Page 82 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

Chapter 4
Although no signi cant di erences could be found when comparing interrupted and continuous suture techniques using the same suture material, we agree with the recommendations of the European Hernia Society to use a continuous suture technique to close the fascia(10). The superiority of the combination of a continuous technique with a slowly-absorbable suture on the incidence of incisional hernia has been determined in high-quality systematic reviews and meta-analyses(11, 13). Furthermore, a continuous technique is faster than an interrupted technique thereby reducing the length of surgery(13).
Two RCTs proved that a small bites suture technique using 2-0 mono lamented slowly-absorbable stuture material signi cantly reduces incisional hernia rate compared to a large bite 1-0 suture technique(4, 25). This suture method was rstly described by Israelsson et al. and is also referred to as the 4:1 suture method, as the suture length should be at least four times as long as the laparotomy incision(39). Using twice the amount of stitches including the aponeurosis only, provides close to ideal conditions for fascial healing due to avoidance of necrosis of the rectus abdominis muscles and to optimal distribution of forces leading to a lower incidence of incisional hernia(4, 25, 40). Whether it is the size of the bites or the size of the suture, that is important in decreasing hernia rate is still unknown. Hypothetically, it is technically more di cult to perform the small bites technique with a larger needle and thicker suture.
The incidences of SSI reported in the included RCTs emphasize that wound infection remains a frequent complication after laparotomy and should be scored carefully. Furthermore, it was reported in the RCTs that incisional hernias were preceded by SSI in up to 40% of the cases(25-29), stressing that SSI is an important risk factor for incisional hernia formation. However, in this meta-analysis the suture material or suture method did not seem to in uence the rate of SSI and burst abdomen.
Optimizing all surgical-technical factors in closing a midline laparotomy and the increasing use of minimally invasive surgery unfortunately does not reduce incisional hernia rate to zero. Patients undergoing open surgery for abdominal aortic aneurysm and obese patients have a higher risk of incisional hernia formation(8, 41). In these high-risk patients, other interventions might be needed to further reduce the incidence of incisional hernia. Patients with an abdominal aneurysm or obesity were found to bene t from prophylactic mesh augmentation with a signi cant reduction in the incisional hernia rate
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