Page 99 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

Does the type of abdominal wall incision in uence the incidence of incisional hernias or burst abdomen?
Laparotomy incisions can be classi ed as midline, transverse, oblique or paramedian incisions(61). Six systematic reviews have compared midline laparotomies to alternative incisions(26, 27, 31, 36, 38, 61), but only two were considered High Quality (26, 27). A recent systematic review by Bickenback et al.(26) compared midline, transverse (including oblique) and paramedian incisions. This review included all relevant studies from previous reviews and no additional RCT’s were detected that were published after this review. The literature search of this systematic review(26) identi ed studies published until 2009 and 24 RCT’s directly comparing di erent laparotomy incisions were included in the analysis. The incisional hernia rates after non-midline incisions were signi cantly lower compared to the incisional hernia rates after midline incisions, for both transverse incisions (RR = 1.77; 95 % CI:1.09–2.87) and paramedian incisions (RR = 3.41; 95 % CI: 1.02–11.45)(26). However, data on burst abdomen (deep wound dehiscence or fascial dehiscence) were not signi cantly di erent between the di erent incisions types.
A Cochrane review by Brown et al.(27) published in 2005 and updated in 2011, compared transverse versus midline incisions, but excluded studies comparing paramedian incisions. A decreased incisional hernia rate after transverse incisions was reported compared to midline incisions (OR = 0.49; 95 % CI: 0.30–0.79).
Both reviews concluded that non-midline incisions signi cantly reduced the risk of incisional hernia compared to midline incisions, but did not in uence the risk of burst abdomen. Interestingly, the Cochrane conclusions were more moderate, due to methodological and clinical heterogeneity of the studies and the risk of potential bias.
What is the optimal technique to close a laparotomy incision?
Ten systematic reviews on the techniques and/or the materials to close abdominal wall incisions were identi ed (4, 32, 34, 37, 38, 42, 43, 48, 62, 63). The data from the di erent systematic reviews are very incoherent and conclusions
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EHS guidelines
Statement
Non-midline incisions are recommended where possible
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