Meta-analysis on Materials and Techniques for Laparotomy Closure: The MATCH Review.

BACKGROUND: The aim of this systematic review and meta-analysis was to evaluate closure materials and suture techniques for emergency and elective laparotomies. The primary outcome was incisional hernia after 12 months, and the secondary outcomes were burst abdomen and surgical site infection. METHODS: A systematic literature search was conducted until September 2017. The quality of the RCTs was evaluated by at least 3 assessors using critical appraisal checklists. Meta-analyses were performed. RESULTS: A total of 23 RCTs were included in the meta-analysis. There was no evidence from RCTs using the same suture technique in both study arms that any suture material (fast-absorbable/slowly absorbable/non-absorbable) is superior in reducing incisional hernias. There is no evidence that continuous suturing is superior in reducing incisional hernias compared to interrupted suturing. When using a slowly absorbable suture for continuous suturing in elective midline closure, the small bites technique results in significantly less incisional hernias than a large bites technique (OR 0.41; 95% CI 0.19, 0.86). CONCLUSIONS: There is no high-quality evidence available concerning the best suture material or technique to reduce incisional hernia rate when closing a laparotomy. When using a slowly absorbable suture and a continuous suturing technique with small tissue bites, the incisional hernia rate is significantly reduced compared with a large bites technique.

Triclosan-coated sutures and surgical site infection in abdominal surgery: the TRISTAN review, meta-analysis and trial sequential analysis.

INTRODUCTION: Surgical site infection (SSI) is a frequent complication of abdominal surgery causing increased morbidity. Triclosan-coated sutures are recommended to reduce SSI. The aim of this systematic review and meta-analysis was to evaluate the evidence from randomized controlled trials (RCT) comparing the rate of SSI in abdominal surgery when using triclosan-coated or uncoated sutures for fascial closure. METHODS: A systematic literature search was conducted using Medline, EMBASE, the Cochrane library, CINAHL, Scopus and Web of Science including publications until August 2017. The quality of the RCTs was evaluated using critical appraisal checklists from SIGN. Meta-analyses and trial sequential analysis were performed with Review Manager v5.3 and TSA software, respectively. RESULTS: Eight RCTs on abdominal wall closure were included in the meta-analysis. In an overall comparison including both triclosan-coated Vicryl and PDS sutures for fascial closure, triclosan-coated sutures were superior in reducing the rate of SSI (OR 0.67; 0.46-0.98). When evaluating PDS sutures separately, there was no effect of triclosan-coating on the rate of SSI (OR 0.85; 0.61-1.17). Trial sequential analysis showed that the required information size (RIS) of 797 patients for triclosan-coated Vicryl sutures was almost reached with an accrued information size (AIS) of 795 patients. For triclosan-coated PDS sutures an AIS of 2707 patients was obtained, but the RIS was estimated to be 18,693 patients. CONCLUSION: Triclosan-coated Vicryl sutures for abdominal fascial closure decrease the risk of SSI significantly and based on the trial sequential analysis further RCTs will not change that outcome. There was no effect on SSI rate with the use of triclosan-coated PDS sutures for abdominal fascial closure, and it is unknown whether additional RCTs will change that.

European Hernia Society guidelines on the closure of abdominal wall incisions

BACKGROUND: The material and the surgical technique used to close an abdominal wall incision are important determinants of the risk of developing an incisional hernia. Optimising closure of abdominal wall incisions holds a potential to prevent patients suffering from incisional hernias and for important costs savings in health care. METHODS: The European Hernia Society formed a Guidelines Development Group to provide guidelines for all surgical specialists who perform abdominal incisions in adult patients on the materials and methods used to close the abdominal wall. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and methodological guidance was taken from Scottish Intercollegiate Guidelines Network (SIGN). The literature search included publications up to April 2014. The guidelines were written using the AGREE II instrument. An update of these guidelines is planned for 2017. RESULTS: For many of the Key Questions that were studied no high quality data was detected. Therefore, some strong recommendations could be made but, for many Key Questions only weak recommendations or no recommendation could be made due to lack of sufficient evidence. RECOMMENDATIONS: To decrease the incidence of incisional hernias it is strongly recommended to utilise a non-midline approach to a laparotomy whenever possible. For elective midline incisions, it is strongly recommended to perform a continuous suturing technique and to avoid the use of rapidly absorbable sutures. It is suggested using a slowly absorbable monofilament suture in a single layer aponeurotic closure technique without separate closure of the peritoneum. A small bites technique with a suture to wound length (SL/WL) ratio at least 4/1 is the current recommended method of fascial closure. Currently, no recommendations can be given on the optimal technique to close emergency laparotomy incisions. Prophylactic mesh augmentation appears effective and safe and can be suggested in high-risk patients, like aortic aneurysm surgery and obese patients. For laparoscopic surgery, it is suggested using the smallest trocar size adequate for the procedure and closure of the fascial defect if trocars larger or equal to 10 mm are used. For single incision laparoscopic surgery, we suggest meticulous closure of the fascial incision to avoid an increased risk of incisional hernias.(AU)

Surgery in the treatment of type 2 diabetes mellitus.

BACKGROUND AND AIMS: The prevalence of diabetes is increasing worldwide, and most of the cases are type 2 diabetes mellitus. The relationship between type 2 diabetes mellitus and obesity is well established, and surgical treatment is widely used for obese patients with type 2 diabetes mellitus. The aim was to present current knowledge about the possible mechanisms responsible for glucose control after surgical procedures and to review the surgical treatment results. MATERIAL AND METHODS: Medical literature was searched for the articles presenting the impact of surgical treatment on glycemic control, long-term results, and possible mechanisms of action among obese individuals with type 2 diabetes mellitus. RESULTS: Remission of type 2 diabetes mellitus after bariatric surgery depends on the definition of the remission used. Complete remission rate after surgery with the new criteria is lower than was considered before. Randomized controlled studies demonstrate that surgery is superior to best medical treatment for the patients with type 2 diabetes mellitus. The recurrence of type 2 diabetes mellitus after bariatric surgery is observed in up to 40% of cases with ≥ 5 years of follow-up. Despite the recurrence of type 2 diabetes mellitus in this group, better glycemic control and lower risk of macrovascular complications are present. Incretin effects on glycemic control after bariatric surgery are well described, but the role of other possible mechanisms (bile acids, microbiota, intestinal gluconeogenesis) in humans is unclear. CONCLUSION: Surgery is an effective treatment of type 2 diabetes mellitus in obese patients. The most optimal surgical procedure for the treatment of obese patients with type 2 diabetes mellitus is still to be established. More research is needed to explore the mechanisms of glycemic control after bariatric surgery.

European Hernia Society guidelines on the closure of abdominal wall incisions.

BACKGROUND: The material and the surgical technique used to close an abdominal wall incision are important determinants of the risk of developing an incisional hernia. Optimising closure of abdominal wall incisions holds a potential to prevent patients suffering from incisional hernias and for important costs savings in health care. METHODS: The European Hernia Society formed a Guidelines Development Group to provide guidelines for all surgical specialists who perform abdominal incisions in adult patients on the materials and methods used to close the abdominal wall. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and methodological guidance was taken from Scottish Intercollegiate Guidelines Network (SIGN). The literature search included publications up to April 2014. The guidelines were written using the AGREE II instrument. An update of these guidelines is planned for 2017. RESULTS: For many of the Key Questions that were studied no high quality data was detected. Therefore, some strong recommendations could be made but, for many Key Questions only weak recommendations or no recommendation could be made due to lack of sufficient evidence. RECOMMENDATIONS: To decrease the incidence of incisional hernias it is strongly recommended to utilise a non-midline approach to a laparotomy whenever possible. For elective midline incisions, it is strongly recommended to perform a continuous suturing technique and to avoid the use of rapidly absorbable sutures. It is suggested using a slowly absorbable monofilament suture in a single layer aponeurotic closure technique without separate closure of the peritoneum. A small bites technique with a suture to wound length (SL/WL) ratio at least 4/1 is the current recommended method of fascial closure. Currently, no recommendations can be given on the optimal technique to close emergency laparotomy incisions. Prophylactic mesh augmentation appears effective and safe and can be suggested in high-risk patients, like aortic aneurysm surgery and obese patients. For laparoscopic surgery, it is suggested using the smallest trocar size adequate for the procedure and closure of the fascial defect if trocars larger or equal to 10 mm are used. For single incision laparoscopic surgery, we suggest meticulous closure of the fascial incision to avoid an increased risk of incisional hernias.

Reinforced tension line versus simple suture: a biomechanical study on cadavers.

UNLABELLED: The aim of our experimental biomechanical study was to compare the strength of two different midline laparotomy suture techniques: simple suture and reinforced tension line (RTL) suture. MATERIALS AND METHODS: Sixty midline laparotomies on cadavers were performed: simple and RTL sutures in each 30 cases. Cadavers were patients who died in the hospital during the last 24 hours and had no previous abdominal operations and no arterial aneurysm disease. Simple and RTL sutures were made with slowly absorbable polydioxanone (PDS II loop, 1/0 size). The strength of both sutures was measured with tensiometer and expressed in Newton (N). The maximal suture strength was assessed at the moment when the suture tore the tissues. RESULTS: The simple suture strength was significantly lower than RTL suture strength (86.3 +/- 16.8 N vs. 113 +/- 16.6 N, p < 0.001). The midline laparotomy suture strength increased up to 31% when RTL suture was performed. The RTL suture strength was significantly higher in all three abdomen regions: epigastric (80 +/- 15.7 N vs. 106.6 +/- 14 N, p < 0.001), umbilical (86.2 +/- 16 N vs. 112.9 +/- 14.8 N, p < 0.001) and hypogastric (93.7 +/- 17.2 N vs. 120.7 +/- 18.1 N, p < 0.001). CONCLUSIONS: The reinforced tension line suture is significantly stronger than simple suture when closing the midline laparotomy. This suture can be used in patients with higher fascia dehiscence or incisional hernia risk.

One-year follow-up after incisional hernia treatment: results of a prospective randomized study.

BACKGROUND: The incidence of incisional hernia after midline laparotomies ranges from 10 to 20%. The recurrence rate after this hernia surgery varies from 25 to 52% using autogenous tissue. The use of prosthetic meshes can decrease the postoperative hernia recurrence by up to 10%. The aim of this prospective randomized clinical study was to analyze and compare the results of three different incisional hernia surgical techniques. MATERIALS AND METHODS: One hundred and sixty-one patients who underwent incisional hernia surgery were randomized into three groups. The Keel technique was used in the first group, the "Onlay" technique (prosthetic mesh is fixed on the external abdominal muscle slip) in the second group, and the "Sublay" technique (prosthetic mesh is placed on the posterior abdominal muscle sheath) in the third group. Age, sex, hospitalization time, body mass index (BMI), intraabdominal pressure, postoperative complications, postoperative pain, normal physical activity recovery time, and recurrence rate were compared between the groups. The postoperative follow-up period was 12 months. RESULTS: Fifty-four patients in the Keel group, 57 patients in the "Onlay" group, and 50 patients in the "Sublay" group were operated. Age, hospitalization time, and BMI were similar in all of the groups. The operative time was significantly longer in the prosthetic mesh groups compared with the Keel group. The intraabdominal pressure changes before and after surgery was significantly higher in the Keel group compared with the prosthetic mesh groups (5.66 ± 2.5 mmHg vs. 1.88 ± 1 mmHg vs. 1.76 ± 1 mmHg; P < 0.05). The postoperative wound complications rate was significantly higher in the "Onlay" technique group compared with the Keel and "Sublay" technique groups (49.1% vs. 22.2% vs. 24%; P < 0.05). Postoperative pain (VAS score) was significantly lower in the "Onlay" and "Sublay" groups (5.53 ± 1.59 vs. 3.96 ± 1.56 vs. 3.78 ± 1.97; P < 0.05). All of the patients in "Sublay" group recovered to normal physical activity during the 6 months follow-up period compared with 94.4% of patients in the Keel group and 98.3% of patients in the "Onlay" group. The recurrence rate was 22.2% in the Keel group, 10.5% in the "Onlay" group, and 2% in the "Sublay" group during the follow-up period. The general complications rate after hernia surgery was 5.6%. Postoperative pneumonia was the most frequent complication, which appeared in 4.3% of patients. There was no postoperative death in our prospective study. CONCLUSIONS: Mesh repair is the first-choice technique for incisional hernia treatment. The results of the "Sublay" technique are better than the "Onlay" technique.