Page 58 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

Chapter 3
by studies for elective laparotomies can be extrapolated to emergency laparotomies remains a topic of discussion.
We hypothesise that the small bite suture technique in our trial, with twice the amount of stitches including the aponeurosis only, provides close to ideal conditions for fascia healing because of avoidance of necrosis of the rectus abdominis muscles and of optimum distribution of forces leading to a reduced incidence of incisional hernia. Experimental studies show that a suture technique with an equal distribution of forces on the fascia is necessary to achieve an optimum ratio of collagen type 1 to type 3. Too high tensile force per suture will result in more scar tissue(23, 24). The holding force of a suture depends on the collagen that deposits in the suture, which is best achieved by suturing of the aponeurosis without muscle or fat tissue(25). Experimental data show that the small bites technique is stronger than the large bites technique, which is consistent with the results of this clinical study(26).
In this era of minimally invasive and robotic surgery, many patients with high-risk pro les or undergoing major abdominal surgical procedures will still have to have open surgical procedures with midline incision. Compared with previous trials, we examined a relatively high-risk group, which is relevant and consistent with present surgical practice. Challenging patient and surgical characteristics could be an explanation of the overall complication rate and the fairly high incidence of surgical site infection in both groups. The higher incidence of surgical site infection in our trial than in the Swedish trial might be explained by the di erence in patient condition (eg, previous midline incision, more patients with diabetes, perioperative chemoradiation, and malnutrition), more major surgical procedures, and use of a strict standardised wound scoring method in this trial(10, 27). Although surgical site infection was not the primary endpoint of our trial, our results emphasise that wound infection remains a frequent complication in this surgical population and should be monitored carefully.
We also reported health-related quality of life and pain of patients who received the small bites suture technique. Postoperative quality of life or pain did not di er between the two groups. Patients with incisional hernia in both groups had signi cantly lower scores on the general health dimension and had more mobility problems. Furthermore, most of our patients had malignant disease, which is associated with a reduced quality of life in general(5, 28, 29).
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