Prevention of incisional hernia using different suture materials for closing the abdominal wall: a comparison of PDS, Vicryl and Prolene in a rat model.

PURPOSE: An incisional hernia occurs frequently after a midline incision with an incidence of 12.8%. The choice in suture material used for abdominal wall closure is not straightforward and the conflicting literature focuses on clinical outcomes. This study compares a non-absorbable, slow-absorbable and fast-absorbable suture in a rat model, focusing on histological outcomes predicting better fascia healing. METHODS: 33 male Wistar rats, divided over three groups, each received two separate 1 cm incisions closed with either Prolene 4/0, PDS 4/0 or Vicryl 4/0. At 7 days and 21 days, one of the incisions was explanted. Tissue was semi-quantitatively scored regarding inflammatory cells and collagen fibres present. Using qPCR macrophage polarisation, fibroblast activity and vascularisation were evaluated. Data were analysed by Kruskal-Wallis test with Mann-Whitney U post hoc test. A p value of 0.017 was considered significant after Bonferroni correction. RESULTS: All animals recovered without complications and completed the 21 days of follow-up. The Vicryl group showed a higher presence of macrophages after 21 days in comparison with Prolene (p = 0.003) and PDS (p = 0.006) and more foreign body giant cells compared to Prolene at 7 days (p = 0.010) and PDS at 21 days (p < 0.001). qPCR showed 2.5-fold higher expression of clec10A in PDS compared to Prolene after 7 days (p = 0.007). CONCLUSIONS: The results of this study carefully support the use of PDS suture, compared to Prolene and Vicryl, in abdominal wall closure based on a favourable macrophage response. The heterogeneity and variability in the data might be explained by the spectrum of the macrophage subtype paradigm.

Incidence of arcuate line hernia in patients with abdominal complaints: radiological and clinical features.

INTRODUCTION: Acute abdominal complaints are a frequent cause for consultation in the emergency department, with a large differential diagnosis. One cause is arcuate line herniation, but this entity is little known and rarely considered during initial analysis. The incidence of arcuate line herniation in this population is unknown. METHODS: A retrospective cohort study was performed. All patients who presented to the emergency department for surgical consultation during an 18-month period with abdominal complaints in who no diagnosis was found after analysis, and who had computed tomography imaging of the abdomen were included. CT scans were reviewed with a focus on abdominal wall pathology and correlated with clinical features. RESULTS: Eight hundred and ten patients presented with abdominal complaints, 415 of these had CT scans available for review and were included in the study. In 47 patients (11.3%), an arcuate line anomaly was found, and in 14 patients (3.4%), a frank arcuate line herniation (grades 2 or 3) was found. Retrospective correlation with clinical complaints was found in 50% of these patients. Patients with arcuate line hernia had a significantly higher BMI, and diabetes mellitus and aortic aneurysm were more prevalent in these patients. CONCLUSION: Arcuate line herniation has a higher incidence than previously thought in patients with acute abdominal complaints and should be considered when evaluating these patients.

Laparotomy closure techniques: Do surgeons follow the latest guidelines? Results of a questionnaire.

PURPOSE: Incisional hernias after laparotomy are associated with significant morbidity and increased costs. Recent research on prevention of incisional hernia formation suggests that a laparotomy closure technique using a slowly absorbable monofilament suture with small fascial steps and bites in a continuous, single layer with a suture length to wound length (SL/WL) ratio of at least 4:1 is effective in lowering morbidity. Little is known about application of this evidence in daily practice. Therefore, a survey was performed among Dutch surgeons. METHODS: All members of the Dutch Surgical Society were invited to participate in a 24-question online survey on techniques and materials used for abdominal wall closure after midline laparotomy. Subgroup analysis was performed based on surgical subspecialty, type of hospital and experience. RESULTS: Response rate was 26% (402 respondents), representing 97% of all Dutch surgical departments. More than 90% of participants closed the abdominal wall in a single mass layer, using a slowly absorbable monofilament running suture The SL/WL ratio of >4:1 is practiced by only 35% of participants and preferred suture size was variable among participants. Risk factors for incisional hernia development were generally identified correctly but more than half of the participants were unaware of the incidence and time of occurrence of incisional hernia. Subgroup analysis found that gastrointestinal and oncologic surgeons preferred smaller diameter sutures and higher suture-length to wound-length ratios. Trauma, vascular and pediatric surgeons had lower estimates of incidence of incisional hernia than other subspecialties. Surgeons employed in academic hospitals were more likely to use small fascial steps and smaller suture sizes than their colleagues in non-academic hospitals. Correct estimates of incisional hernia incidence decreased when surgeons perform less than 10 laparotomies annually. CONCLUSION: Implementation of the latest evidence regarding closure techniques of the abdominal wall is not widespread. Only 35% of surgeons close the abdominal fascia using a suture length to wound length ratio of 4:1, which is recommended based on the latest evidence. Surgical trainees, gastrointestinal and oncological surgeons are most familiar with the recommended technique and use it in their daily practice. Efforts should be directed at improving spreading of this technique.

Pitfalls and clinical recommendations for the primary lumbar hernia based on a systematic review of the literature.

PURPOSE: The lumbar abdominal wall hernia is a rare hernia in which abdominal contents protrude through a defect in the dorsal abdominal wall, which can be of iatrogenic, congenital, or traumatic origin. Two anatomical locations are known: the superior and the inferior lumbar triangle. The aim of this systematic review is to provide a clear overview of the existing literature and make practical clinical recommendations for proper diagnosis and treatment of the primary lumbar hernia. METHODS: The systematic review was conducted according to the PRISMA guidelines. A systematic search in PubMed, MEDLINE, and EMBASE was performed, and all studies reporting on primary lumbar hernias were included. No exclusion based on study design was performed. Data regarding incarceration, recurrence, complications, and surgical management were extracted. RESULTS: Out of 670 eligible articles, 14 were included and additional single case reports were analysed separately. The average quality of the included articles was 4.7 on the MINORS index (0-16). Risk factors are related to increased intra-abdominal pressure. CT scanning should be performed during pre-operative workup. Available evidence favours laparoscopic mesh reinforcement, saving open repair for larger defects. Incarceration was observed in 30.8% of the cases and 2.0% had a recurrence after surgical repair. Hematomas and seromas are common complications, but surgical site infections are relatively rare. CONCLUSION: The high risks of incarceration in lumbar hernias demand a relatively fast elective repair. The use of a mesh is recommended, but the surgical approach should be tailored to individual patient characteristics and risk factors.

The association between executive functioning and psychopathology: general or specific?

BACKGROUND: We modeled both psychopathology and executive function (EF) as bi-factor models to study if EF impairments are transdiagnostic or relate to individual syndromes, and concurrently, if such associations are with general EF or specific EF impairments. METHODS: Data were obtained from the Tracking Adolescents' Individual Lives Survey (TRAILS; N = 2230). Psychopathology was assessed with parent-report questionnaires at ages 11, 14, 16, and 19, and EF with tasks from the Amsterdam Neuropsychological Tasks program at ages 11 and 19. Bi-factor models were fitted to the data using confirmatory factor analysis. Correlations were estimated to study the associations between general or specific components of both psychopathology and EF. RESULTS: A bi-factor model with a general psychopathology factor, alongside internalizing (INT), externalizing, attention deficit/hyperactivity (ADHD), and autism spectrum (ASD) problem domains, and a bi-factor model with a general EF factor, alongside specific EFs were adequately fitting measurement models. The best-fitting model between EF and psychopathology showed substantial associations of specific EFs with the general psychopathology factor, in addition to distinct patterns of association with ASD, ADHD, and INT problems. CONCLUSIONS: By studying very diverse psychopathology domains simultaneously, we show how EF impairments cross diagnostic boundaries. In addition to this generic relation, ADHD, ASD, and INT symptomatology show separable profiles of EF impairments. Thus, inconsistent findings in the literature may be explained by substantial transdiagnostic EF impairments. Whether general EF or specific EFs are related to psychopathology needs to be further studied, as differences in fit between these models were small.

Incidence and diagnosis of heparin-induced thrombocytopenia (HIT) in patients with traumatic injuries treated with unfractioned or low-molecular-weight heparin: a literature review.

INTRODUCTION: The incidence of thromboembolic complications after major traumatic injuries is high (>50%). Thromboprophylaxis, often by low-molecular-weight heparin (LMWH) or unfractioned heparin (UH) is therefore routinely administered. Thromboprophylaxis is also advised after immobilisation for isolated lower leg injuries. Heparin induced thrombocytopenia (HIT) is a rare but very serious immune mediated complication of treatment with LMWH, which can cause potentially fatal thromboembolism. In the general medical and surgical population the incidence of HIT is 0.2%. Little is known about the incidence of HIT and value of screening in trauma patients and in isolated lower extremity injuries. Therefore, we performed a systematic literature review. METHODS: The online databases Medline and EMBASE were searched independently by two authors. Manuscripts were selected for analysis by quantitative and qualitative selection. After eliminating duplicate articles and irrelevant studies, seven relevant papers reporting on the incidence of HIT in trauma patients were identified and two studies reported the incidence of HIT in patients with lower leg injuries. RESULTS: The selected papers varied in study design: three randomised controlled trials, three cohort studies and one case report were identified. The methodological quality of the studies varied. In a total population of 1920 patients, HIT was identified in seven patients (0.36%). Pooling of data was impossible due to heterogeneity in study design and populations. No HIT was reported in 826 patients with lower extremity injuries, requiring immobilisation. DISCUSSION: Only a few studies have reported on the incidence of HIT in trauma patients who receive prophylactic LMWH. In the heterogenous populations of the available studies, the incidence of HIT appears to be very low and comparable to other patient populations. There is hardly any literature on the incidence of HIT in patients with isolated lower leg injuries receiving LMWH, but incidence seems to be very low. CONCLUSION: The incidence of HIT in trauma patients who receive LMWH thromboprophylaxis appears to be low (0.36%). Incidence of HIT in patients with isolated lower leg injuries receiving LMWH seems very low. Monitoring of platelet count could be considered in hospitalised patients with a high risk for development of HIT. A pre-test scoring system may identify these patients.

Comparison of ultrasonography and physical examination in the diagnosis of incisional hernia in a prospective study.

PURPOSE: Incisional hernia is a frequent complication of abdominal surgery (incidence 2-20%). Diagnosis by physical examination is sometimes difficult, especially in small incisional hernias or in obese patients. The additional diagnostic value of standardized ultrasonography was evaluated in this prospective study. METHODS: A total of 456 patients participating in a randomized trial comparing two suture materials for closure of the abdominal fascia underwent physical examination and ultrasonography at 6-month intervals. Wound complaints and treatment of incisional hernia were also noted. Statistical analysis was performed using the Chi-squared and Fisher's exact tests (SPSS). Interest variability analysis was performed. RESULTS: During a median follow-up of 31 months, 103 incisional hernias were found. A total of 82 incisional hernias were found by physical examination and an additional 21 with ultrasonography. Six of these additional hernias were symptomatic and only one of the additional hernias received operative treatment. The false-negative rates for physical examination and ultrasonography were 25.3 and 24.4%, respectively. Interest variability was low, with a Kappa of 0.697 (P < 0.001). CONCLUSIONS: There are no clear diagnostic criteria for incisional hernia available in the literature. Standardized combination of ultrasonography with physical examination during follow-up yields a significant number of, mostly asymptomatic, hernias, which would not be found using physical examination alone. This is especially relevant in research settings.

Randomized clinical trial comparing polypropylene or polydioxanone for midline abdominal wall closure.

BACKGROUND: Incisional hernia is a frequent complication of abdominal surgery, often requiring surgical intervention. This prospective randomized trial compared suture materials for closure of the fascia after abdominal surgery. METHODS: In 456 patients the abdominal fascia was closed with either non-absorbable (polypropylene; Prolene(®)) or absorbable (polydioxanone; PDS(®)) suture material. Follow-up was by clinical examination and ultrasonography at 6-month intervals. Outcome measures were incisional hernia, surgical-site infection and suture sinus. RESULTS: Some 223 patients were analysed after closure with Prolene(®) and 233 after PDS(®) . Median follow-up was 32 and 31 months respectively. There was no significant difference in the incidence of incisional hernia between the groups: 20·2 per cent (45 of 223) for Prolene(®) and 24·9 per cent (58 of 233) with PDS(®) (P = 0·229). Kaplan-Meier analysis showed a cumulative rate after 4 years of 23·7 and 30·2 per cent for Prolene(®) and PDS(®) respectively (P = 0·222). Secondary outcome measures showed no significant differences. CONCLUSION: The incidence of incisional hernia in both groups was higher than expected from previous literature. There were no significant differences between the two suture methods. REGISTRATION NUMBER: ISRCTN65599814 (http://www.clinical-trials.com).