Closure Techniques

The STITCH Trial. Small bites versus large bites for closure of abdominal midline incisions.

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“Incisional hernia is a frequent complication of abdominal operations with an incidence of 10–23%, which can increase to 38% in specific risk groups. In the USA 4 million to 5 million laparotomies are done annually, suggesting that at least 400 000–500 000 incisional hernias can be expected to occur every year. Incisional hernia is associated with pain and discomfort, resulting in a decreased quality of life. Moreover, incarceration and strangulation of abdominal contents can take place, for which emergency surgery is indicated, with associated morbidity and mortality. About 348 000 operations for incisional hernia are done every year in the USA with US$3·2 billion in annual associated costs. Prevention of
incisional hernia is therefore of paramount importance.”

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Negative Pressure Wound Therapy for Surgical-site Infection

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“Despite improvement in infection control, SSIs remain a common cause of morbidity after abdominal surgery. SSI has been associated with an increased risk of reoperation, prolonged hospitalization, readmission, and higher costs. Recent retrospective studies have suggested that the use of negative pressure wound therapy can potentially prevent this complication.”

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The STITCH trial: a summary

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One discussion this week mentioned the STITCH trial.

Reference: Deerenberg EB, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised control trial. Lancet. 2015 Sep 26;386(10000):1254-1260. doi: 10.1016/S0140-6736(15)60459-7.

Summary: Incisional hernia is a frequent complication of abdominal operations with an incidence of 10–23%, which can increase to 38% in specific risk groups. It is associated with pain and discomfort, resulting in a decreased quality of life. Incarceration and strangulation of abdominal contents can take place, for which emergency surgery is indicated, with associated morbidity and mortality. The authors (2015) estimate about 348,000 operations for incisional hernia are done every year in the US with $3.2 billion in annual associated costs.

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Mesh sutured repairs of the abdominal wall

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“All high-tension internal surgical closures require that the ultimate tensile strength (UTS) of the repair remains greater than the forces applied. Otherwise, changes at the suture/tissue interface (STI) will lead to acute or chronic suture pull-through and surgical failure. For the abdominal wall, prophylactic flat meshes have been shown to improve outcomes of laparotomy closures and hernia repairs. Unfortunately, flat planar meshes have their own drawbacks, including increased time for placement, increased foreign material, increased tissue dissection, pain, infection, and cost.”

“One hundred and seven patients underwent a mesh sutured abdominal wall closure. Seventy-six patients had preoperative hernias, and the mean hernia width by CT scan for those with scans was 9.1 cm. Forty-nine surgical fields were clean-contaminated, contaminated, or dirty. Five patients had infections within the first 30 days. Only one knot was removed as an office procedure. Mean follow-up at 234 days revealed 4 recurrent hernias.”

Lanier, S. T., et al (2016). Mesh Sutured Repairs of Abdominal Wall Defects. Plastic and reconstructive surgery. Global open, 4(9), e1060. Free Full Text

The impact of abdominal incisional closure techniques on rates of fascial dehiscence

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Tolstrup MB, Watt SK, Gögenur I. Reduced Rate of Dehiscence After Implementation of a Standardized Fascial Closure Technique in Patients Undergoing Emergency Laparotomy. Ann Surg. 2017 Apr;265(4):821-826.

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RESULTS: We included 494 patients from 2014 to 2015 and 1079 patients from our historical cohort for comparison. All patients had a midline laparotomy in an emergency setting. The rate of dehiscence was reduced from 6.6% to 3.8%, P = 0.03 comparing year 2009 to 2013 with 2014 to 2015. Factors associated with dehiscence were male gender [hazard ratio (HR) 2.8, 95% confidence interval (95% CI) (1.8-4.4), P < 0.001], performance status ≥3 [HR 2.1, 95% CI (1.2-3.7), P = 0.006], cirrhosis [HR 3.8, 95% CI (1.5-9.5), P = 0.004], and retention sutures [HR 2.8, 95% CI (1.6-4.9), P < 0.000]. The 30-day mortality rate was 18.4% in the standardized group vs 22.4% in 2009 to 2013, P = 0.057 and 90-day mortality 24.2% vs 30.4%, P = 0.008.

CONCLUSION: The standardized procedure of closing the midline laparotomy by using a “small steps” technique of continuous suturing with a slowly absorbable (polydioxanone) suture material reduces the rate of fascial dehiscence.

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WARC Journal Club: STITCH Trial

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Deerenberg EB, Harlaar JJ, Steyerberg EW, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet. 2015 Sep 26;386(10000):1254-1260.

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FINDINGS: Between Oct 20, 2009, and March 12, 2012, we randomly assigned 560 patients to the large bites group (n=284) or the small bites group (n=276). Follow-up ended on Aug 30, 2013; 545 (97%) patients completed follow-up and were included in the primary outcome analysis. Patients in the small bites group had fascial closures sutured with more stitches than those in the large bites group (mean number of stitches 45 [SD 12] vs 25 [10]; p<0·0001), a higher ratio of suture length to wound length (5·0 [1·5] vs 4·3 [1·4]; p<0·0001) and a longer closure time (14 [6] vs 10 [4] min; p<0·0001). At 1 year follow-up, 57 (21%) of 277 patients in the large bites group and 35 (13%) of 268 patients in the small bites group had incisional hernia (p=0·0220, covariate adjusted odds ratio 0·52, 95% CI 0·31-0·87; p=0·0131). Rates of adverse events did not differ significantly between groups.

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