The search for an ideal method of abdominal fascial closure: a meta-analysis

Abstract

Background and objective: The ideal suture for abdominal fascial closure has yet to be determined. Surgical practice continues to rely largely on tradition rather than high-quality level I evidence. The authors conducted a systematic review and meta-analysis of randomized controlled trials to determine which suture material and technique reduces the odds of incisional hernia.

Methods: MEDLINE and Cochrane Library databases were searched for articles in English published from 1966 to 1998 using the keywords "suture", "abdomen/surgery", and "randomized controlled trials". Randomized controlled trials, trials of adult patients, and trials with a Jadad Quality Score of more than 3, comparing suture materials, technique, or both, were included. Two independent reviewers critically appraised study quality and extracted data. The reviewers were masked to the study site, authors, journal, and date to minimize bias. The primary outcome was postoperative incisional hernia. Secondary outcomes included wound dehiscence, infection, wound pain, and suture sinus formation.

Results: The occurrence of incisional hernia was significantly lower when nonabsorbable sutures were used. Suture technique favored nonabsorbable continuous closure. Suture sinuses and wound pain were significantly lower when absorbable sutures were used. There were no differences in the incidence of wound dehiscence or wound infection with respect to suture material or method of closure. Subgroup analyses of individual sutures showed no significant difference in incisional hernia rates between polydioxanone and polypropylene. Polyglactin showed an increased wound failure rate.

Conclusions: Abdominal fascial closure with a continuous nonabsorbable suture had a significantly lower rate of incisional hernia. The ideal suture is nonabsorbable, and the ideal technique is continuous.

Figure 1. Meta-analysis of all outcomes comparing absorbable versus nonabsorbable sutures. Squares indicate point estimates of odds ratio, and horizontal bars signify 95% confidence intervals. Values less than 1 favor the nonabsorbable group and values more than 1 favor the absorbable group. Point estimates are significant at the P < .05 level if their confidence intervals exclude the vertical line at 1 (“no effect”).

Figure 2. Pooled estimates of risk of incisional hernia comparing absorbable versus nonabsorbable. The weight attributed to a particular study is represented by the size of the square on the point estimate of each odds ratio; the width of the horizontal bars reflects the 95% confidence interval. Point estimates crossing the vertical bar represent statistically nonsignificant results, with 95% confidence intervals that include 1. An odds ratio of less than 1 favors nonabsorbable suture; an odds ratio of more than 1 favors absorbable suture.

Figure 3. Pooled estimates of continuous versus interrupted suture technique. Squares indicate point estimates of odds ratios, and horizontal bars represent 95% confidence intervals. Values less than 1 favor the continuous group and values more than 1 favor the interrupted group.

Figure 4. Pooled estimates of incisional hernia comparing continuous nonabsorbable versus continuous absorbable closure. Squares indicate point estimates of odds ratios, with the size of the square representing the weight of each study. Horizontal bars signify 95% confidence intervals. The summary odds ratio is represented by the diamond; values to the left of the vertical bar favor the continuous nonabsorbable group and values to the right favor continuous absorbable.