Page 81 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

Non-absorbable or slowly-absorbable sutures was not superior to fast- absorbable sutures in decreasing incisional hernia rate in this meta-analysis. In accordance, a recent systematic review by Bosanquet et al(3). did also conclude that there is no evidence that suture type has an intrinsic e ect on incisional hernia rate. However, this nding is controversial compared with previous meta-analyses concluding that slowly-absorbable sutures are superior to fast absorbable sutures(11, 13). These previous meta-analyses di er from the current meta-analysis, which may explain the di erent conclusions. Firstly, only RCTs on midline laparotomies were included. Further, RCTs comparing a continuous suture technique using slowly-absorbable sutures with an interrupted suture technique using rapid absorbable suture were compared in the forest plots(11). Lastly, both meta-analyses included papers that were rejected in the current meta-analysis because of inadequate quality judged by the critical appraisal checklists.
Although no signi cant di erences between sutures could be found on incisional hernia and SSI rate, we agree with the recommendations of the European Hernia Society to use a slowly-absorbable suture when closing the fascia(10). When considering the biology of wound healing, using a slowly or non-absorbable suture for fascial closure seems appropriate. Fascial healing starts by recruiting in ammatory cells. Two to ve days after laparotomy broblasts enter the wound and start producing collagen. During the proliferation phase of the rst three weeks, mainly type III collagen is produced and an extracellular matrix is created. Type III collagen consists of thin, weak bers and is replaced by strong and thick type I collagen during the following maturation phase(35, 36). The last part of the maturation phase is remodeling or realignment of collagen bers along tension lines and can take up to years. The half-life tensile strength of absorbable sutures like polyglactin 910 (Vicryl®) and polyglycolid acid (Dexon®) is around 2-3 weeks(37), suggesting an insu cient support of the healing fascial tissue. The half-life tensile strength of slowly-absorbable suture polydioxanone (PDS®) is 6 weeks(37). Since fascia needs at least 14 days to regain its strength(35, 38), using a fast-absorbable suture might not provide long enough support to the healing fascia, although this is not supported by our data. Since suture sinus formation, palpable knots and wound pain was reported to be a problem with the use of non-absorbable sutures(19-21, 23, 26, 28), a slowly-absorbable suture is preferred over a non- absorbable suture.
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