Page 27 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

Background
The median laparotomy is frequently used by abdominal surgeons to gain rapid and wide access to the abdominal cavity with minimal damage to nerves, vascular structures and muscles of the abdominal wall. However, incisional hernia remains the most common complication after median laparotomy, with reported incidences varying between 2-20%(1-5). Even higher incidences up to 30-35% have been reported in obese and aortic aneurysm patients(6-10). Incisional hernia can cause discomfort, impair quality of life or result in serious life-threatening conditions, such as incarceration or strangulation of the bowel(5). Median laparotomies and incisional hernias have been subject of investigation for a long period of time already. Although a lot is known about patient related risk factors and suture materials, technical risk factors such as suture techniques have not been investigated thoroughly(5, 11, 12).
For prevention of incisional hernia, many clinical trials and meta-analyses have demonstrated that a mass closure technique with a simple running suture is the best option to close a midline incision. A mass closure technique with a running suture is also easier and quicker to perform than layered techniques with interrupted sutures(5, 12-14). Furthermore, the use of slowly absorbable suture material compared with non-absorbable suture material decreases the incidence of incisional hernia, and it also lowers the incidence and intensity of postoperative pain and wound infection(12, 15, 16).
Suture length to wound length ratio and small bites
Several authors have stated that a suture length to wound length ratio (SL:WL) of four or more must be achieved, since a lower ratio is associated with an increased rate of incisional hernia(7, 17-20). It has often been recommended to place continuous stitches more than 10 mm from the wound edge in combination with a long stitch length(19, 21-28). A long stitch is the result of a large bite with the largest portion of fascia possible, aiming to increase tensile strength and to decrease the risk of fascial dehiscence. However, long stitches have been associated with high rates of both wound infection and incisional hernia(17, 29, 30). A long stitch length may be associated with higher risks of wound infection due to an increase in the amount of necrotic tissue within the wound. In experimental studies, the long stitch length has been found to compress or cut through soft tissue included in the stitch(31, 32). The risk
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STITCH protocol
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