Page 347 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

In Chapter 1 the subject of this thesis, incisional hernia (IH), is introduced. IH is the most frequent complication following abdominal surgery, and has great impact on patients’ lives, as well as being a burden in terms of healthcare costs. Several patient factors and technical aspects play a role in the development of IH. As stated back in 1914 by Sir Victor Horsley, the radical cure of a hernia is best represented by its prevention.
Part 1. Prevention and incidence of incisional hernia
In the rst part of the thesis, research is presented which determines the technical aspects of surgery that in uence the development of IH.
Chapter 2 describes the design of a multicentre randomized controlled trial (RCT) – the STITCH trial – to compare the upcoming ‘small bites’ suture technique to the generally performed ‘large bites’ suture technique of the midline fascia after laparotomy. Across 10 participating hospitals, 560 patients were randomly allocated to these two techniques. The ‘small bites’ technique consisted of a running suture with small tissue bites of 5 mm and a stitch every 5 mm, performed with a 2-0 polydioxanone (PDS®) suture, with a 31 mm needle. The ‘large bites’ technique consisted of a running suture with large tissue bites of 1 cm and a stitch every 1 cm, performed with a 1 double loop PDS® suture, with a 48 mm needle.
In Chapter 3, the results of the STITCH trial are presented. Patients in the small bites group had fascial closures sutured with signi cantly more stitches than those in the large bites group (mean number of stitches 45 [SD 12] vs 25 [10]); a signi cantly higher ratio of suture length to wound length (5.0 [1.5] vs 4.3 [1.4]); and a signi cantly longer closure time (14 [6] vs 10 [4] min). During follow-up, radiological imaging of the abdominal wall was performed in 76% of patients. At 1-year follow-up, 57 (21%) of the 277 patients in the large bites group, and 35 (13%) of the 268 patients in the small bites group, had developed IH (p=0.0220, covariate adjusted odds ratio 0.52, 95% Con dence Interval 0.31– 0.87; p=0.0131). Rates of adverse events did not di er signi cantly between the two groups.
Chapter 4 presents the ndings of a systematic review and meta-analysis performed to analyze the evidence from RCTs on the optimal method or suture material for closing the midline fascia. When using the same suture technique,
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