Page 118 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

Chapter 5
on the strength of recommendation (weak or strong). For this reason, an additional meta-analysis was performed (Figure 2). Although the e ect size in favour of mesh augmentation is large and consistent over the studies, the Guidelines Development Group felt that larger trials are needed to support a strong recommendation for prophylactic mesh augmentation in high-risk patients. Indeed, the number of patients in the reported studies for each risk group separately (e.g. abdominal aortic aneurysm, obesity surgery, oncological surgery) seems too low to recommend prophylactic mesh augmentation in all these patient groups. Nevertheless, we are aware that several large RCT’s are on-going and this grade of recommendation might be changed in the light of future publications.
No recommendations could be made on non-midline incisions due to insu cient evidence. Nevertheless, it seems reasonable to promote similar material (slowly absorbable suture) and techniques (continuous aponeurotic closure with small bites and SL/WL >4/1) for closure of non-midline incisions.
No recommendations could be made on the type or the size of the needle used to close abdominal incisions. No studies comparing the size of the sutures were identi ed in our searches.
No recommendation could be made for emergency surgery, which is often a contaminated procedure. The Guidelines Development Group consider that the use of retention sutures or of reinforced tension line sutures, should be prospectively studied in patients at high risk for development of burst abdomen. A risk model and score for burst abdomen has been developed by van Ramshorst et al.(141) and could be used as basis for including patients in these studies.
No recommendations could be made on the postoperative care after laparotomies. Long-term follow-up studies are needed to assess the impact on the occurrence of incisional hernias of prescribing abdominal binders or restricting or indeed encouraging early postoperative activity.
Applicability
To adopt the guidelines and “evidence based principles” for abdominal wall closure, surgeons must be convinced that these are valid recommendations with a large impact on the outcome for the patients. These guidelines are an attempt to create awareness amongst surgeons about these principles. Adaptation can be done by systematic quality control of the suturing technique
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