Page 83 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

with an odds ratio of 0.25(42, 43). Furthermore, many patients with high- risk pro les such as many previous laparotomies, emergency surgery and/or major abdominal surgical procedures will still have to undergo open surgical procedures through midline incisions. In these high-risk groups the avoidance of incisional hernia remains a challenge. Further studies on the optimal closure technique in emergency laparotomies are still needed, and should include the small bites technique in one study arm. To the best of our knowledge, there is only one ongoing RCT on midline emergency laparotomies comparing continuous all-layer suturing with slowly-absorbable suture to an interrupted technique with fast-absorbable sutures(44). The meta-analysis design is limited by the fact that the results depend on the included studies. Furthermore, one could argue that only studies on elective midline laparotomies should be included in order to minimize heterogeneity. On the other hand, the reality rarely represents with only elective midline laparotomies. Yet this is the rst systematic review and meta-analysis to compare studies on the suture material using the same technique in both arms, which is essential to conclude anything on type of sutures. Likewise, to evaluate the suture technique, the same suture type must be used in both arms. Further, to minimize risk of bias, the SIGN checklists were used by two independent assessors for evaluation of the RCTs.
In conclusion, no suture material proved superior to other in the meta- analyses. However, a slowly-absorbable suture material seems wise to use as it keeps its strength until the fascial tissue is healed. Further, a slowly-absorbable suture does not increase the SSI rate compared to fast-absorbable sutures and decreases the risk of wound pain and suture sinus, which is a risk when using non-absorbable material. Moreover, there were no di erence on an interrupted suture technique compared with a faster continuous technique. On the other hand, this meta-analysis signi cantly concludes that the best-evidenced technique for closure of a laparotomy incision is a small bites suture technique with a 2-0 slowly-absorbable suture including the aponeurosis only in a suture to wound length ratio of at least 4:1.
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