S. Dąbrowiecki. S. Pierściński. A. Kapała. S. Prywiński. W. Szczęsny. W. Gniłka. J. Pypkowski. J. Szopiński. D. Sosnowski. J.Szmytkowski. P.Wierzchowski. J.

Andruszkiewicz

 

Poland

         

                                                                

Loop suture in abdominal wound closure – advantages or illusions?     

Dept. of General & Endocrine Surgery, Collegium Medicum, Bydgoszcz, Poland

PDS II
Ethicon Needle Type Needle Shape Needle Length Material Suture Length

CT

1/2 Circle

40mm

Violet Monofil ament

36" ~90cm

Absorption time 180 – 210 days

Engelova D.. Antos F.: Surgical wound dehiscence and a technique for laparotomy closure with continuous loop sutures. Rozhl Chir. 1995;74:172-5. Results: frequency of a burst abdomen: silon – 2.2% vs PDS loop 1.2% Hoch J.. Murinova D. Laparotomy closure with continuous polydioxanone sutures Rozhl Chir. 1995;74:198-200. Results: PDS loop suture utilized in 166 laparotomies; fast, simple, and safe method Bohanes T. Role of modern absorbable suture materials in decreasing the occurrence of early complications after laparotomy. Rozhl Chir. 2002; 81: 24-6 Results: PDS loop & Vicryl - less freq. early complication, less infection; burst abdomen and hernia - more frequent in Silon group; PDS loop vs Vicryl - no difference between group Conclusion: Running, mass closure is the best method of lap wound closure

RCT: polyglactin 910 (Vicryl) vs polydioxanone loop (PDS loop) 340 pts. elective procedure, layered abdominal closure Results: at FU 2y  2.9% incisional hernias

Research design
• • • Pts with the elevated risk of the complications in laparotomy wound healing Standardized technique of laparotomy wound closure End points: – Primary: wound dehiscence. incisional hernia – Secondary: infection, edema, erythema, seroma, suture sinus, and pain • FU: examination at the outpatient department at 1, 3, and at least at 12 ms after the surgery

Inclusion criteria
• • • • • • • • • • • anemia < 10g% sepsis with abdominal origin pneumonia or COPD hemodynamic instability age > 65 y BMI > 30 neoplasmatic disease (life expectancy >1 y) hipoalbuminemia <3.4 g/L ascites hypercortisolemia any condition deteriorating wound healing

com bine d in dica tion s

• re-laparotomy • wound contaminated during the surgery and dirty wound • surgery time > 2.5 h

Surgical technique

Surgical technique
A B

• obligatory: mass closure, running
C

suture, monofilament, PDS 2-0 • randomization: single vs loop suture • registered values : wound length, suture length, number of loops • calculated variables : SL/WL, loops distance, width of sutured

Patients
• Indication to surgery – 32 diseases; the most frequent: • 42 ca colonis • 41 morbid obesity • 33 different path. of biliary tract • 19 dig. tract perforation • 7 ca ventriculi • 6 abdominal trauma

Evaluation
• P-ts lost to FU » following 1 ms – 8 pts » 3 ms – 17 pts » 12 ms – 27 pts • Statistical analysis:
– Kaplan & Meier product-limit method comparing two and multiple samples – Cox's Proportional Hazard Model – Mann-Whitney U Test

Groups comparison
All
Pts number Age years; mean (range) Hospitalization (days) Possum scale points 185 56.3 (21-92) 12.5 (2-79) 13.6 (6-37)

Loop
85 55.4 11.9 13.8

Single
100 56.9 13.2 13.5

Difference
ns ns ns

M/F; ASA; lap wound healing risk factors (surgical vs medical vs combined); urgent vs elective treatment; indication to surgery – no difference laparotomy localisation; wound drainage; skin closure technique; skin healing on discharge – no difference

Results – the whole group

Results in the compared groups

All
Incisional hernia Burst abdomen Deaths 27 10 10

PDS Loop
10 5 5

PDS Single
17 5 5

Cumulative prop. of surviving w/o burst abdomen or hernia

months

Cumulative prop. of surviving w/o burst abdomen

Cumulative prop. of surviving w/o incisional hernia

Not always „more” - means „better”

Groups comparison
Rank Sum wound length suture length SL/WL SL/loop suture distance fascia margin 7346.000 8775.500 9051.500 8603.000 6472.000 9051.500 Rank Sum 9490.00 8244.50 7784.50 8417.00 10364.00 7784.50 U 3776.00 0 3294.50 0 2834.50 0 3467.00 0 2902.00 0 2834.50 0 Z -1.0697 6 2.5348 3 3.7063 7 2.0559 0 -3.5173 4 3.7063 7 p-level 0.284727 0.01125 1 0.00021 0 0.03979 3 0.00043 6 0.00021 0 single 18,4 71 3.8 2.9 0.8 0.9 loop 18,9 60 3.1 2.6 0.9 0.8

     S. Dąbrowiecki, S. Pierściński, A. Kapała, S. Prywiński, W. Szczęsny, W. Gniłka, J. Pypkowski, J. Szopiński, D. Sosnowski, J. Szmytkowski, P. Wierzchowski, J. Andruszkiewicz

 

Poland

         

                                                                

Insights into individual technique of post-laparotomy wound closure    
Dept. of General & Endocrine Surgery, NCU College of Medicine, Bydgoszcz, Poland

vertical midline incision, 12 ms FU  5% - 15% incisional hernias (= 50% whole hernias)

burst abdomen  up to 3%; mortality rate > 25%

What matters more?

OR

Israelsson LA:The surgeon as a risk factor for complications of midline incisions. Eur J Surg. 1998;164(5):353-9 CONCLUSION: The suture technique, monitored by the SL:WL ratio, is the most important factor for variability in the incidence of incisional hernia among surgeons in continuously sutured midline incisions. The suture technique may also help to explain the variability in rates of wound infection.

SL / WL 
The width of the sutured fascia margin

The distance of the subsequent suture loops

Research design
• • • Pts with the elevated risk of the complications in laparotomy wound healing Standardized technique of laparotomy wound closure Endpoints: – Primary: wound dehiscence. incisional hernia – Secondary: infection, edema, erythema, seroma, suture sinus, and pain • FU: examination at the outpatient department at 1, 3, and at least at 12 ms after the surgery

Inclusion criteria
• • • • • • • • • • • anemia < 10g% sepsis with abdominal origin pneumonia or COPD hemodynamic instability age > 65 y BMI > 30 neoplasmatic disease (life expectancy >1 y) hipoalbuminemia <3.4 g/L ascites hypercortisolemia any condition deteriorating wound healing

com bine d in dica tion s

• re-laparotomy • wound contaminated during the surgery and dirty wound • surgery time > 2.5 h

Patients n=185
Gender F = 94 (50,8%) Elective = 64 (34,4%) I=8 (4,7%) Cancer =53 (29%) I = 26 (15,3%) M = 91 (49,2%) Urgent =121 (65,6%) III = 64 (37,4%) Other = 92 (49,2%) III = 26 (15,3%) IV = 29 (17,1%) IV = 6 (3,5%) Mean age 56.3 (21-92)

Procedure

ASA

II = 93 (54,4%)

Indication to procedure

BMI = 41 (21,9%), II = 89 (52,4%)

Contamination

Patients
• Indication to surgery – 32 diseases; the most frequent: • 42 ca colonis • 41 morbid obesity • 33 different path. of biliary tract • 19 dig. tract perforation • 7 ca ventriculi • 6 abdominal trauma

Surgical technique

Surgical technique
A B

• obligatory: mass closure, running
C

suture, monofilament, PDS 2-0 • randomization: single vs loop suture • registered values : wound length, suture length, number of loops • calculated variables : SL/WL, loops distance, width of sutured

Study group
12 physicians: SD, AK, SP, WSz, WG, JP, SPi, JSz, KSz, DS, PC, IN 4 consultants, 8 residents

Technical variables
• Wound length, suture length, number of suture loop accros the wound • SL/WL; SL/loop  fascia margin, WL/loop  suture distance

Perioperative variables
Pts: age, sex, ASA, perioperative Possum score, wound healing complication risk factors, indications to surgery (BMI vs carcinoma vs other) Elective vs urgent treatment Laparotomy localisation (median vs paramedian) Wound contamination class

Wound closure detalis vs patients age

Wound closure detalis vs Possum score

Perioperative variables vs wound closure
Varibles suture distance p=0.001 p<0.02 p<0.05 p=0.06 fascia margin p=0.02 p=0.057 p=ns p=ns

indication to surgery risk factors lap localisation pts gender

Varibles w/o influence: • urgent vs elective treatment • ASA class, • wound contamination class

Conclusions
• Simple measurements and counting during wound closure allows on insight into a individual surgical technique. • Surgeons differ considerably in details of their surgical technique even during the standardized closure of a operative wound • Surgeons’ repeatability of simple manoeuvres is small/moderate („muscular memory” is poor) • There are probably numerous factors (patient, illness, laparotomy) which influence beyond our consciousness the execution of a surgical technique